The URL can be used to link to this page

Home My WebLink About05-6388IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No.OS, G 3 S? 2005 Civil Action - (XX) Law ( ) Equity JURY TRIAL DEMANDED DAVIDSON M. BLACK 25 Penny Lane, Mounted Lane Enola, PA 17025 vs. Plaintiff(s) & Address(es) ROSE E. BREHM 212 Ponderosa Road Carlisle, PA 17013 JIM BREHM a/k/a JAMES BREHM 212 Ponderosa Road Carlisle, PA 17013 ROSE E. SETCHELL 212 Ponderosa Road Carlisle, PA 17013 PRAECIPE FOR WRIT OF SUMMONS TO THE PROTHONOTARY OF SAID COURT: Please issue A Writ of Summons in the above-captioned action. X Writ of Summons Shall be issued and forward W. Scott Hennino Esquire Handler. Henning & Rosenberg LLP 1300 Linglestown Road Harrisburg PA 17110 (717) 238-2000 Name/Address/Telephone No. of Attorney WRIT OF SUMMONS TO THE ABOVE NAMED DEFENDANT(S): Defendant(s) & Address(es) YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFF(S) H V/HAVE COMME ED AN ACTION AGAINST YOU. (J Protho otary Date: /_5' ?2O6S1' by ( ) Check here if reverse is used for additional information Deputy PROTHON. - 55 G. ?'" ,. w _. ?? ? '? - ,.c, -? G ce _.._ DAVIDSON M. BLACK, : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA V. ROSE E. BREHM and JAMES BREHM, Defendants TO THE PROTHONOTARY: CIVIL ACTION - LAW NO. 05-6388 JURY TRIAL DEMANDED ENTRY OF APPEARANCE Kindly enter the appearance of the undersigned as counsel on behalf of the Defendants, Rose E. Brehm and James Brehm, with respect to the above-referenced matter. DATE: /--- 'X 0 - 06 MARSHALL, DENNEHEY, WARNER, COLEMAN & OGGIN BY: DONALD L. CARMELITE, ESQUIRE I.D. No. 84730 4200 Crums Mill Road, Suite B Harrisburg, PA 17112 (717) 651-3504 Attorney for Defendants CERTIFICATE OF SERVICE 1, Susan M. Williams, an employee with the law firm of Marshall, Dennehey, Warner, Coleman & Goggin, do hereby certify that on this a,Y -aay of January, 2006, 1 served a true and correct copy of the Entry of Appearance via U.S. first-class mail, postage pre-paid, as follows: W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 k 6tl.ay'1X SUSAN M. WILLIAMS :., .. „- ?_ ?; I DAVIDSON M. BLACK, V. : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA ROSE E. BREHM and JAMES BREHM, Defendants CIVIL ACTION - LAW NO. 05-6388 JURY TRIAL DEMANDED PRAECIPE FOR RULE TO FILE A COMPLAINT TO THE PROTHONOTARY: Kindly issue a Rule upon the Plaintiff to file a Complaint within twenty (20) days hereof or suffer judgment non pros. MARSHALL, DENNEHEY, WARNER, COLEMAN &-rwOGGIN DATE: / aV - (::? BY: DbKALD L. CARMELITE, ESQUIRE I.D. No. 84730 4200 Crums Mill Road, Suite B Harrisburg, PA 17112 (717) 651-3504 Attorney for Defendants Rose E. Brehm and Jaynes Brehm CERTIFICATE OF SERVICE I, Susan M. Williams, an employee with the law firm of Marshall, Dennehey, Warner, Coleman & Goggin, do hereby certify that on this ?Yj_"day of January, 2006, I served a true and correct copy of the Praecipe for Rule to File a Complaint via U.S. first-class mail, postage pre-paid, as follows: W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 SUSAN M. WILLIAMS ` - ? _; _ . < - - ?.;z -ft DAVIDSON M. BLACK, V. Plaintiff ROSE E. BREHM and JAMES BREHM, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION-LAW NO. 05-6388 JURY TRIAL DEMANDED RULE AND NOW, this??ay of 2006, upon consideration of the foregoing Praecipe, a Rule is hereby issued upon the laintiff, Davidson M. Black, to file a Complaint within twenty (20) days or suffer judgment of non pros. BY THE PROTHONOTARY: SEAL CASE NO: 2005-06388 P SHERIFF'S RETURN - REGULAR COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND BLACK DAVIDSON M VS BREHM ROSE E ET AL DAVID MCKINNEY , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within WRIT OF SUMMONS was served upon ROSE E the DEFENDANT , at 1510:00 HOURS, on the 28th day of December , 2005 at 212 PONDEROSA ROAD CARLISLE, PA 17013 ROSE by handing to a true and attested copy of WRIT OF SUMMONS together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 6.72 Postage .37 Surcharge 10.00 .00 35.09 Sworn and Subscribed to before me this day of uc l A.D. Pr o a So Answers: R. Thomas Kline 12/28/2005 HANDLER HENNING ROSENBERG By : Deputy Sheriff SHERIFF'S RETURN - REGULAR CASE NO: 2005-06388 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND K DAVIDSON M VS BREHM ROSE E ET AL DAVID MCKINNEY , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within WRIT OF SUMMONS was served upon BREHM JIM A/K/A JAMES BREHM the DEFENDANT at 1510:00 HOURS, on the 28th day of December , 2005 at 212 PONDEROSA ROAD CARLISLE, PA 17013 by handing to JAMES BREHM a true and attested copy of WRIT OF SUMMONS together with and at the same time directing His attention to the contents thereof. Sheriff's Costs Docketing 6.00 Service .00 Affidavit .00 Surcharge 10.00 .00 16.00 Sworn and Subscribed to before me this day of So Answers: R. Thomas Kline 12/29/2005 HANDLER HENNING ROSENBERG By: Deputy Sheriff SHERIFF'S RETURN - REGULAR CASE NO: 2005-06388 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND BLACK DAVIDSON M VS BREHM ROSE E ET AL DAVID MCKINNEY Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within WRIT OF SUMMONS SETCHELL ROSE E was served upon DEFENDANT the , at 1510:00 HOURS, on the 28th day of December , 2005 at 212 PONDEROSA ROAD ISLE, PA 17013 ROSE SETCHELL BREHM a true and attested copy of WRIT OF SUMMONS by handing to together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge So Answers: 6.00 .00 .00 10.00 R. Thomas Kline .00 16.00 12/29/2005 HANDLER HENNING ROSENBERG Sworn and Subscribed to before By: 1 me this 11 day of Deputy Sheriff 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 DAVIDSON M. BLACK, Plaintiff V. ROSE E. BREHM and JAMES BREHM, Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 05-6388 CIVIL ACTION - LAW 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 en las siguientes paginas, debe tomar acci6n dentro de los pr6ximos veinte (20) dias despues de la notificaci6n de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objecciones a, Ias demandas presentadas aqui en contra suya. Se le advierte de que si usted falla 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 en contra suya por la Corte sin mas aviso adicional. Usted puede perder dinero o propiedad u otros 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 HANDLER, HENNING & ROSENBERG, LLP By: 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 DAVIDSON M. BLACK, Plaintiff V. ROSE E. BREHM and JAMES BREHM, Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 05-6388 CIVIL ACTION - LAW JURY TRIAL DEMANDED COMPLAINT AND NOW, comes the Plaintiff, Davidson M. Black, by and through their attorneys, HANDLER, HENNING & ROSENBERG, LLP, by W. Scott Henning, Esquire, and makes the within Complaint against the Defendants, Rose E. Brehm and James Brehm, and in support thereof aver the following: 1. Plaintiff, Davidson M. Black, is a competent adult individual currently residing at 25 Penny Lane, Mounted Lane, Enola, Cumberland County, Pennsylvania 17025. 2. Defendant, Rose E. Brehm, is a competent adult individual currently residing at 212 Ponderosa Road, Carlisle, Cumberland County, Pennsylvania 17013. 3. Defendant, Jim Brehm, is a competent adult individual currently residing at 212 Ponderosa Road, Carlisle, Cumberland County, Pennsylvania 17013. J 4. At all times material hereto, Defendants were the owners of and/or had control and possession of an St. Bernard type dog that attacked and bit Plaintiff, Davidson M. Black, causing serious and permanent bodily injury. 5. Plaintiffs believe, and therefore aver, that Defendants knew or should have known about the dog's vicious propensities as it has shown aggressive tendencies and/or behavior toward other people previously to the incident involving Plaintiff, Davison M. Black, and had generally exhibited vicious propensities. 6. On or about December 16, 2003, Plaintiff, Davidson M. Black, was at the home of Defendants to meet with Defendants regarding a construction/remolding job. 7. At approximately the same time and date, Plaintiff, Davidson M. Black, was approaching the Defendants' front door and porch area when suddenly, without warning, the St. Bernard type dog charged out of the front door and attacked the Plaintiff inflicting bite wounds to the Plaintiff's left hand/wrist area, right hand and causing Plaintiff to fall while trying to fend off the dog whereby Plaintiff was harshly pushed to the ground by the weight of the large dog and sustained a strain/sprain injury and rotator cuff tear to his left shoulder, thereby necessitating immediate Emergency Room treatment. Plaintiff's footing and ability to brace himself against the lunging attack of the Defendants' dog was also inhibited by the icy conditions on the Defendants' premises. 8. At all times material hereto, Plaintiff, Davidson M. Black, was lawfully upon the Defendants' premises. 9. As a direct and proximate result of the negligence of Defendants, Jose M. Martinez and Susanna C. Martinez, Plaintiff, Davison M. Black, sustained the injuries -2- .. described above which required sutures and a protracted course of medical treatment. 10. The occurrence of the aforesaid incident and the resultant injuries sustained by Plaintiff, Davidson M. Black, were caused directly and proximately by the negligence of Defendants, James Brehm and Rose Brehm, generally and more specifically as set forth below: (a) In failing to properly secure the dog and in otherwise failing to restrain and control the animal, when the Defendants knew, or should have known, that the dog had a dangerous nature and vicious propensities; (b) In failing to provide warning by posting signs that the dog was present on said premises and to be wary of the dog, when the Defendants knew, or should have known of the dog's vicious tendencies; (c) In failing to take adequate precautions which may have prevented injury to the Plaintiff, Davidson M. Black, as a result of the dog's actions; (d) In failing to secure the dog in an area where anyone near or about the Defendants' premises would not be harmed or affected by the dog's actions, when the Defendants knew, or should have known of the dog's dangerous propensities; (e) In violating the various provisions of the Pennsylvania Dog Law, 3 P.S.§459-101 to 551 and 3 P.S. §459.502A; §459-504A; and §459- 505A;and -3- (f) In failing to take appropriate steps and measures to maintain the premises free from accumulation of ice and snow. 11. As a direct and proximate result of the negligence of Defendants, Plaintiff, Davidson M. Black, suffered serious injuries including, but not limited to injuries to his right and left hand/wrist, and his left shoulder which required immediate medical treatment. 12. As a direct and proximate result of the negligence of Defendants, Plaintiff, Davidson M. Black, has undergone great physical pain, discomfort, and mental anguish, and he may continue to endure the same for an indefinite period of time in the future to his great physical, emotional, and financial detriment and loss. 13. As a result of the negligence of Defendants, Plaintiff, Davidson M. Black, has been, and will in the future be, hindered from performing the duties required by his usual occupation and from attending to his daily duties and chores, to his great loss, humiliation and embarrassment. 14. As a result of the negligence of Defendants, Plaintiff, Davidson M. Black, has suffered lost wages and will in the future continue to suffer a loss of income and/or loss of earning capacity. 15. As a direct and proximate result of the negligence of the Defendants, Plaintiff, Davidson M. Black, has been compelled, in order to effect a cure for the aforesaid injuries, to expend large sums of money for medicine and medical attention. 16. As a direct and proximate result of the negligence of Defendants, Plaintiff, Davidson M. Black, has suffered a loss of life's pleasures, and may continue to suffer the same in the future to his great detriment and loss. -4- 17. Plaintiff, Davidson M. Black, believes, and therefore avers, that his injuries are permanent in nature, including permanent scarring. WHEREFORE, Plaintiff, Davidson M. Black, seeks damages from the Defendants, Rose E. Brehm and James Brehm, in an amount in excess of the compulsory arbitration limits of Cumberland County, plus costs and such further relief as this Court deems just. Respectfully submitted, & ROSENBERG, LLP Date: L C?? By: W. Scott H? (ing, squire Attorney I.D.# 32 ?98 1300 Linglesto Road Harrisburg, PA 17110 (717) 238-2000 Attorney for Plaintiff -5- VERIFICATION PURSUANT TO PA R.C.P. NO. 1024 (c) W. SCOTT HENNING, ESQUIRE, states that he is the attorney for the party filing the foregoing document; that he makes this affidavit as an attorney, because the party he represents is outside the jurisdiction of the Court and the Verification of the party cannot be obtained within the time allowed for filing this Pleading; the averments set forth herein are based upon information provided by the Plaintiffs; and that this statement is made subject to the penalties of 18 Pa C.S. §4904 relating to unsworn falsification to authorities. Date: / -27/ b W. SCOTT HENNING/ESWIRE DAVIDSON M. BLACK, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION - LAW NO. 05-6388 ROSE E. BREHM and JAMES BREHM, Defendants JURY TRIAL DEMANDED NOTICE TO PLEAD TO: Davidson M. Black, Plaintiff c/o W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 You are hereby notified to plead to the enclosed New Matter within twenty (20) days from service hereof or a default judgment may be filed against you. MARSHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN DATE: C6 BY: Attorneys for Defendants Rose E. Brehm and James Brehm 4200 Crums Mill Road, Suite B Harrisburg, PA 17112 (717) 651-3504 DAVIDSON M. BLACK, : IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION - LAW NO. 05-6388 ROSE E. BREHM and JAMES BREHM, Defendants JURY TRIAL DEMANDED ANSWER WITH NEW MATTER OF DEFENDANTS, ROSE E. BREHM AND JAMES BREHM, TO PLAINTIFF'S COMPLAINT AND NOW comes Defendants, Rose E. Brehm and James Brehm, by and through their counsel, Marshall, Dennehey, Warner, Coleman & Goggin, and file this Answer to Plaintiffs Complaint and in support thereof states as follows: 1. Admitted in part; denied in part. It is admitted that Plaintiff is who he says he is. All remaining allegations are denied and strict proof thereof is demanded at the time of trial. 2. Admitted in part; denied in part. It is admitted that Rose E. Brehm is a Defendant. The remaining averments set forth in this Paragraph are denied in accordance with Pa.R.C.P. 1029(e). 3. Admitted in part; denied in part. It is admitted that Jim Brehm is a Defendant. The remaining averments set forth in this Paragraph are denied in accordance with Pa.R.C.P. 1029(e). 4. Denied. The averments set forth in this Paragraph constitute conclusions of law to which no responsive pleading is required. To the extent a response is deemed required, the averments set forth in this Paragraph are denied in accordance with Pa.R.C.P. 1029(e). 16. Denied. The averments set forth in this Paragraph constitute conclusions of law to which no responsive pleading is required. To the extent a response is deemed required, the averments set forth in this Paragraph are denied in accordance with Pa.R.C.P. 1029(e). 17. Denied. The averments set forth in this Paragraph constitute conclusions of law to which no responsive pleading is required. To the extent a response is deemed required, the averments set forth in this Paragraph are denied in accordance with Pa.R.C.P. 1029(e). WHEREFORE, Defendants, Rose E. Brehm and James Brehm, respectfully request judgment in their favor and against the Plaintiff, together with such other costs this Honorable Court deems appropriate. NEW MATTER 18. Plaintiff has failed to state a cause of action against Defendants upon which relief can be granted. 19. No act or omission on the part of Defendants was a substantial or contributing factor in bringing about Plaintiffs alleged injuries and/or damages, all such injuries and/or damages being expressly denied. 20. Any and all injuries and or damages as described by Plaintiff in his Complaint, the same being expressly denied, were caused in whole or in part by the acts or omissions on the part of Plaintiff and/or others over whom Defendants had no control nor right of control. 21. Plaintiffs claims are derivative in nature and are barred as a matter of law. 22. Defendants breached no duty of care owed to Plaintiff under the circumstances. 23. Plaintiffs claims are barred and/or limited by the Pennsylvania Comparative Negligence Act. 4 24. Plaintiffs claims are barred and/or limited by the applicable provisions of the Pennsylvania Worker's Compensation Act. 25. At all times material hereto, Defendants acted in a safe, legal and non-negligent manner. 26. Plaintiffs claims are barred by the defenses listed in Pa.R.C.P. 1030. WHEREFORE, Defendants, Rose E. Brehm and James Brehm, respectfully request judgment in their favor and against the Plaintiff, together with such other costs this Honorable Court deems appropriate. MARSHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN DATE: 0, C> BY: D99ALD L.- ARMELITE, ESQUIRE YD No. 84730 4200 Crums Mill Road, Suite B Harrisburg, PA 17112 (717) 651-3504 Attorneys for Defendants Rose E. Brehm and James Brehm 5 VERIFICATION The undersigned hereby verifies that the statements in the foregoing Answer with New Matter to Plaintiffs Complaint are based upon information which has been furnished to counsel by me and information which has been gathered by counsel in the preparation of the defense of this lawsuit. The language of the Answer with New Matter to Plaintiffs Complaint is that of counsel and not my own. I have read the Answer with New Matter to Plaintiffs Complaint, 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 Answer with New Matter to Plaintiffs Complaint are that of counsel, I have relied upon my counsel in making this verification. The undersigned also understands that the statements therein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. BY: 4,4,- ROSE E. BREHM DATE: r. q. of VERIFICATION The undersigned hereby verifies that the statements in the foregoing Answer with New Matter to Plaintiffs Complaint are based upon information which has been furnished to counsel by me and information which has been gathered by counsel in the preparation of the defense of this lawsuit. The language of the Answer with New Matter to Plaintiffs Complaint is that of counsel and not my own. I have read the Answer with New Matter to Plaintiffs Complaint, 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 Answer with New Matter to Plaintiffs Complaint are that of counsel, I have relied upon my counsel in making this verification. The undersigned also understands that the statements therein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. BY: ?)9'Q.t. t &jl?l Lea . JAMES BREHM DATE: ?.160 CERTIFICATE OF SERVICE I, Susan M. Williams, an employee with the law firm of Marshall, Dennehey, Warner, Coleman & Goggin, do hereby certify that on this «th day of May, 2006, I served a true and correct copy of the Answer with New Matter of Defendants, Rose E. Brehm and James Brehm, to Plaintiffs Complaint via U.S. first-class mail, postage pre-paid, as follows: W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 SUSAN M. WILLIAMS c-? ? o c ,?, _ -?;4? ? ? -?,;?, _ N ? ?? ? `?? ?= ._ _T ?:i' -- ? -? „, _ s ._ ? ' C? a- ; ? w ? ? i =-? ?, 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: HenninaraWHRLaw.com DAVIDSON M. BLACK, : IN THE COURT OF COMMON PLEAS Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA V. ROSE E. BREHM and JAMES BREHM, CIVIL ACTION - LAW NEW MA AND NOW, comes the Plaintiff, Davidson M. Black, through his attorneys, HANDLER, HENNING & ROSENBERG. LLP, by W. Scott Henning, Esquire, and reply to Defendants' New Matter as follows: 18. Denied. .NThe allegation set forth in Paragraph 18 is a conclusion of law to which no responsive pleading is required, however, to the extent that the Honorable Court deems a response necessary, it is denied that the Plaintiff has failed to state a cause of action upon which relief can be granted, and proof to the contrary is demanded at the trial in this matter. 19. Denied. It is denied that there was not any act or omission on the part of the Defendants that was a substantial or contributing factor in bringing about the Plaintiffs injuries and damages, and proof to the contrary is demanded at the trial in this matter. 20. It is denied that the injuries and damages sustained by the Plaintiff as set : NO. 05-6388 forth in his Complaint were caused in whole or in part by the acts or omissions of the Plaintiff or other individuals over whom the Defendants had no control nor right of control, and proof to the contrary is demanded at the trial in this matter. 21. Denied. The allegation set forth in Paragraph 21 is a conclusion of law to which no responsive pleading is required, however, to the extent that the Honorable Court deems a response necessary, it is denied that the Plaintiffs claims are derivative in nature and/or are barred as a matter of law, and proof to the contrary is demanded at the trial in this matter. 22. Denied. It is denied that the Defendants did not breach a duty of care that was owed to the Plaintiff, Davidson Black, and proof to the contrary is demanded at the trial in this matter. 23. Denied. The allegation set forth in Paragraph 23 is a conclusion of law to which no responsive pleading is required, however, to the extent that the Honorable Court deems a response necessary, it is denied that the Plaintiffs claims are barred and/or limited by the Pennsylvania Comparative Negligence Act. By way of further answer, it is specifically denied that the Plaintiff was in any way contributorily or comparatively negligent, and proof to the contrary is demanded at the trial in this matter. 24. Denied. The allegation set forth in Paragraph 24 is a conclusion of law to which no responsive pleading is required, however, to the extent that the Honorable Court deems a response necessary, it is denied that the Plaintiffs claims are barred and/or limited by the Pennsylvania Workers' Compensation Act. 25. Denied. It is denied that the Defendants acted in a safe, legal and non-negligent manner, and proof to the contrary is demanded at the trial in this matter. 26. Denied. The allegation set forth in Paragraph 26 is a conclusion of law to which no responsive pleading is required. To the extent that other defenses listed in Pennsylvania Rule of Civil Procedure 1030 are applicable to the subject cause of action, the Plaintiffs demand proof of the same at the trial in this matter. WHEREFORE, Plaintiffs demand judgment against Defendants Rose E. Brehm and James Brehm, for the relief set forth in their Complaint. Respectfully submitted, HANDLER, HENNPW?,& ROSENBERG, LLP DATE W. Scott Henning, EXqu I.D. #32298 (j 1300 Linglestown Road Harrisburg, PA 17110 717-238-2000 Attorney for Plaintiffs DAVIDSON M. BLACK, IN THE COURT OF COMMON PLEAS Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. : NO. 05-6388 ROSE E. BREHM and JAMES BREHM, : CIVIL ACTION - LAW Defendants : JURY TRIAL DEMANDED CERTIFICATE OF SERVICE On the 17th day of May, 2004, 1 hereby certify that a true and correct copy of Plaintiffs Reply To New Matter was served upon the following by depositing in U.S. Mail; Donald L. Carmelite, Esq. Marshall, Dennehey, Warner, Coleman & Goggin 4200 Crums Mill Road, Suite B Harrisburg, PA 17112 DATE Respectfully submitted, W. Scott Henn' g, E I. D. #32298 1300 Linglest w Harrisburg, PA 1711 717-238-2000 Attorney for Plaintiff ROSENBERG,LLP VERIFICATION PURSUANT TO PA R.C.P. NO. 10241c1 W. SCOTT HENNING, ESQUIRE, states that he is the attorney for the party filing the foregoing document; that he makes this affidavit as an attorney, because the party he represents lacks sufficient knowledge or information upon which to make a verification and/or because he has greater personal knowledge of the information and belief than that of the party for whom he makes this affidavit; and that he has sufficient knowledge or information and belief, based upon his investigation of the matters averred or denied in the foregoing document; and that this statement is made subject to the penalties of 18 Pa C.S. §4904 relating to unsworn falsification to authorities. /1-"N Date:/ n ' _ T W. SCOTT H N9 I , ESQUIRE n ^? ?? a c: ?, -n -?, i; . n-,. rn? a ? Q ? -=-?, _? '<? r , ? - a CY! ^? M . '1 CASE NO: 2005-06388 P SHERIFF'S RETURN - REGULAR COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND BLACK DAVIDSON M VS BREHM ROSE E ET AL SHANNON SHERTZER Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within WRIT OF SUMMONS E DEFENDANT the , at 1130:00 HOURS, on the 3rd day of May , 2006 at 212 PONDEROSA ROAD CARLISLE, PA 17013 JAMES BREHM, HUSBAND was served upon by handing to a true and attested copy of WRIT OF SUMMONS together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 6.16 Postage .39 Surcharge 10.00 .00 34.55 Sworn and Subscribed to before me this I ?:(:4 day of A. D. Pro ota So Answers: leo?- R. Thomas Kline 05/04/2006 HANDLER HENNING ROSENBERG By: / W /1 Deputy heriff " N CASE NO: 2005-06388 P SHERIFF'S RETURN - REGULAR COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND BLACK DAVIDSON M VS BREHM ROSE E ET AL SHANNON SHERTZER , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within WRIT OF SUMMONS was served upon BREHM JIM A/K/A JAMES BREHM DEFENDANT the , at 1130:00 HOURS, on the 3rd day of May , 2006 at 212 PONDEROSA ROAD CARLISLE, PA 17013 by handing to JAMES BREHM a true and attested copy of WRIT OF SUMMONS together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 6.00 Service .00 Affidavit .00 Surcharge 10.00 nn 1 V . V V Sworn and Subscribed to before me this fday of Q? O?p A.D. Pro otary So Answers: R. Thomas Kline 05/04/2006 HANDLER HENNING ROSEINBERG By. I ! I Deputy S riff DAVIDSON M. BLACK, V. : IN THE COURT OF COMMON PLEAS OF Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA ROSE E. BREHM and JAMES BREHM, Defendants CIVIL ACTION - LAW NO. 05-6388 JURY TRIAL DEMANDED NOTICE OF SERVING DISCOVERY TO THE PROTHONOTARY: Please take notice that Defendants, Rose E. Brehm and James Brehm, served Interrogatories and Request for Production of Documents addressed to Plaintiff, Davidson M. Black, pursuant to the Pennsylvania Rules of Civil Procedure, by mail, postage prepaid, on the +`- day of , 2006. MARSHALL, DENNEHEY, WARNER, COLEMAN & G09G'11r% DATE: Co-6ovoo BY: CARMELITE, I.D. No. 84730 4200 Crums Mill Road, Suite B Harrisburg, PA 17112 (717) 651-3504 Attorney for Defendants CERTIFICATE OF SERVICE I, Susan M. Williams, an employee with the law firm of Marshall, Dennehey, Warner, Coleman & Goggin, do hereby certify that on this L;t4_? day of June, 2006, I served a true and correct copy of the Notice of Serving Discovery via U.S. first-class mail, postage pre-paid, as follows: W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 J I "?-, l ?d4l?t?\ SUSAN M. WILLIAMS C.J ° P O G C, 06146008 COMMONWEALTH OF PENNSYLV. COUNTY OF CUMBERLAND DAVIDSON M. BLACK VS. PLAINTIFF/S ROSE E. BREHM AND JAMES BREHM DEFENDANT/S COURT OF COMMON PLEAS NO. 05-6388 CERTIFICATE PREREQUISITE TO SERVICE OF A SUBPOENA PURSUANT TO RULE 4009.22 AS A PREREQUISITE TO SERVICE OF A SUBPOENA FOR DOCUMENTS AND THINGS PURSUANT TO RULE 4009.22, DEFENDANT CERTIFIES THAT (1) A NOTICE OF INTENT TO SERVE THE SUBPOENA WITH A COPY OF THE SUBPOENA ATTACHED THERETO WAS MAILED OR DELIVERED TO EACH PARTY AT LEAST TWENTY DAYS PRIOR TO THE DATE ON WHICH THE SUBPOENA IS SOUGHT TO BE SERVED; (2) A COPY OF THE NOTICE OF INTENT, INCLUDING THE PROPOSED SUBPOENA, IS ATTACHED TO THIS CERTIFICATE (3) NO OBJECTION TO THE SUBPOENA HAS BEEN RECEIVED, AND (4) THE SUBPOENA THAT WILL BE SERVED IS IDENTICAL TO THE SUBPOENA WHICH IS ATTACHED TO THE NOTICE OF INTENT TO SERVE THE SUBPOENA. DATE: 7/13/06 01226-01090 5132493916 B19 DAVIDSON M. BLACK VS. COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND PLAINTIFF/S ROSE E. BREHM AND JAMES BREHM DEFENDANT/S COURT OF CIMMON PLEAS NO. 05-6388 NOTICE OF INTENT TO SERVE A SUBPOENA TO PRODUCE DOCUMENTS AND THINGS FOR DISCOVERY PURSUANT TO RULE 4009.21 TO: W. SCOTT HENNING, ESQ. HANDLER, HENNING & ROSENBERG 1300 LINGLESTOWN RD. HARRISBURG PA 17110 ATTORNEY(S) FOR PLAINTIFF 06146008 12/25/06 DEFENDANT INTENDS TO SERVE A SUBPOENA IDENTICAL TO THE ONE THAT IS ATTACHED TO THIS NOTICE TO THE DEPONENT/S LISTED BELOW, REQUESTING RECORDS BE PRODUCED AT RECORD COPY SERVICES, 1880 JOHN F. KENNEDY BLVD., PHILADELPHIA, PA 19103. YOU HAVE TWENTY (20) DAYS FROM THE DATE LISTED BELOW IN WHICH TO FILE OF RECORD AND SERVE UPON THE UNDERSIGNED AND RECORD COPY SERVICES (215-241-5858), AN OBJECTION TO THE SUBPOENA. IF NO OBJECTION IS MADE THE SUBPOENA/S MAY BE SERVED. CARLISLE REGIONAL MEDICAL CENTER DR. ALLAN J. MIRA, M.D. CENTRAL PENN MEDICAL GROUP INDIV. & CUST OF THE RECDS OF DR. ROBERT LASEK DATE: 6/15/06 DONALD L. CARMELITE, ESQ. MARSHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN 4200 RUMS MILL RD. HARRISBURG PA 17112 ATTO Y(S) FOR DEFENDANT A.N 06146008 .12/25/06 COFtIONWEALTH OF PENNSYLVANIA OOUNPY OF CI 90U AND DAVIDSON M. BLACK Vs ROSE E. BREHM AND JAMES BREHM File No., Court of Common Pleas 05-6388 SU113POENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RUUL9.22 MEDICAL RECORDS DEPARTMENT CARLISLE REGIONAL MEDICAL CENTER 246 PARKER ST. TO: P.O. BOX 310 CARLISLE PA 17013 of Person or Ent Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents or things: SEE ATTACHED ADDENDUM at RECORD COPY SERVICES, 1880 JOHN F. KENNEDY BLVD., S-300, PHILADELPHIA, PA. (Address) You may deliver or mail legible copies of the documents or produce things requested by this subpoena, together with the certificate of carpliance, to the party making this request at the address listed above. You have the right to seek in advance the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the doc rents or things required by this subpoena within twenty (20) days after its service, the party serving this subpoena may seek a court order campelling you to omply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING? PERSON: NAME: DONALD L. CARMELITE, ESQ. ADDRESS: TELEPHONE: FOR INFORMATION: (215) 241-5858 SUPREME COURT ID # ATTORNEY FOR:DEFENDANT DATE: til Lqd sea] of the Court 1 Division Deputy BY THE OOURT: (Eff. 7/97) 06-14-ZD06 09:36 From-MARSHALL DENNEHEY +7172321549 T-552 P.003/003 P-659 PAGE 2 OF 2 Instructions for MEDICAL records: Any and all medical records, including, but not limited to, physical therapy records, rehab records, lab reports, reports regarding x-ray films, MRis, CT scans, or other diagnostic testing performed, together with all medical reports, notes, memoranda, correspondence and medical bills concerning Davidson M. Black; Date of Birth: 1118145; Social Security No. 168-36-3263. (No actual films need to produced at this time; however, we may require films at a later date.) N 2/25/06 COFMJNWmxii OF PE[Il?SYLVANIA cOUNTY OF Ci14BER AM DAVIDSON M. BLACK Vs ROSE E. BREHM AND JAMES BREHM File No. Court of Common Pleas 05-6388 SUBPOENA TO PRODUCE DOCUMENTS OR TH 1 NOS FOR DISCOVERY PURSUANT TO RULE 4009.22 CUSTODIAN OF THE RECORDS OF DR. ALLAN J. MIRA, M.D. 220 WILSON ST. S-206 TO: CARLISLE PA 17013 (Name of Person or Entity)I Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents or things: SEE ATTACHED ADDENDUM at g9ro n COPY SERVICES, 1880 JOHN F. KENNEDY BLVD., S-300, PHILADELPHIA, PA. (Address) You may deliver or mail legible copies of the docuamts or produce things requested by this subpoena, together with the certificate of ompliance, to the party making this request at the address listed above. You have the right to seek in advance the reasonable cost of preparing the copies or producing the things sought.. If you fail to produce the documents or things required by this subpoena within twenty (20) days after its service, the party serving this subpoena may seek a court order cmpel l irg you to ccnply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME:DONALD L. CARMELITE, ESQ. ADDRESS: TELEPHONE:FOR INFORMATION: (215) 241-5858 SUPREME COURT ID # ATTORNEY FORDEFENDANT DATE: ? fq?1fo Seal of the court (Eff. 7/97) 06-14-2006 09:36 From-MARSHALL DENNEHEY +7172321849 T-552 P.003/003 F-66S PAGE 2 OF 2 Instructions for MEDICAL records: Any and all medical records, including, but not limited to, physical therapy records, rehab records, lab reports, reports regarding x-ray films, MRls, CT scans, or other diagnostic testing performed, together with all medical reports, notes, memoranda, correspondence and medical bills concerning Davidson M. Black; Date of Birth: 1118145; Social Security No. 168.36.3263. (No actual films need to produced at this time; however, we may require films at a later date.) . 01460 112/25/06 COI*UNWEALTH 00 PENISMVMM OO(1N'lY OF CLIMEEMAND DAVIDSON M. BLACK Vs. File No.l ROSE E. BREHM AND JAMES BREHM TO: Court of Common Pleas 05-6388 SUBPOENA TO PRODUCE DOCIJrENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 THE RECORDS OF MEDICAL GROUP INDIV. 6 CUST OF THE RECDS OF DR. ROBERT LASEK CARLISLE PA 17013 Person or Ent Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following doo meats or things: SEE ATTACHED ADDENDUM at RECORD COPY SERVICES, 1880 JOHN F. KENNEDY BLVD., 5-300 (Address) You may deliver or mail legible copies of the docunen s or produce things requested by this subpoena, together with the certificate of caTp'iance, to the party making this request at the address listed above. You have the right to seek in advance the reasonable cost of preparing the copies or producing the things soughta if you fail to produce the docunents or things required by this subpoena within twenty (20) days after its service, the party serving this subpoena may seek a court order ccrtpellirg you to cenply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: DONALD L. CARMELITE, ESQ. ADDRESS: TELEPHONE: FOR INFORMATION: (215) 241--3858 SUPREME OOURT ID ATTORNEY FOR: DEFENDANT DATE: (,'-I q -06 Seal of the Court (Eff. 1/97) 06-+4-2006 08:36 From-MARSHALL DENNEHEY +717232164 T-552 p.003/DDS 7-666 PAGE 2 OF 2 Instructions for MEDICAL records: Any and all medical records, Including, but not limited to, physical therapy records, rehab records, lab reports, reports regarding x-ray films, MRls, CT scans, or other diagnostic testing performed, together with all medical reports, notes, memoranda, correspondence and medical bills concerning Davidson M. Black; Date of Birth: 1118145; Social Security No. 168-363263. (No actual films need to produced at this time; however, we may require films at a later date.) CERTIFICATE OF SERVICI i I, Susan M. Williams, an employee with the law firm of Marshall, Dennehey, Warner, Coleman & Goggin, do hereby certify that on this 1ST day of July, 2006, I served a true and correct copy of the Certificate-Prerequisite to Service of a Subpoena Pursuant to Rule 4009.22 via U.S. first-class mail, postage pre-paid, as follows: W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 SUSAN M. WILLIAMS Y?? ? l (?1 Yi ?. ? (_ . `. ? (?. ? '. _ l ( 4 ` .r .+: (r .` I DAVIDSON M. BLACK, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA V. CIVIL ACTION - LAW NO. 05-6388 ROSE E. BREHM and JAMES BREHM, Defendants JURY TRIAL DEMANDED MOTION OF DEFENDANTS, ROSE E. BREHM AND JAMES BREHM, TO COMPEL DISCOVERY RESPONSES FROM PLAINTIFF Defendants, Rose E. Brehm and James Brehm, (hereinafter "Defendants"), by and through their counsel, Marshall, Dennehey, Warner, Coleman and Goggin, hereby move this Honorable Court to compel Plaintiff, Davidson M. Black, (hereinafter "Plaintiff') to respond to Defendants' Interrogatories and Request for Production of Documents and in support thereof asserts the following: 1. On or about December 15, 2005, Plaintiff instituted this action by filing a Praecipe for Writ of Summons in the Court of Common Pleas of Cumberland County, Pennsylvania. 2. On or about April 26, 2006, Plaintiff filed a Complaint against Defendants, Rose E. Brehm and James Brehm. 3. On or about May 12, 2006, Defendants filed an Answer with New Matter to Plaintiffs Complaint. 4. On or about June 6, 2006, Defendants served Plaintiff with Interrogatories and Request for Production of Documents. (A true and correct copy of Defendants' Interrogatories and Request for Production of Documents are attached hereto as Exhibit "A".) S ? • a { 5. On or about September 20, 2006, counsel for Defendants reminded counsel for Plaintiff that he had not responded to written discovery. (A true and correct copy of this correspondence is attached hereto as Exhibit "B".) 6. To date, Plaintiff has failed to respond, either by Answer or Objection, to Defendants' Interrogatories and Request for Production of Documents. 7. The Pennsylvania Rules of Civil Procedure, specifically Rules 4006 and 4009.12, require the party upon whom Interrogatories and Request for Production of Documents is served to file Answers and/or Objections within thirty (30) days from the receipt of said discovery requests. 8. Under the Pennsylvania Rules of Civil Procedure, Plaintiff should have responded to Defendants' Interrogatories and Request for Production of Documents on or about July 6, 2006. 9. Plaintiff has failed to answer or otherwise respond to Defendants' discovery requests and hence is in violation of the foregoing Rules of Civil Procedure. 10. Therefore, Defendants, Rose E. Brehm and James Brehm , request that this Court enter an Order compelling Plaintiff to provide full and complete Answers to the Interrogatories and to provide full and complete Responses to the Request for Production of Documents at the risk of such further sanction in the event of further non-compliance as this Court may deem appropriate. 11. Defendants believe that Plaintiff does not concur with this Motion due to Plaintiffs failure to respond to counsel's September 20, 2006 correspondence attached hereto as Exhibit "B." 2 a WHEREFORE, Defendants, Rose E. Brehm and James Brehm, hereby move this Honorable Court to issue an Order compelling Plaintiff to respond to Defendants' Interrogatories and Request for Production of Documents within twenty (20) days or suffer sanctions upon further application to this Court. Respectfully submitted, MARSHALL,R?T EHE ARNER, COLEMA GO GIN'"I DATE: 1?I?D? BY: 3 DO&ALD L.TARIGIELITE, ESQUIRE I.D. No. 84730 4200 Crums Mill Road, Suite B Harrisburg, PA 17112 (717) 651-3504 Attorney for Defendants I EXhlblf ?1 DAVIDSON M. BLACK, Plaintiff V. ROSE E. BREHM and JAMES BREHM, . Defendants ? s IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 05-6388 JURY TRIAL DEMANDED INTERROGATORIES OF DEFENDANTS. ROSE E. BREHM AND JAMES BREHM, ADDRESSED TO PLAINTIFF Defendants, Rose E. Brehm and James Brehm, by their counsel, Marshall, Dennehey, Warner, Coleman & Goggin, propounds the following Interrogatories upon the Plaintiff, Davidson M. Black, to be answered under oath, within thirty (30) days after service hereof. Definitions. -- The following definitions are applicable to these interrogatories: "Document" means any written, printed, typed, or other graphic matter of any kind or nature, however produced or reproduced, including photographs, microfilms, phonographs, video and audio tapes, punch cards, magnetic tapes, discs, data cells, drums, and other data compilations from which information can be obtained. "Identify" or "Identity" means when used in reference to -- (1) A natural person, his or her: (a) Full name; and (b) Present or last known residence and employment address (including street name and number, city or town, and state or county); (2) A document: (a) Its description (e.g., letter, memorandum, report, etc.), title, and date; (b) Its subject matter; (c) Its author's identity; (d) Its addressee's identity; (e) Its present location; and (fl Its custodian's identity; (3) An oral communication: (a) Its date; (b) The place where it occurred; (c) Its substance; (d) The identity of the person who made the communication; (e) The identity of each person to whom such communication was made; and (f) The identity of each person who was present when such communication was made; (4) A corporate entity: (a) Its full corporate name; (b) Its date and place of incorporation, if known; and (c) Its present address and telephone number; (5) Any other context: A description with sufficient particularity that the thing may thereafter be specified and recognized, including relevant dates and places, and the identification of relevant people. entities, and documents. "Incident" or "accident" means the occurrence that forms the basis of a cause of action or claim for relief set forth in the complaint or similar pleading. 2 "Person" means a natural person, partnership, association, corporation, or governmental agency. Instructions. -- The following instructions are applicable to these interrogatories: (1) Duty to answer. -- The interrogatories are to be answered in writing, verified, and served upon the undersigned within thirty (30) days of their service on you. Objections must be signed by the attorney making them. In your answers, you must furnish such information as is available to you, your employees, representatives, agents, and attorney. Your answers must be supplemented and amended as required by the Pennsylvania Rules of Civil Procedure. (2) Claim of privilege. -- With respect to any claim of privilege or immunity from discovery, you must identify the privilege or immunity asserted and provide sufficient information to substantiate the claim. (3) Option to produce documents. -- In lieu of identifying documents in response to these interrogatories, you may provide copies of such documents with appropriate references to the corresponding interrogatories. These Interrogatories shall be deemed to be continuing and any information secured subsequent to the filing of answers, which would have been includable in the answers had it been known or available, shall be supplied by supplemental answers as soon as such information becomes known or available, and in all events, prior to the trial of this action, pursuant to Pa. R.C.P. 4007.3. 3 a. INTERROGATORIES 1. State: (a) (b) (c) (d) (e) M (9) Your full name; Any other names you have used or been known by, Your marital status at the time of the accident; Your present marital status; Your present home address; Your Social Security number; and Your date and place of birth. 4 2. If you have not fully recovered from your injuries, state in what respects you are still affected by them. 5 3. State the names and addresses of all hospitals, clinics, nursing homes or other institutions in which you have been confined or received out-patient treatment because of this accident. List dates of confinement and out-patient treatments, the charges for same and the amount that has been paid. 6 t 4. State the names and addresses of all doctors, nurses and therapists who have examined, treated or rendered services to you, whether in a hospital or elsewhere, because of this accident. State the dates on which the examinations, treatments or services were rendered and identify the place where rendered, whether at home, in the doctors office, in a hospital or elsewhere, the charges for same and the amount of each charge that has been paid. 5. When, where and by whom were you last examined or given medical attention for the injuries received in this accident? 6. Are you claiming loss of earnings from any employer because of this accident? If so, state: (a) The amount of such loss; (b) The nature of your employment immediately prior to the accident; (c) The name and address of your employer immediately before and at the time of the accident and whether you are still employed by him. If not, state the date and reasons you left his employ; (d) The names and addresses of all employers you have worked for since the accident and the dates of such employment; (e) The dates you were absent from your employment by reason of the injuries sustained in this accident; (f) Whether you were paid by the year, month, week, day, hour or otherwise, at what rate, and whether you were paid for any of the periods mentioned in the interrogatory sub-part above; (g) The date you returned to work after the accident; (h) The names and addresses of all employers for two years preceding this accident and the respective dates of such employment; state reasons for the termination of such employment in any instance; and (i) Your gross and net income as stated in your Federal Income Tax Returns for each of the three years immediately preceding the date of the accident and for each of the years thereafter to date. 9 S . a 7. At the time of the occurrence, were you self-employed. If so, state: (a) The nature, location and business name of such self-employment, and the length of time you have been so self-employed; (b) The dates you were unable to engage in your self-employment by reason of the injuries sustained in this accident; (c) The names and addresses of any employees hired s a result of your disability, the dates of such employment and the amount of money paid to each such employee; (d) The amount of your lost earnings; (e) Your gross and net income as stated in your Federal Income Tax Returns for each of the three years immediately preceding the date of the incident and for each of the years thereafter to date; and (f) The date you resumed activity in your self-employment after the accident. 10 . a • a f s 8. Did you sustain financial losses as a result of the accident other than those covered by the preceding interrogatory. If so, state in detail the nature, dates and amounts of such additional losses. If claim is made for household help, state the name and address of each such person employed, the period of employment and the amount actually paid to such person, and whether such person has been employed by you prior to the accident and for what period. 11 9. Have you ever been involved in an accident of any kind before or after the accident upon which this suit is based, in which the same part or parts of your body were injured as alleged in this suit? If so, state the place and date on which it occurred, the names and addresses of all persons involved, and, in detail, the injuries sustained by you; state the court, term and number of any suit which you commenced for the recovery of damages for such injuries. 12 10. State the name, home address and business address of the following individuals: (a) All persons known to you (or known to any person acting on your behalo who actually saw all or any part of the accident; and (b) All persons known to you (or known to any person acting on your behalo who were present at or near the scene at the time of the accident. 13 11. Do you or any representative, agent or employee have any statement (signed or unsigned), diagram, report, and/or photographs in your possession from any other party, witnesses or persons at or near the scene at the time of or after the accident. If so, state: (a) The name, address, and telephone number (work or home) of each individual; and (b) Attach copied of said statements, diagrams, reports and photographs to your answers. 14 1 ? 12. State in detail all injuries you sustained in the accident upon which this suit is based. 15 13. Prior or subsequent to the accident alleged in this action, did you ever suffer any injury, sickness, disease or abnormality involving any part or function of the body alleged to have been injured in this suit? (a) If so, state when, where, under what circumstances, and the nature of such injury, sickness, disease or abnormality, and (b) If any suit was commenced for the injuries sustained, state the names and addresses of all persons involved, and the court, term and number of such suit. 16 14. State as precisely as possible where on said premises said incident or occurrence took place. 17 15. Have you ever been bitten or attacked by an animal before this incident? If so, state forth details. 18 16. State whether, at the time of said occurrence the dog was tied or chained to any object in any fashion. 19 17. State whether, just prior to this occurrence the dog was engaged in eating or consuming food, a bone, or other edibles provided for him. 20 18. State whether there were other dogs or other animals of any type on the premises or near the dog at the time of this incident or occurrence, and if so, identify and describe each one. 21 19. State what activity the plaintiff was engaged in just prior to this occurrence as precisely as possible. 22 20. State whether there were children on the premises or in the area of the dog and if so, please give the name and address and age of each one. 23 21. State whether, to your knowledge, the dog had any deformity, illness or disease of any kind. 24 22. Do you allege that you are entitled to damages for any medical expenses arising out of the care and treatment that was rendered by any medical care providers for injuries you allegedly sustained as a result of the accident in question? (a) If so, please enter the names of the medical care providers who rendered these services in Column A of the accompanying chart. (b) Please enter the total amount of charges for each medical care provider in Column B of the accompanying chart. (c) Please regard this as a Request for Production of Documents to attach copies of all medical bills/invoices for the treatment rendered due to the injuries alleged in the Complaint and reflected in the amounts claimed in Column B. 25 23. Do you have any health insurance? If so, have you submitted medical bills related to this accident to your health care insurer? If not, why were these medical bills not submitted to your health care insurer? 26 24. Did any form of medical insurance (including Medicare or Medicaid) pay any portion of Plaintiff s alleged medical expenses? (a) If so, please state the name of the insurer, the address and the policy numbers of the medical insurance which paid any portion of Plaintiff's alleged medical expenses. (b) Please enter the total amount of the medical expenses for each provider that was paid by any insurance carrier in Column C of the accompanying chart. (c) Please regard this as a Request for Production of Documents to attach copies of any receipts showing amounts paid by medical insurers reflecting the amounts paid in Column C. 27 ,. 25. Were any of Plaintiff's medical expenses "written off', forgiven or otherwise not owed by reason of a contract or agreement between the medical care provider and Plaintiff's medical insurer as a compromise of a bill between the medical care provider and the Plaintiff or for any other reason? (a) Please enter in Column D of the accompanying chart the amount of the medical expenses that were "written off' or forgiven or otherwise not owed by reason of a contract between the health care provider and Plaintiffs medical insurer as a compromise of a bill between the medical care provider and the Plaintiff or for any other reason. 28 26. Were or are any of your medical expenses personally owed or owing by Plaintiff or his or her representatives and, therefore, not paid by Plaintiff s insurance carrier and/or "written off', forgiven or otherwise not owed with respect to any medical care provided by any medical care providers who provided care for the Plaintiff who is claiming damages? (a) Please enter in Column E of the accompanying chart the amount of the medical expenses that were or are personally owed by Plaintiff or his or her representatives and therefore not paid by Plaintiff s insurance carrier and/or "written off', forgiven or otherwise not owed with respect to any medical care provided by any medical care providers who provided care for which Plaintiff is claiming damages. A Medical Care Provider B Total Medical Charges for Each Medical Care Provider C Amount of Medical Charges Paid by Plaintiffs Insurance D Amounts "Written Off", Forgiven or Otherwise Not Owed E Amounts Paid or Owed by Plaintiff or His or Her Representatives Personally (i.e. not paid by insurance and written of 29 A B C D E Medical Care Total Medical Amount of Amounts Amounts Paid Provider Charges for Each Medical Medical Charges Paid by "Written Off", Forgiven or or Owed by Plaintiff or His Care Provider Plaintiffs Otherwise Not or Her Insurance Owed Representatives Personally (i.e. not paid by insurance and written of MARSHALL, DENNEHEY, WARNER, COLEMAN & GOIGGIN DATE: BY: ' DO ALD L. CARMELITE, ESQUIRE I.D. No. 84730 4200 Cruets Mill Road, Suite B Harrisburg, PA 17112 (717) 651-3504 Attorney for Defendants 30 CERTIFICATE OF SERVICE I, Susan M. Williams, an employee with the law firm of Marshall, Dennehey, Warner, ? day of June, 2006, I served a true and Coleman & Goggin, do hereby certify that on this ?* correct copy of the Interrogatories of Defendants, Rose E. Brehm and James Brehm, Addressed to Plaintiff via U.S. first-class mail, postage pre-paid, as follows: W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 n Q .oiM SUSAN M. WILLIAMS DAVIDSON M. BLACK, V. ROSE E. BREHM and JAMES BREHM, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 05-6388 Defendants JURY TRIAL DEMANDED REQUEST FOR PRODUCTION OF DOCUMENTS OF DEFENDANTS, ROSE E. BREHM AND JAMES BREHM, ADDRESSED TO PLAINTIFF PLEASE TAKE NOTICE that you are hereby requested to produce for inspection and other purposes, including copying, pursuant to the Pennsylvania Rules of Civil Procedure, at the office of the counsel for the requesting party, or at such other location as may be mutually agreeable between counsel for you and counsel for the requesting party, not less than thirty (30) days after service of these requests, documents herein cited. The word "document" or "documents" as herein used includes but is not limited to photographs, video tapes, drawings, reports, statements and memoranda, as well as all other documents as defined in the Rules. 1. All medical bills, reports, records, and x-rays, relating to the injury allegedly sustained in the occurrence described in the Complaint, as well as all medical bills, records, and reports relating to prior or subsequent injuries to the same parts of the body claimed by Plaintiff to have been injured in the occurrence described in the Complaint. 2. All employee reports, records, tax returns, attendance records, and wage statements relating to the claim of loss of income as a result of the occurrence in Plaintiff s Complaint. 3. Copies of all statements, memoranda, summaries of other writings, documents, diagrams and pictures obtained from your investigation, your insurance company's investigation, or your attorney's investigation into the incident involved. (You need not supply any attorney's "work product" or other material which is specifically accepted as privileged by the above Rules). 4. All documents in your possession, custody or control prepared in anticipation of litigation or trial of this case, except those documents which disclose the mental impressions of your attorney or your attorney's conclusions, opinions, memoranda, notes or summaries, legal research or legal theories, and except those documents prepared in anticipation of litigation by your representatives to the extent that they would disclose the representatives' mental impression, conclusions or opinions respecting the value or merit of the claim or defense. To the extent that you have not already provided the same in response to previous requests herein, all statements obtained from any witnesses or memoranda of conversations with witnesses or recordings of witnesses' statements, memoranda, or recordings made by parties to this lawsuit or their representative. 6. To the extent not already provided in response to previous requests herein, all statements made by any party to this action, including written statements signed or otherwise adopted or approved by the person making it or stenographic, mechanical, electrical, or other recording or transcription thereof, which is a substantially verbatim recital of an oral statement 2 and contemporaneously recorded, as allowed by Pennsylvania Rules of Civil Procedure No. 4003.4. 7. To the extent that you have not already provided the same, copies of all records, documents and memoranda, which have any bearing upon the matters alleged against the requesting party or upon the responsibility of the requesting party for the matters alleged against the requesting party. 8. To the extent not already provided, all reports of those experts who are to be called by you as witnesses at trial, which reports made or secured by you in connection with your investigation of the matters relating to this lawsuit. 9. To the extent not already provided, copies of all experts' reports made or secured by you in connection with your investigation of the matters relating to this lawsuit. 10. To the extent not already provided, all photographs, diagrams, maps, surveys, plans and models of the site of the incident in question that are in your possession. 11. To the extent not already provided, all documents containing the names and addresses of witnesses or potential witnesses with the exception of material described above, specifically correspondence privileged by the above rules. 12. To the extent not already provided, copies of all exhibits which you intend to offer into evidence at the trial of this matter. 13. To the extent not already provided in response to one or more of the foregoing requests, copies of your Individual and/or if applicable Joint Tax Returns filed with the United States Department of Revenue, Internal Revenue Service and Commonwealth of Pennsylvania Department of Revenue for the tax years 2000 through 2005, inclusive. MARSHALL, DENNEHEY, WARNER, COLEMAN & GOGGIN DATE: BY: D . CARMEL , ESQUIRE I.D. No. 84730 4200 Crums Mill Road, Suite B Harrisburg, PA 17112 (717) 651-3504 Attorney for Defendants 4 CERTIFICATE OF SERVICE I, Susan M. Williams, an employee with the law firm of Marshall, Dennehey, Warner, Coleman & Goggin, do hereby certify that on this day of June, 2006, I served a true and correct copy of the Request for Production of Documents of Defendants, Rose E. Brehm and James Brehm, Addressed to Plaintiff via U.S. first-class mail, postage pre-paid, as follows: W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 SUSAN M. WILLIAMS LOIN+ B DENNEHEY, N. A P R O F E S S 1 0 N A L C O R P O R A T I O N A REGIONAL DEFENSE LITIGATION LAW FIRM PMNSYLVANU Coi EMAN GoGGIN Bethlehem Doylestown Erie www.mmhaff&nnehey.com Harrisburg King ofPrusr Philadelphia Pittsburgh Scranton Williamsport NEw j"_M Cherry Hill Roseland 4200 Crums Mill Road, Suite B - Harrisburg, PA 17112 (717) 651-3500 - Fax (717) 651-9630 Direct Dial: 717-651-3504 Email: dlcarmelite@mdwcg.com DRtwwARR Wilmington 01¢0 Akron FLORIDA Ft. Lauderdale Jacksonville Orlando Tampa September 20, 2006 W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 RE: Davidson M. Black v. Rose E. Brehm and James Brehm CCP (Cumberland County) No. 05-6388 Our File No.: 01226-01090.A42 Dear Mr. Henning: On or about June 6, 2006, I served Interrogatories and Request for Production of Documents addressed to your client in the above-referenced matter. To date, I still have not received responses to my discovery requests. At your earliest convenience, please advise as to when I can expect to receive your discovery responses. Thank you for your attention and anticipated cooperation in this matter. DLC:smw CERTIFICATE OF SERVICE I, Susan M. Williams, an employee with the law firm of Marshall, Dennehey, Warner, Coleman & Goggin, do hereby certify that on this day of October, 2006, I served a true and correct copy of the Motion of Defendants, Rose E. Brehm and James Brehm, to Compel Discovery Responses from Plaintiff via U.S. first-class mail, postage pre-paid, as follows: W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 SUSAN M. WILLIAMS C 'tt ill C-n r-z DAVIDSON M. BLACK, Plaintiff VS. ROSE E. BREHM and JAMES BREHM, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 05-6388 CIVIL : JURY TRIAL DEMANDED IN RE: DEFENDANTS' MOTION TO COMPEL ORDER AND NOW, this 2 " day of November, 2006, a rule is issued on the plaintiff to show cause why the relief requested in the within motion ought not to be granted. This rule returnable twenty (20) days after service. BY THE COURT, V ? DAVIDSON M. BLACK, V. ROSE E. BREHM and JAMES BREHM, ORIGINAL IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 05-6388 Defendants : JURY TRIAL DEMANDED PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: Donald L. Carmelite, Esquire, counsel for Defendants in the above action, respectfully represents that: 1. The above-captioned action is at issue. 2. The claim of the Plaintiff in the action is $50,000. There is no counterclaim. The following attorneys are interested in the case as counsel or otherwise disqualified to sit as arbitrators: None. WHEREFORE, your Petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. Respectfully submitted, , WARNER, DATE: BY: D ALD L. C TE, ESQUIRE I.D. No. 84730 1 4200 Crums Mill Road, Suite B Harrisburg, PA 17112 (717) 651-3504 Attorney for Defendants JAMMIN Y CERTIFICATE OF SERVICE I, Susan M. Williams, an employee with the law firm of Marshall, Dennehey, Warner, Coleman & Goggin, do hereby certify that on this ZV day of September, 2007, I served a true and correct copy of the Petition for Appointment of Arbitrators, via U.S. first-class mail, postage pre-paid, as follows: W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 r SUSAN M. WILLIAMS 00 ?i PR b ze 9a c? to rn X24 F"je A - . DAVIDSON M. BLACK, V. ROSE E. BREHM and JAMES BREHM, IN THE COURT OF COMMON PLEAS OF Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 05-6388 Defendants : JURY TRIAL DEMANDED ORDER OF COURT AND NOW, this A;a day of 2007, in consideration of the foregoing Petition, , Esquire, and a' sLYV/" _J?' quire, and U . 00 Esquire, are appointed arbitrators in the above-captioned action as prayed for. By theCJ. ? •,n9• . f1?4- DAVIDSON M. BLACK, PLAINTIFF V. ROSE E. BREHM, ET AL., DEFENDANTS COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 05-6388 CIVIL TERM ORDER OF COURT AND NOW, this '? day of November, 2007, the appointment of Stephen J. Hogg, Esquire, to the Board of Arbitrators in the above-captioned cases, IS VACATED. Joseph A. Ricci, Esquire, is appointed in his place. By the Co Joseph A. Ricci, Esquire Cu,.,C_•! 11"Isay, ? Court Administrator :sal Edgar B. , rr 'ES Mkt LSCL /0 7 .C I . ... o .l ?1 c-' W. Scott Henning, Esquire I.D.#32998 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 (717) 238-2000 Attorneys for Plaintiff DAVIDSON M. BLACK, Plaintiff V. ROSE E. BREHM and JAMES BREHM, Defendants : IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 05-6388 : 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 Carlisle Regional Medical Center; 12/16/2003 and 12/30/2003 2. Medical Records from Mira Orthopedics;and 01/05/2004 3. Medical expense billing summary (with corresponding billing statements). Respectfully HENNINO A RO Date: November 8, 2007 By W. Scott Henningo I.D. #32298 ??// 1300 Linglestown Rc Harrisburg, PA 1711 (717) 238-2000 Attorney for Plaintiff , LLP MEOICAC CENTER C-*? ?46 Parker St. Carlisle, PA 17013 Ph:717-249-1212 AOMIT DATE /TIME ROOM 1 12/16/2003 16:15 0000 PATI NT NAM &''ADDRESS BLACK, DAVE 2'S PENNY >LANE ENOLA'SLE PA 1702 US PA Y A RESPONSIBLE BLACK, DAVE ''25 PENNY LANE JENOLASLE PA 17025 US EMERGENCY CONTACT NAME WOLFE, CHAROLETTE rq'r L11 1 INSURANCE CO. NAME & ADDRESS N N 3 a PAYER 1 W§G RA E NAME & A DDRESS :C r E M DR. A ENDING I ADMITTING CORDLE, RANDOLPH S Y DIAGNOSIS SIGN91-VIRMW C ANIMAL BITE IRINCIPAL DIAGNOSIS (The condition established after study to be xcasioning the admission of the patient to the HOSPITAL for care). COMPLICATIONS -OMORBIDITY(IES) ?RINCIPAL PROCEDURE ADMISSION RECORD r ,.;COUNT N0. M 5115 i 9270'1'62 00010283231 PT FC AGE DATE OF BIRTH SEX RA MS LOCATION 1 PROGRAM E1 P 58 01/18/1945 M 1 S ? NS _. _ _ _ W-NUMBER 168-36-3263 PATIENT MPL YER SELF, DAVE BLACK REPAIR EMP7YY €R PHHO N E NO. (717)691-0199 HONE NUMBER COLNTY (717)691-0199 CUMBERLAND' S NUMBER RESPONSIBLE PARTY EMPLOYER PHONE EMPLOYER SELF, DAVE BLACK REPAIR 168-36-3263 25 PENNY LANE (717)691-0199 ENOLA PA 1 7 0 2 5 HONE NUMBER RELATIONSHIP 0 PATIENT (717)691-0199 PATIENT IS G MERGENCY CONTACT PHONE EMERGENCY CONTACT RELATIONSHIP TO PATIENT (717)243-7354 FRIEND M SP MED. KEY PRIVACY ADMIT. BY ?Y (NN ?Y MN , ' EDW NONSTAFF, PHYSICIAN ACCIDENT ACCIDENT A OTHER 112/16/2003 AD001A 9270162 0001026323 IIIIIIIIIIIIIINIIIIIIIIIIIIIIIIIIIIIII IIIIIIIIIIIIIiIIIIIIIIIIIIIIIIIIIIIIiIiIillll MEDICAL RECORDS COPY IIIIIIIIIIIIIIIIIIIII?IIIItII?II?IIIIIIIIIII?II(II) 41TIAL ASSESSMENT FORM r`irlisle Regional Medical Center PRIORITY: 4 Pa,...,)t: BLACK, DAVE Pt#: 9270162 Mots-Urgent DOB: 01/1811945 AGE: 58YRS Sex: M MR#: 0001028323 EDP: CORDLE, RANDOLPH Worker's Comp: DATE: 12/16/2003 PCP: * NON-STAFF, NO PHYSICIAN* Emp. Referred: presentation Time: 16:15 Triage Time: 17:07 Arrival Mode: WALKED -ieight: Weight: 185.0 lbs. 84.1 kgs. LMP: Last Tetanus: unknown Acc By: Chief ANIMAL BITE Complaint: Brief bit by dog on left hand puncture wounds to left hand. Assessment: NIGHT SWEATS NO HEMOPTYSIS NO WEIGHT LOSS NO FEVER NO ANOREXIA NO SAFETY NO KNOW THE ANIMAL YES KNOW THE ANIMAL'S LOCATIOYES Vital Signs T: 98.4 PO P: 74 Regular R: 20 Unlabored BP: 181/086 02: % RA Pain Intensity Scale: 0 / 10 Pain Location: Denies Pain Sudden Onset: Pre-Hospital none Treatment: Pediatric N/A Assesment: Past Medical none History: Allergies: none Medicines: none Nurse Signature: TER Additional Notes: Lz-rj . C;_ sle Regional Medical Cc mr kUlauut,av11a. WWW F+va1uve - UPS a10a11 11eyauve, JAVVIUe CUUMVeral NennIein 1111v1I11Qu V16 4AMS: BLACK, DAVE Pt#: 9270162 DATE OF SERVICE.'-12/16/03 .1 1 )08: 1/18145 ' Age: 58 Yrs 0 'Mos 0 Wks MR#: 0001028323 Pres Time: 16:15 Sex: M Wt: 84.1 KG Ht: Triage Time: 17:07 Chief Complaint: ANIMAL BITE T: 98.4 PO Medicines: none P:74 'Regular R:20 Unlabored Allergies: none BP: 181/086 Sa02 % Normal I HypoXla EDP: CORDLE, RANDOLPH PCP: *.NON-,STAFF, NO PHYSICIF Arrival Mode: WALKED Pain Scale: 0 HISTORY OF PRESENT ILLNESS Exam Tarr e 1 Patient Family MS NH T nslator? ALOC Intoxication Severity Dementia C / C / HPI: (Narrative): M LT. Sx started suddenly I gradually min. I hrs. I days I wks. ago : continuous I intermittent D uratiio Sx last min. / hrs. I days I wks. at a time : present / absent I.,o do hand face neck chest abd back upper ext R / L lower ext R / L i@u ualt cannot describe bite mark skin tear scratches redness swelling Severity` mild moderate severe 1-10 scale Gotext:? human dog cat wild / family pet racoon Bator shark ce ,? at d nothing movement paipationseffi'?d nothing rest ice OTC meds affiM none fever chills purulent drainage cosmetic defect bleeding REVIEW OF SYSTEMS . ALOC Intoxication Severity Dementia Constitutional fever chills weakness diaphoresis u f Ica' HA seizures weakness confusion tNT. sore throat ear pain facial pain ` l oAg anxious depressed Eyes.: pain visual changes polyuria polydipsia Cardovascuilar:. C.P. palpitations DOE PND i'hgu rashes pruritis lesions Respirat` S.O.B. cough congestion 50:000010 anemia bleeding disorders transfusion Gastrointestinal:" N ! V D / C pain melena hematemesis .. . II frequent infections allergies hives GUS flank pain dysuria hematuria frequency Musc?uloskeleta joint pain neck / back pain ext. YES / NO All Other Systems Reviewed And Are Negative Med°Hx none CAD HTN IDDM / NIDDM Past 'Med..Hx: none ...... ...... __ ... _...... Meds:: none Allergies• none Surg'Hx none Appy Chole Hyster Family Hx negative R / L Handed Lives Alone: Y / N Socfai Hx Tobacco: / N Packs/Day Years ETON: Y / N Drinks/Wk. Drugs: Y IN on lmrriumzattons Up-to-date: Y IN Tetanus: unknown ReproductiveiHx: LMP: G P AB Pro-MED Maximus Animal / Human Bite - Page 1 of 2 ®COCYripM 2001 Pro- MED Clinical Systems, L.L.C. Rev. OOW =2 :arllsle Regional Medical Gen (Instructions: circle positive - backsla gative, provide additional pertinent information NAME:: BLACK, DAVE Pt#: 9270162 MR#: .0001028323 GENERAL-" NAD mild / moderate / severe distress HEENT: NC / AT PERRLA EOMI JVD Bruits T 98.4 P 74 R20 BP 181/086 CV: RRR PMI NL murmurs 16 sys / dys _.......... ........... _._........ _._..._.... _....____._...__. rubs clicks _ gallops S3/S4 y?. Location/Description of Symptoms: RESP lungs clear/ equal bilateral resp. effort NL / distress rales rhonchi wheezes ----? 4 Sat:. ,VIL lidL / wSlulluCu UVWul *UUI luo 11Il- / /,ov, Y' c&, j V +r I .% r tender / non-tender guarding rebound rigidity 064v IT-If 2j MS ROM NL clubbing cyanosis edema Joint above and below bite NL / ABN AQ- ?- SKIN warm - dry diaphoretic rashes ?- ryu Ca-c-'j- Zks bite marks scratches swelling erythema h j f S NEURO CN 2-12 intact DTRs equal / symmetric GC O Y??eT? PSYCH,; AAO X3 mood / affect NL ( ' ( (rte OT:, adenopathy G U NL / deferred ?- DECISION MAKING MEDICAL Q Labs reviewed and are negative X-Ray: MEDS: 104vy-- 4- Wound Care V?? ? -???- NL ! ABN ~?-NL / ABN ---r3 -?c- DIFF EKG: NSR no acute disease ................ _.. L UA: SG prot RBCs WBCs RE-EVAL: Time: U C G TA CG: +% - Pulse Ox: %NL / hypoxia ABG: DDX: human bite dog bite cat bite cellulitis abscess abrasions Improved Same Worse puncture wound other: See physicians exam/procedure sheet Snake Bite: Poison Non-Poison _ Critical Care > 30 Min. YY CLINICAL • DISCHARGE INSTRUCTIONS 42 v Discharged to: Home Nursing Home Family 2. y S l•G? Follow-up with Patient's Dr. in days. Other Instructions: 4. CONSULTATION DISPOSITION Discussed with Dr. Discharge Time Out: l Admit Fottow-up in Office Admit: OBS ICU PCU Floor Tele. OR Transfer: Prescriptions I v" Old Records Reviewed Y l N AMA; Q - '-_....___....___....._.___.. __ ._. Reviewed MW - Radiologist Y / N DOA: Case D/W Patient / Family Y / N Condition: Improved Stable Deceas RET RN ER IF CONDITION WORSENS. Signatures: PA/ARNP MD1D0 Pro-MED Maximus Animal / Human Bite - Page 2 of 2 CCopyrignt 2001 Pro-MED CNn" Systems. L.L.C. Rev. 08410/02 Ca ale Regional Medical Ce• )r ` Instructions: circle positive - backslash negative, provide additional pertinent intormation. AME;BLACK, DAVE Pt#: 9270162 DATE OF SERVICE: 12/16/03 013: 1/18/45 Age: 58 Yrs 0 Mos 0 Wks MRM 0001028323 Pros Time: 16:15 ex: M Wt: 84.1 KG Ht: t e Triage Time: 17:07 hief Complaint: ANIMAL BITE T: 98.4 PO ledicines: none P:74 Regular R:.20 Unlabored kilergies: none BP:-181/086 ; Sa02: % Normal / Hypoxia :DP: CORDLE, RANDOLPH PCP: " NON-STAFF, NO PHYSICIP Arrival Mode: WALKED Pain Scale:.0 LACERATION REPAIR Wound Location __.. .-_._-_.._.-_________._- Laceration Size cm ' ..-..__..___-._..-....--.___-...__-_---.-__--_..- Distal neurovascular-status: o function intact cular intac sensa 'on inta Depth: superficial ubcutaneo s musc, le tep Shape: linea r lap stellate avu n - contamination: an foreign body -._....._... __....__..-.....__.....___........_. Anesthesia: o digital block ____.......__................. __.._._._ _.__ _ _ _ _ _ _ _ .._ _._ _.?_._ _..... __. cc's 1 % lido 2% lido 5% marcaine w / e __ w / bicarb - .... _.... _-.-. ? Wound Prep: betadine cien saline irrigati debridementc loratio Repair closure: skin # .. ... . --._...._........ - 0 _pro en o s aples Dermabond ... .._ . _ simple interrupt d ma ress horiz / vert running subcutaneous # _ - 0 vicryl silk simple interrupted running mattress horiz / vert ............. ..._.......... fascia / muscle / ten don # -0 vicryl simple interrupted running _ mattress horiz / vert Sterile Dressing Applied N Other: SECONDARY LACERATION: ....................._.._........_........_.._..._........_......_..._...... Wound Location: ............._._.._.... Laceration Size: c -.._._ -. . ._?..._._.... ___.._.-..._-...... ._................. ..._.-......_.... ...... .__............_................. ......., _._...__._.....___....___ _ .___?.-___.- tion intact vascular intact sensation intact Distal neur status: n func Depth: ci ubcutaneou ........ ..... _.__.. . muscle tendon bone ._..._.._ _-__.. _._ .... ............. _ ..... __........ ._.......... .._ Shape: me ular p stellate avulsion Contaminatio foreign body Anesthesia. igital block .90 D marcaine cc's 1 /D lido 2 /D lido _ _- wound'Prep etadine hibiclen _.... _ _.._.._ .. saline irrigatio ri eme exploratio ...........__....__._.....____..._.. Repair Closure: skin # - ene nylon s aples _ Der _ _ond steristrips - _ -. simple interrupted ....... -._ unnin mattress -horiz I vert i, subcutaneous # --0 vicryl silk _._.._._._ .... ....... ____.__....... _.------ _..- ........... _.......... _-..........._ .............. _.. interrupted running......_......-mat------ _ horiz /vert _...__.._-...-..._...___._ _.... ...._.__..__....._..__ ............._. _. _. _ _ ........ __....._.__.__-...... ___............ fascia / muscle / tendon # -0 vicryl ..._......_..______....._.._..___..._.. -..... _._ . .. ..... _.. . ...... _..... ..............._..._............... ....._..-............... .......... ...... _..... simple interrupted ... _ ........ ..... ................... _...... ......... . . running mattress horiz / vert ...................._...._........_................_..._..................... __...__-._...___................... Sterile Dressing Applied: / N .....__....__....._............._.._._........_......__...._.........___..__-___._....-.....__.__._.___._.-___._ Other: -...... __..... ....... _..._....... _.........____..__._...___ Patient tolerated procedure well: / N Discharge;instructions-given:. Y .r Signatures: PA/ARNP MD/DO Pro-MED Maximus Laceration Repair Rev. 20Dt Pro- MED Clinical Systems. L.L.C. ' 08130/02 )RDER PP:OCEDURE FORM =NV/R0 MENTAL EMERGENGtcS ?ate 16: 12/16/03 Time: ' 'rlisle Regional Medical Center Name:BLACK, DAVE Pt#:9270162_ Age:58YRS DOB:01/18/1945 Sex: M MR#:0001028323 EDP: CORDLE, RANDOLPH PCP: * NON-STAFF, NO PHYSICIAN* ,Diagnostirr sts i? , ? : R,?° `Medica7nNecessity lrformation. ?'"-g,3(r?4?? „??, ;i3, Order Tim Laboratory rder Sent By CBC ? \ 1C. BMP CMP ETOH (Medical), (Legal) - Drug Screen (Urine), (Serum) UA Cardiac Profile Beta HCG Myogiobin (Urine), (Serum) PT/PTT Amylase Lipase Type creen , ross - Fibrinogen Lactic Acid Blood Cultures X ( ) Wound Culture Radiolo CXR (PA/LAT - Portable) C-Spine (XTable), (Complete) CT Head - plain Cardiopulmonary ABG EKG Physical Therapy - Eval & Tx (? ?. `? s 4-o 5v- u?l .? I A 41 -Mu ? KVO Device r LL_ ? IV i ' Procedures 7?,lursing*iiss fiance ? Cardiac Monitor ? NGT Insertion ? Antivenin Administration ? NIBP Monitor ? Urinary Catheter Insertion ? Notification of Proper Agency(s) ? Pulse Oximetry ? Central Line Placement ? Laceration Repair ? Warming/Cooling Blanket with Core Temp. Sensor ? Splinting/Immobilization ? Foreign Body Removal ? Dressings ? CPR ? Irrigation (Wound), (Eye[s]) ? Endoscopic Procedure 1,11 g:111 [A 'Ill'iloillilll'll Rill W0,00 RIM, Disctargetilnstruct?oris Initials/Signature: InitiaWSignature: Initi Is/Signature: Initi aisls ignatur PA/ARNP: PhystiAA? Signature ev. 06/30/02 EMERGENCY DEPARTMENT ONGOING NURSING ASSESS,.„ANT Date: 12/16/03 Airway Clearance, Ineffective -Anxiety `Breathing Patterns, Ineffective Cardiac Output, Decreased Comfort, Alteration in -Other Communication Impaired Coping, Ineffective Fluid Volume, Alteration in Gas Exchange, Impaired Hyperthermis (Fever) Not Met Met Int ' rlisle Regional Medical Center Name:BLACK, DAVE Pt#:9270162 Age:58YRS DOB:01/18/1945 Sex: M MR#:0001028323 EDP: CORDLE, RANDOLPH PCP: * NON-STAFF, NO PHYSICIAN* Infection, Potential -Injury, Potential Knowledge Deficit Mobility Impaired Non-Compliance Other Self Care Deficit Skin Integrity Impairment Thought Processes, Impaired Thought Processes, Alteration in Tissue Perfusion, Alteration in Not Met Met Int Not Met Met Int ? FB REMOVAL ? IMMOBILIZATION'/ PROPER ALIGNMENT ? IMPROVEMENT OF BREATHING ? BLEEDING CONTROL ? DECREASE / PREVENT SWELLING ? STABILIZE PATIENT IN DISTRESS ? PAIN CONTROL ? MAINTAIN STABLE HOMEOSTASIS ? meet ENVIRONMENTAL NEEDS ? ALLEVIATE NN ? MAINTAIN SKIN / TISSUE INTEGRITY ? meet PSYCHOSOCIAL NEEDS ? FEVER CONTROL ? PREVENT FURTHER INJURY ? meet SELF CARE ABILITY NEEDS ? DECREASE ANXIETY ? MAINTAIN / IMPROVE CIRCULATION ? meet EDUCATIONAL NEEDS ? SAFETY IN THE ED ? INFECTION CONTROL ? Other Int: N = documentation in nurses notes, oth 11171 er'codes' per H os pital Po licy. f C z "-L_? S' Xd4t k?C? IlJ T'T C 1 F.? (?' 1 t/ •? ( -40 I D/C to the care of: M Amb ? W/C ? Stret ? Carried D/C instructions given to: / / fNerballzed understanding Bated & Released ? Ad it -Room #: to Dr. ? Trans to ? Left without treatment ? Left AMA . Report called at and given to D/C Condition: ?improv d, table ?Serious ?Expired Pain: Severity Scal ; r ? Im ved oUnchan ed ? Wor pr ms g D/C Vitals: T P R 2 y D/C Date:;? 65 Time: l Nurse Rev. 06130/02 'MERGENCY DEPARTMENT C- rlisle Regional Medical Center 4USCULOSKELETAL NURSIA, ASSESSMENT Name:BLACK, DAVE Pt#9270162 Age:58YRS DOB:01/18/1945 Sex: M MR#:0001028323 ate Irr:12/16/03 Time: EDP: CORDLE, RANDOLPH PCP:' NON-STAFF, NO PHYSICIAN Subjective Notes: Location: Quality: []Sharp []Dull ?Cramping?Buming []Aching Severity scale. Onset: Provocation: []Other: Aggravating factors: Radiating: ?No ?Yes (specify) []Constant []Intermittent Relieving factors: . 'P_sycilosocial' Appearance: []Clean []Unkempt []Other Environment: ?No steps ? Few steps ? Many steps Mood / Affect / Behavior: []Appropriate ? Depressed []Anxious Nutritional status: a Normal ? Cachetic ? Obese []Tearful []Other Religious /Cultural preference: []None (specify) Caregiver: []Self []Family member []Significant Other []Group home Best learn by: []Verbal []Written ?Retum demo Activity level: []Ambulates independently []Requires assistance []Non-ambulatory Learning Barriers: ?TDD phone []Interpreter ?No ?Yes ? Performs ADL's independently ? Requires assistance with ADL's ? Other: 'Mect?anisrn Direction and amount of force: Use number; to Indicate Injury location and type 1 1.Abrasion 2. Amputation 3. Avulsion 4. Bum What was felt or heard upon injury: s. Closed Fx i Dis. 6. Contusion 7. Crepitus 8. Deforraty 8. Edema 10.GSW Pre-hospital treatment: ? Full spinal immobilization ? C-Collar []Splint 11.1.acerafion 12.Open Fx. ? Pressure dressing ? Ice ? Heat ? Ace wrap Right Left Left Right 13. Stab 14. 15. 4 PMH from triage: none ? Previous Sx involving musculoskeletal system and date: ? Diabetes ? Arthritis ? Osteoporosis ? Hemophilia ? Cancer. ? Anticoagulant medicine: ? ASA ? Coumadin? Other. A Muscle strengh: 0= no strengh 5= normal Lacerations / Abrasions I Avulsions ! Contusions RUE?0 ?1 ?2 ?3 ?4 ?5 Location: (see graph.) Size: LUE ? 0 ? 1 ?2 ?3 ?4 ? 5 Bleeding: ? Absent ? Present ? Scant ? Moderate ? Heavy ? Pulsating RLE ?0 ?l o2 ?3 ?4 ?5 Immunization:unknown LLE ?0 ?1 p2 ?3 ?4 ?5 Scars: Edema: Extremity Assessment RUE Pulses: ? Yes ? No Cap. Ref.: ? < 2 s. ? > 2 s. Motion: ? Yes ? No Sensation: ? Yes ? No Temp. ? W ? C Color LUE Pulses: ? Yes ? No Cap. Ref.: 0 < 2 s. ? > 2 s. Motion: ? Yes ? No Sensation: ? Yes ? No Temp. ? W ? C Color RLE Pulses: ? Yes ? No Cap. Ref.: 0<2s. ? > 2 s. Motion: ? Yes ? No Sensation: ? Yes 0 No Temp. ? W ? C Color LLE Pulses: ? Yes ? No Cap. Ref.: ? < 2 s. ? > 2s. Motion: 0 Yes ? No Sensation: ? Yes ? No Temp. ? W ? C Color Neurological rt ted r2 0Uncooperative []Combati ve Cardiovascul r;- =Resp"irto D! Skin: a Dry[] Moist oDiaphoretic ..Airway '; ar []Other. Colo ink;Phen []FlushedEffort Unlabored ?Mildly?Severely op era6ve• Awake butconfused []Agitated []Restrained artotic []Jaundiced , 0Cy ]Retractions: `.?Strdor []Nasal Flaring !Lung .' ypClearpWheezing []Crackles Rhonchi p Decreased Vital Signs: 17:07 T: 98.4 P: 74 Regular R: 20 BP: 181/086 Nurse Signature: CARLISLE REGIONAL MEDICAL CEN1 Ir R RADIOLOGICAL INTERPRETATION PATIENT NAME: BLACK DAVE X-RAY#: 1028323 -EXAM DATE: 12/16/2003 ORDERING: RANDOLPH CORDLE,MD 245-5500 ATTENDING: CONSULTING: DOCTOR NON STAFF,MD- HISTORY: ANIMAL BITE LEFT HAND, FOUR VIEWS - 12/16/03. CLINICAL HISTORY: Animal bite. MED REC #: 1028323 ACCOUNT #: 9270162 D.O.B.: 01/18/1945 ROOM: ER Four views of the left hand were obtained on 12/16/03. No acute fracture is identified. There is deformity of the fifth metacarpal which is probably related to previous trauma. There is no radiographic evidence of osteomyelitis. No radiopaque foreign body is seen. J G REVIEWED SIGNED JAY ROSENBLUM, M.D. INTERPRETING PHYSICIAN DATE DICTATED: 12/17/2003 DATE TRANSCRIBED: 12/17/2003 9:56 DATE SIGNED: 12/17/2003 11:26:08 TRANSCRIPTIONIST: KLR 7143086 E.R. PAGE 1 OF 1 HAND MIN 3 VIEWS jbJU nU to PILQI -- GI I IVI 14GI IL.y LJIVWQI LI IIV I IL Parker St. Carlisle, PA 17013 -- (717 '-5500 12/16/' :55gm 9270162 POSITION SUMMARY Patient: BLACK DAVE Aqe/DOB: SS #: Current Ph: CURRENT Address: Medical Record: 9270162 City: - Zip: Arrival: 12/16/03 5:55pm Disch: 12/16/03 6:07pm Disposition: MD ED: Randolph Cordle. MD PMD: Res/PA/NP: PMD Ph: Dx #1: Dog Bite ICD-9 #1: E906.0 #1 Dx Engl: ANIMALBT.ESW #1 Dx Span: ANIMALBT.SSW Dx #2: Laceration (Unspecified Site) ICD-9 #2:870-897 ? #2 Dx Engl: LACERATS.ESW #2 Dx Span: LACERATS.SSW Rx #1: Vicodin (Hvdrocodone & Acetaminophen) 5ma/500mg 1 tablet by mouth every 4 to 6 hours as needed 20(twenty) tablets Rx #2: Keflex 500mo 1 PO QID X 5 DAYS 20 Rx#1 Printed: 12/16/03 6:07pm ". Follow-up: SADLER CLINIC 117N HANOVER ST CARLISLE. PA F/U MD Ph: 717-218-6670 - F/U D/T: 2 WEEKS Other Instr: RETURN TO ED IN 1-2 DAYS AND IMMEDIATELY FOR RECHECK IF YOU NOTICE REDNESS. SWELLING. PUS OR HAVE ANY OTHER CONCERNS Restrictions: NO USE OF L HAND FOR 10 DAYS SIGNATURE BELOW INDICATES: I have received and understood the oral instructions reqardinq my current nedical problem. I will arranqe follow-up care as instructed above. I acknowledge receipt of the written instructions as outlined on thi any previous paqe(s). I will read and review these instruction ?Zi x / a tien or Legal an} S gnatur Sta VVitnes: v? C? ? -y C/O,- 246 Parker St. Carlisle, PA 17013 Ph:717.249-1212 'IENT'S NAME :OUNT NO BLACK, DAVE 9270162 CONDITIONS OF TREATMENT AND ADMISSION ATTENDING PHYSICIAN CORDLE, RANDOLPH J DATE & TIME OF ADMISSION 12/16/2003 16:15 ))SENT TO HOSPITAL CARE AND TREATMENT VI PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND I VOLUNTARILY CONSENT TO THE RENDERING OF SUCH 1E, INCLUDING DIAGNOSTIC TESTS AND MEDICAL TREATMENT, BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL, AND BY ITS MEDICAL kFF, OR THEIR DESIGNEES, AS MAY IN THEIR PROFESSIONAL JUDGEMENT BE DEEMED NECESSARY OR BENEFICIAL TO MY WELL BEING. CKNOWLEDGE AND UNDERSTAND THAT MANY OF THE PHYSICIANS ON THE STAFF OF THIS HOSPITAL, INCLUDING THE ATTENDING PHYSICIAN(S) MED ABOVE, AND RADIOLOGISTS, ANESTHESIOLOGISTS, PATHOLOGISTS AND EMERGENCY PHYSICIANS, ARE NOT EMPLOYEES OR AGENTS OF THE SPITAL, BUT RATHER ARE INDEPENDENT CONTRACTORS WHO HAVE BEEN GRANTED THE PRIVILEGE OF USING THE HOSPITAL FACILITIES FOR THE RE AND TREATMENT OF THEIR PATIENTS. I AGREE TO ACCEPT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPITAL. NDERSTAND THAT THE EXAMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY BASIS IS NOT INTENDED AS A SUBSTITUTION OR )LACEMENT FOR COMPLETE MEDICAL CARE. NTENT TO RELEASE INFORMATION EREBY AUTHORIZE THE HOSPITAL TO DISCLOSE TO INSURANCE COMPANIES, INCLUDING WORKERS COMPENSATION CARRIERS, OR OTHER PARTIES AT MAY BE LIABLE FOR ALL OR PART OF THE HOSPITAL CHARGES, ALL OR PART OF MY HOSPITAL RECORDS AS MAY BE NECESSARY (INCLUDING ANY EATMENT FOR ALCOHOL OR DRUG ABUSE OR DEPENDENCE), TO DETERMINE BENEFITS ENTITLEMENT AND PROCESS PAYMENT CLAIMS FOR HEALTH RE SERVICES PROVIDED. IDICARE CERTIFICATION RELEASE ERTIFY THAT THE INFORMATION GIVEN BY ME IN APPLYING FOR PAYMENT UNDER THE TITLE XVIII AND TITLE XIX OF THE SOCIAL SECURITY ACT IS RRECT. I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS 7ERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM. I REQUEST THAT PAYMENT OF AUTHORIZED NEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSIGNMENT. RSONAL EFFECTS AND VALUABLES NDERSTAND THAT THE HOSPITAL SHALL NOT BE LIABLE FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES (MONEY, JEWELRY, ASSES, DENTURES, DOCUMENTS, CLOTHING, ETC.) UNLESS SUCH ITEMS ARE DEPOSITED IN THE HOSPITAL SAFE. THE HOSPITAL WILL NOT BE LIABLE EXCESS OF 650 FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE. TOUT YOUR BILL INDERSTAND THAT I WILL RECEIVE A BILL FROM THE HOSPITAL FOR PROVISION OF THE HOSPITAL SERVICES, INCLUDING STAFF AND EQUIPMENT, AND ?R ANY SUPPLIES OR MEDICINES UTILIZED. I WILL ALSO RECEIVE A BILL FROM ANY PHYSICIAN WHO PROVIDES PROFESSIONAL CARE TO ME. FOR AMPLE, I MAY RECEIVE A SEPARATE BILL FROM ONE OR MORE OF THE FOLLOWING TYPES OF PHYSICIANS WHO RENDER SERVICES TO ME: MY 'TENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN, RADIOLOGIST, ANESTHESIOLOGIST, PATHOLOGIST, OR ANY OTHER 'ECIALIST. SURANCE ASSIGNMENT HEREBY ASSIGN TO AND AUTHORIZE THE HOSPITAL AND PHYSICIANS INVOLVED IN CARE DURING THIS PERIOD OF ILLNESS OR TREATMENT EREINAFTER "PHYSICIANS"), OR THEIR DULY AUTHORIZED ASSIGNS TO TAKE ALL NECESSARY STEPS, WITHOUT LIMITATIONS, TO ENSURE THAT ANY SURANCE BENEFITS OTHERWISE PAYABLE TO ME OR MY ESTATE ARE PAID DIRECTLY TO THE HOSPITAL OR PHYSICIANS. THIS ASSIGNMENT OF SURANCE BENEFITS INCLUDES BUT IS NOT LIMITED TO BILLING INSURANCE, FILING PETITIONS, FILING SUIT, IN MY NAME OR ON BEHALF OF THE 3SPITAL OR PHYSICIANS, FILING PROOFS OF CLAIM, FILING PROBATE CLAIMS AND FILING GRIEVANCES AND ALL OTHER SIMILAR PROCEDURES, AS AY BE AMENDED FROM TIME TO TIME WITH THE STATE DEPARTMENT OF INSURANCE. I ALSO AGREE TO PROVIDE AND SIGN ANY OTHER DOCUMENTS 4AT MAY BE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES. 7ATEMENT OF FINANCIAL RESPONSIBILITY JNDERSTAND THAT I AM FINANCIALLY AND LEGALLY RESPONSIBLE FOR CHARGES NOT COVERED IN FULL BY ANY THIRD PARTY. I FURTHER AGREE 1AT SHOULD I NOT PAY THE BALANCE WITHIN THIRTY (30) DAYS AFTER THE DATE OF DISCHARGE, MY ACCOUNT WILL BE CONSIDERED DELINQUENT. I 3REE TO PAY COSTS OF COLLECTION, INCLUDING REASONABLE ATTORNEY'S FEES AND COSTS, COLLECTION AGENCY FEES AND COSTS, AND TEREST WHICH SHALL ACCRUE AT THE MAXIMUM RATE ALLOWED BY LAW. LAUD . NY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY, OR FILES A STATEMENT OF CLAIM JNTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE SUBJECT TO PROSECUTION UNDER APPLICABLE LAW. DVANCE DIRECTIVE (FOR ADMISSION TO HOSPITAL ONLY) I AM TO BE ADMITTED TO THE HOSPITAL, I HAVE BEEN GIVEN WRITTEN MATERIALS ABOUT MY RIGHT TO ACCEPT OR REFUSE MEDICAL TREATMENT. I AVE BEEN INFORMED OF MY RIGHTS TO FORMULATE ADVANCE DIRECTIVES. I UNDERSTAND THAT I AM NOT REQUIRED TO HAVE AN ADVANCE IRECTIVE IN ORDER TO RECEIVE MEDICAL TREATMENT AT THIS HOSPITAL. I UNDERSTAND THAT THE HOSPITAL AND MY CAREGIVERS WILL FOLLOW AE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW. VITIAL THE FOLLOWING OPTION THAT APPLIES) I HAVE EXECUTED AN ADVANCE DIRECTIVE AND WILL PROVIDE A COPY 0 FOR MY MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME. INIT. HAVE NOT EXECUTED AN ADVANCE DIRECTIVE AND DO NOT WIS 0 DO SO. INI4. (FOLLOW-UP DONE BY DATE I WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITA INIT. CERTIFY THJT(?7VE RE11pD?AVE BEER EAD) THE ABOVE CONSENTS AND CERTI TIONS AND UNDERSTAND AGREE WITH THEM. too- A ONTH Ej(jAY YEAR IGNATURE OF PATIENT OR LEGALLY AUTHORIZED REPRESENTATIVE WITN S PRINT NAME OF PERSON ABOVE U 01B 927 0001028323 IIIIIIIIIIIIIillllllllllllillllllillll IIIIIIIIIIIIoil IIIIIIIIIIIilll11l111llillil IIIIIIIIIIIIIIIIIIIIIIIN IIIIIIIIIillill111111ll111111llll ?l?l7.iI?lAL. AtE01CAL CENTER 246 Parker St. Carlisle, PA 17013 Ph:717-249-1212 ACKNOWLEDGEMENT: RECEIPT OF PRIVACY NOTICE HIPAA FORM 20 Purpose: This form is used to document (a) an individual's acknowledgement of receipt of our Privacy Practices Notice or (b) when we have not obtained this acknowledgement, our good faith effort to obtain the acknowledgement. Patient Name: Medical Record Number: Date of Admission: BLACK, DAVE 0001028323 12/16/2003 Acknowledgement of receipt of Privacy Practices Notice Notice Version (Date): 4/14/2003 I, BLACK, DAVE , acknowledge that I have received a Privacy Practices Notice from: CARLISLE REGIONAL MEDICAL CTR Further, by signing below I provide my permission for this facility to use and disclose my medical information for the permitted purposes of treatment, payment and health care operations as discussed in the Notice of P 'v y Practices. Patient Signature: Date: ?? VJ Notice has pr iously been distributed by another location in our OHCA (except for physicians): List location that distributed the Joint Notice: If a personal representative on behalf of the individual signs this authorization, complete the following: Personal Representative's Name: Relationship to Individual: IF NOT SIGNED:(Good faith effort to obtain acknowledgement of receipt) Describe your good faith effort to obtain the individual's signature on this form: Describe the reason why the individual would not sign this form: SIGNATURE: (Hospital Representative) I attest that above information is correct. Signature Date: 1 Print Name: ` Title: Include this acknowledgement form in the individual's records. Hospital Copy Social Security Number: 168-36-3263 C70" ADMISSION RECORD A L c c N r e n ACCOUNT NO, MEDICAL RECORDS NO. 246 Parker St. Carlisle, PA 17013 Ph:717-249-1212 9 2 715'5 3 0001028323 '- ADMIT DATE/ TIME ROOM NO. PT FC AGE DATE OF BIRTH SEX RA MS LOCATION PROGRAM 12/30/2003 15:29 0000 E1 P 58 01/18/1945 M 1 S NS ' TATIENTNAME & ADDRESS S NUMBER PATIENT EMPLOYER EMPLOYER PHONE N0. BLACK, DAVIDSON 168-36-3263 SELF, DAVE BLACK REPAIR (717)691-0199 25 PENNY LANE ENOLAS.LE PA 1 7 0 2 5 PHONE NUMBER COUNTY -US (717)691-0199 CUMBERLAND RESPONSIBLE PARTY & ADDRESS NUMBER RESPONSIBLE A "LYER EMPLOYER H N BLACK, DAVE SELF, DAVE BLACK REPAIR 25 PENNY LANE 168-36-3263 25 PENNY LANE (717)691-0199 ENOLA PA 17025 " ENOLASLE PA 17025 PHONE NUMBER RELATIONSHIP TO PA71EN US (717)691-0199 PATIENT IS EMERGENCY CONTACT NAME EMERGENCY CONTACT PHONE EMERGENCY CONTACT RELATIONSHIP TO PATIENT WOLFE, CHAROLETTE (717)243-7354 FRIEND MMENTS MSP MED. KEY PRIVACY ADMIT. BY ?Y MN DY MN EDW !VACY 4 ?i.. - I j PAYEfi PLAN :::1.1 .Y iIUMBER OATS F B,I.R .. t.l ..? ..........2 .... . 3 YEr3 i IN U Y U O. NAME & ADDRESS n DR. ATTENDING /ADMITTING CORDLE, RANDOLPH J > DIAGNOSIS / SIGNS SYMPTOMS "HAND INJURY/PAIN NCIPAL DIAGNOSIS (The condition established after study to be asioning the admission of the patient to the HOSPITAL for care). MPLICATIONS MORBIOITY(IES) NCIPAL PROCEDURE FAMILY / PRIMARY CARE NONSTAFF, PHYSICIAN ACCIDENT ACCIDENT DATE OTHER 112/16/2003 AD001AI 9271553 0001028323 l???II?I?IIIIlI?IIlIlIIIIIIIIIIIIlI IIIlIIllflllllliilllllllllllllil81111111111? MEDICAL RECORDS COPY IIlfllllllllllllllllglllNllllflllflllllfllllllllflllgllll VlT1AL ASSESSMENT FORM r -lisle Regional Medical Center PRIORITY: ' 4 Patient: BLACK, DAVIDSON Pt#: 9271553 Non-Urgent DOB: 01/18/1945 AGE: 58YRS Sex: M MR#: 0001028323 EDP: CORDLE, RANDOLPH Worker's Comp: DATE: 12/30/2003 PCP: `' NON-STAFF, NO PHYSICIAN* Emp. Referred: >resentation Time: 15:29 Triage Time: 16:18 Arrival Mode: WALKED -/eight: I I. Weight: 185.0 lbs. 84.1 kgs. LMP: Last Tetanus: under 5 ye Acc By: 'hief HAND INJURY/PAIN 'omplaint: SHOULDER INJURY/PAIN 3rief PT STS WAS SEEN ON 12-16 FOR A DOGBITE L HAND C/O PAIN L HAND UPPER ARM AND 4ssessment: SHOULDER JIGHT SWEATS NO HEIGHT LOSS NO kNOREXIA NO HEMOPTYSIS NO FEVER NO iAFETY NO DUMBNESS NO DECREASED SENSATION NO ROM INTACT ' YES 'ULSE DISTAL TO INJURY ABSNO 'AP REFILL > 2 SECONDS NO NUMBNESS NO DECREASED SENSATION NO ROM INTACT YES PULSE DISTAL TO INJURY ABSNO CAP REFILL > 2 SECONDS NO Sudden Onset: Pre-Hospital Treatment: Pediatric N/A Assesment: Past Medical none History: Allergies: none Medicines: none vital Signs T: 97.1 PO P: 69 Regular R: 20 Unlabored BP: 175/092 02: % RA Pain Intensity Scale: 3 / 10 Pain Location: Multiple Areas Nurse Signature KES Additional Notes: . Ca sle Regional Medical Ce r Instructions: circle positive - backslash negative, provide additional pertinent intormation. NAME: BLACK, DAVIDSON Pt#: 9271553 DATE OF SERVICE: 12/30/03 DOB: 1/18/45 Age: 58 Yrs _ 0 Mos 0.: Wks MR#: 0001028323 Pres Time: 15:29 Sex: M Wt: 84.1 KG Ht: Triage Time: 16:18 Chief Complaint: HAND INJURY/PAIN T: 97.1 PO Medicines: none P: 69 Regular R: 20 Unlabored Allergies: none BP: 175/092 ?. Sa02: % Normal / Hypoxia EDP: CORDLE, RANDOLPH PCP: * NON-STAFF, NO PHYSICIA Arrival`Mo. !! WALKD Pain Scale: 3 HISTORY OF PRESENT ILLNESS Exam'Time ; ?7 To F by: P Family EMS NH Translator Limited by ALOC Intoxication Severity Dementia •__._______.__...__.___-..__ C / C I HPI (Narrative) ,__ - -.... ___.._ Timing: ix started uddeAly radually in./hrs./days/ w13c ago : continuous / intermittent •-- _ _ Duration: Sx last min. / hrs. / days / wks. at a time : present / absent Location R: wrist hand finger L: wrist hand finger (see diagram) Quality f cannot describe pain" throbbing swollen crushed bleeding ild? erit S d t 1 1 l - ? -? ?? ev y:;. mo era e severe - 0 sca e -?? ?, ? - , Context:'. a dent sports related MVA altercation fall Exacerbated ti nothin vement '?'?""""`" _ y g i?w palpation Re7ie„;?re? nothinc,?OTC meds ice re i4ssoc ,Signs?8 S?rn tints::" none bleeding swelling erythema ? ? REVIEW OF SYSTEMS Llmifhtdui 70: _ A N`IBT&Idation Severity Dementia Constitutional fever chills weakness diaphoresis N cal ' HA seizures weakness confusion - -, . ENT: sore throat ear pain facial pain Psychological: anxious depressed Eyes- pain visual changes ndocrlne:" polyuria polydipsia Cardiovascular C .P. palpitations DOE PND _... _.. Infegumerit: rashes /pruritis lesions Respiratory: S.O.B. cough congestion hematologic: anemi bleeding disorders transfusion Gastrointestinal .% N / V D / C pain melena hematemesis Ailergy/lmm.: frequent-infections allergies hives GU: flank pain dysuria hematuria frequency Other Musculoskeletal ' Joint pain neck / b in ?. ------- ------ ' wed And Are Negative MEDICAL AND SOCIAL HISTORY Med. H non AD HTN IDDM / NIDDM carpal tunnel Fx Past Me . Meds: none rtt4,; ._ _._. .: c• .. . All ies: none - P11 ysj?j fl/lild; Surg, Hx: a Appy Chole Hyster carpal tunnel "v1Af4T Family Hz" negative R / L Handed Lives Alone Y / N Social Hx Tobacco: Y / N Packs/Day Years ETOH: Y / IL. E) ip /Wk. Drugs: Y / N Occupations''. lmmurtlzations; Up-to-date: Y / N Tetanus: under 5 ye _.._.._. ......__.__.._.... _.._............. _-....... __._..._. _._._...._.M....... _._...___._.._.__....._-....___.____...... _...._ _,..-.__ -?_......_.___...___..__._.... .... ...,_..... _..... ..... ...... Reproductive Hx LMP: G P AB Pro-MED Maximus Upper Extremity / Hand / Wrist - Page 1 of 2 CCopyright 2001 Pro-MED Clinical Systems, L.L.C. Rev. 0830102 ..arlisle EZegional Medical Cent (Instructions: circle positive - backsla, gative, provide additional pertinent information. NAME: BLACK, DAVIDSON Pt#c 9271553 MR#: 0001028323 GENERAL: AD Ild / moderate / severe distress VITAL- SIGNS' T97.1 P 69 R20 BP 175/092 HEENT: NC? PE E JJVD Bruits CV.; R PMI NL murmurs /6 sys / dys bs clicks allops S3/S4 Location/Description of Symptoms: RESP` I fear / equal bilateral resp. errors 1141L i aisiress _ rales rhonchi wheezes - - - G1: soft flat / distended bowel sounds NL / ABN tender / non-tender guarding rebound rigidity pulsatile mass /r' t ' ?f IT limit fltarct Ian on Fxn intact I _ L MS /hand N 77 sec ot es intact equal Allen's + / - cap refill < 2 sec Phalen's + / - tinel's + / - snuff box tenderness - _ ??- -- - Joint exam above and below level of injury NL / ABN SKIN: rm - diaphoretic rashes m ct DTRs equal / symmetric NEU PSYCH: X3 mect,; Nt-_. N F e LYMp:. pathy --7 - k• GU: NL / deferred -?_ .... iJ OTHER: DECISION MAKING Labs reviewed and are negative X-Ray: hand / wrist --- FB - soft tissue Ice;,(&f NL / ABN NL / ABN _ NL / ABN _ DIFF Immobiliiation!.?` B RE-EVAL: Time: Pulse Ox: % NL / hypoxia DDX Colle's Fx wrist pain DJD carpal tunnel laceration dislocation Improved Same Worse .......... _.._......... _ ._....._._.-_....._._.......___......_--. tendonitis contusion cellulitis other. See physicians exam/procedure sheet Critical Care > 30 Min. Y CLINICAL IMPRESSION(S) DISCHARGE INSTRUCTIONS 771- Discharged to: Home Nursing Home Family 2 -- Follow-up with Patient's Dr. in days. ti : Oth I t 3. ons er ns ruc __.-_._ ....___.._........._................ 4. ......__......___.._.-._._ ..__.._._-._.... _5 ......... ........ ......... -_...-......... ____._ .______....___.......... .... ___....__...- CONSULTATION DISPOSITION Discussed with Dr. Discharge Time Out: Admit Admit: OBS ICU PCU Floor Tele. OR Prescriptions Given: -......_____T..... ------- ._........... . Follow-up in Office Transfer: _____--.__ ._..... .....---- ....._...._..._____.._.._ ....__.....____.._..... _........ ..__..___.. _..........._-_-_-__..____.-..._.___.?_- Old Records Reviewed Y / N AMA: Reviewed DNY Radiologist Y ! N DOA: _ _ Case DIW Patient / Family Y / N Condition: Improved table Deceased _ RETURN TO ER IF CONDITION WORSENS 't MD/DO Signatures: P NP ,:. Pro-MED Maximus, Upper Extremity / Hand / Wrist - Page 2 of 2 CCopyngM 2001 Pro-MED Clinical Systems. L.C. L.Rev. 06190/02 )RDER PROCEDURE FORM ORTHOPEDIC EMERGENCIES late In; 12/30/03 Time: C'-lisle Regional Medical Center Name:BLACK, DAVIDSON Age:58YRS DOB:01/18/1945 EDP: CORDLE, RANDOLPH Pt#:9271553 Sex: M MR#:0001028323 PCP: * NON-STAFF, NO PHYSICIAN* r, DisgosticTests"" ; ,x' edic?l Ne'"ces"si>•y:Inforniatioit??-ir"t. Order rm Laboratory Order Sent By CBC ?'7 S" r o f CQ V- f C C2 BMP CMP Sed rate Z ? { K RA factor . ?-- J r d Uric acid UA 7 -Z / G ETOH Drug screen serum urine Type & (screen), (cross) # Radiol gy E2 L2 ar ulmonary ti f EKG 1 ri',ry - . f' ABG v:y'rfy Physical Therapy - Evai & Tx ,AWE ' rde? , .. 10( rcie ,;??m ? O& ? KVO Device e ? IV sic ProceclGresj1Jursig Ass`?stapce,,,; ? Cardiac Monitor ? Splint Application (Local), (Regional) Anesthesia ? NIBP Monitor ? Ace Bandage Application ? Conscious Sedation ? Pulse Oximetry ? Sling Application ? Laceration Repair ? (Cold), (Heat) Application ? C-Spine Immobilization ? CastApplication ? Wound Irrigation ? Foreign Body Removal ? Fracture Care (open), (closed) ? Dressings Discharge instructions ` s? ?'' MW RMWELF7 777-777777"?, Initials/Signature: Initials/Signature: Initials i lure: n J Initials/Signature: PA/ARNP: Physician' atu ,: (i_ Rev. 06/30/02 EMERGENCY DEPARTMENT ONGOING NURSING ASSESSt..?NT Date' 12/30/03 1 lisle Regional Medical Center Name:BLACK, DAVIDSON Pt#:9271553 Age:58YRS DOB:01/18/1945 Sex: M MR#:0001028323 EDP: CORDLE, RANDOLPH PCP: * NON-STAFF, NO PHYSICIAN` xtajcn,,panentmust;,n!veYaW,Cd??P??P o,gP.au;? ? ? arc z x,wr?-?- , ma y - in orderDt?prippV IAGNOSISJNumber NURSING . , Airway Clearance, Ineffective ' Communication Impaired Infection, Potential Self Care Deficit - -'Anxiety Coping, Ineffective --Injury, Potential Skin Integrity Impairment - -Breathing Patterns, Ineffective Fluid Volume, Alteration in -Knowledge Deficit Thought Processes, Impaired Decreased Cardiac Output Gas Exchange, Impaired Mobility Impaired Thought Processes, Alteration in , - Alteration in Comfort, Hyperthermis (Fever) Non-Compliance -Tissue Perfusion, Alteration in - Other Other - Not Not Not Met Mat Int Met Met Int ? FB REMOVAL ? IMMOBILIZATION / PROPER ALIGNMENT ? IMPROVEMENT OF BREATHING ? BLEEDING CONTROL ? DECREASE / PREVENT SWELLING ? STABILIZE PATIENT IN DISTRESS ? PAIN CONTROL ? MAINTAIN STABLE HOMEOSTASIS ? meet ENVIRONMENTAL NEEDS ? ALLEVIATE NN ? MAINTAIN SKIN / TISSUE INTEGRITY ? meet PSYCHOSOCIAL NEEDS ? FEVER CONTROL ? PREVENT FURTHER INJURY ? meet SELF CARE ABILITY NEEDS ? DECREASE ANXIETY ? MAINTAIN / IMPROVE CIRCULATION ? meet EDUCATIONAL NEEDS ? SAFETY IN THE ED ? INFECTION CONTROL ? Other Int: N = documentation me T. in nurses notes, other'co des' per H os pital Policy. aw- 6D D/C to the care of: [2 AAmb ? W/C ? Stret ? Carried i // : ?-Verbalized understanding D/C instructions given to ? Treated & Released - Room #: to Dr. \<dmit ? Trans. to ? Left without treatment ? Left AMA Report called at and given to D/C Condition: Z mproved ? Stable ? Serious ? Expired Unchanged ? Worse Pain: Severity Scale: l n PilImproved ? h- D/C Vitals: T ?ZP ? R 7Z BP 7D 02 ' D/C Date: g6me: ?? ?.3 Nurse: Q?Lx' EMERGENCY DEPARTMENT WUSCULOSKELETAL NURSINt, ASSESSMENT i Iro Ira' 17/9(1/nq Tima• C --lisle Regional Medical Center Name:BLACK, DAVID, A Pt#S271553 Age:58YRS DOB:01/18/1945 Sex: M MR#:0001028323 EDP: CORDLE, RANDOLPH PCP:* NON-STAFF, NO PHYSICIAN /4 ? ILIJVIVV ""' - Subjective Notes: de?1e?s dam harp ? Dull ? Cramping Burning ? Aching Severity scale Onset Location: Quality. ? S Provocation: ? Other: Aggravating facto Radiating: ?No ?Yes spepfyl ?Constant ?Intermittent Relieving factors: 5111 psyhosocii3l ,_ ,rc 0111111111MI Appearance: Clean oUnkempt ? Other Environment: ?No steps El Few steps E3 Many steps Mood / Affect / Behavior: pA`ppropriate ?Depressed ?Anxious Nutritional status: oNormal ? Cachetic ? Obese ?Tearful aotti6r Religious / Cultural preference: ?None (specify) Caregiver: ?Self ? ily member ?Significant Other ?Group home Best learn by: ?Verbal ?Written ?Retum demo Activity level: ?Ambulates independently ?Requires assistance ?Non-ambulatory Learning Barriers: ?TDD phone ?Interpreter ?No ?Yes ? Performs ADL's independently ? Requires assistance with ADL's ? Other: Mechaglsmof,l#juW -IN Direction and amount of force: Use numbers to indicate injury location and type 1. Abrasion 2. Amputation 3. Avulsion 4. Bum What was felt or heard upon injury: s. Closed Fxi Dis. 6. Contusion 7. Crepitus 8. Defomity 9. Edema 1o.Gsw 11. Laceration Pre-hospital treatment: ? Full spinal immobilization ? C-Collar ?Splint 12.ope Fx. ? Pressure dressing ? Ice ? Heat ? Ace wrap Right Lett Left Right 13.Sta 14. 15. 4 ?Pn.,88t?.. s 15t0 a ?? ,-,- PMH from triage: none ? Previous Sx involving musculoskeletal system and date: ? Diabetes l7 Arthritis ? Osteoporosis ? Hemophilia ? Cancer: ? Anticoagulant medicine: ? ASA ? Coumadin? Other: P ysical 7ssesm`"gQecflY Muscle strengh: 0= no strengh 5= normal Lacerations / Abrasions / Avulsi ons 1 Contusions RUE?0 ?l o2 ?3 ?4 ?5 Location: (see graph.) Size: LUE ? 0 ? 1 ? 2 ? 3 ?4 ? 5 Bleeding: ? Absent ? Present ? Scant ? Moderate ? Heavy ? Pulsating RLE?0 ?l ?2 ?3 ?4 ?5 Immunizatiowunder 5 ye LLE ?0 ?l ?2 ?3 ?4 ?5 Scars: Edema: _/' Extremity Assessment 116 RUE Pulses: ? Yes ? No Cap. Ref.: ? < 2 s. ? > 2 s. --Motion: ? Yes ? N Sensation: ? Yes ? No Temp. ? W ? C Color LUE Pulses: ? Yes ? No Cap. Ref.: ? < 2 s. ? > 2 s. Motion: ? Yes ? No Sensation: ? Yes ? No Temp. ? W ? C Color RLE Pulses: ? Yes ? No Cap. Ref.: ? < 2 s. ? > 2 s. Motion: ? Yes ? No Sensation: ? Yes ? No Temp. ? W ? C Color LLE Pulses: ? Yes ? No Cap. Ref.: ? < 2 s. ? > 2 s. Motion: ? Yes ? No Sensation: ? Yes ? No Temp. ? W ? C Color S ```tem?Re?tew: Neurological - Cardiovascular Respiratory r ?Other. f3Moist ?Diaphoretic Airway' m r r tiv Skin: a U y r ncoope a e e ? ., ' r'iented:X _ p Combative Color. Ink ? Pale ?Ashen [I " Flushed: Effort: ored ? Mildly ? Severely C ratiVe ?Agitated ?Cyanotic ?Jaundiced ?Retractions, ?Stddor ?Nasal Fladng " pAwake butconfused ?Restrained Lung: ?Clear?Wheezing ?Crackles ? Rh I Decr sed \\ Signs: 16:18 T: 97 P: 1 , .751092 Nurse Sign. .1 P: 69 Regular R: 20 BP: atu Vital re: L PATIENT NAME: X-RAY#: EXAM DATE: ORDERING: ATTENDING: CONSULTING: HISTORY: +• - CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION BLACK DAVIDSON 1028323 12/30/2003 RANDOLPH CORDLE,MD 245-5500 DOCTOR NON STAFF,MD- HAND INJURY/PAIN MED REC #: 1028323 ACCOUNT #: 9271553 D.O.B.: 01/18/1945 ROOM: ER LEFT SHOULDER - THREE VIEWS HISTORY: Injury. No fracture or other bony abnormality is seen. The joints appear normal, and no soft tissue abnormality is noted. IMPRES'SION: Negative left shoulder. REVIEWED AND SIGNED MATTHEW PASTO, M.D. DATE DI -TATED : DATE TRH",.INSCRIBED: DATE SIGNED: TRANSCR_PTIONIST: 7117237 OULDER COMM.. CE 3V 12/31/2003 12/31/2003 11:07 1/01/2004 8:31:15 JND REPR :ANT ERNEST CAMPONOVO, M.D. DICTATED BY PAGE I OF 1 isle mospitai -- tmergencv uepanrnen` 1028323 Parker St. Carlisle, PA 17013 -- (717) '-5500 12/30/r 1:46pm POSITION SUMMARY Patient: Black Davidson SS #: Current Ph: CURRENT Address: City: Arrival: 12/30103 6:460m Zip: Disch: 12/30/03 7:06pm MD ED: Robert Lasek MD PMD: Res/PA/NP: Duane Stroup PA-C PMD Ph: Dx #1: Shoulder Strain (Not Otherwise Specified) ICD-9 #1: 840.9 #1 Dx Engl: SPSHOULD.ESW Dx #2: Dog Bite ICD-9 #2: E906.0 #2 Dx Engl: ANIMALBT.ESW Rx #1: Naorosvn (Naproxen) 500 ma tablets Take 1 tablet by mouth twice a day #20 tablets #1 Dx Span: SPSHOULD.SSW #2 Dx Span: ANIMALBT.SSW Rx#1 Printed: 12/30/03 7:06pm . .. A!JJW Follow-up: MIRA ALLAN J 220 WILSON ST. SUITE 206 CARLISLE. PA F/U MD Ph: 7172497400 F/U D/T: call for an appointment Other Instr: ice packs rest return to the ER as needed SIGNATURE BELOW INDICATES: I have received and understood the oral instructions reqardinq my current nedical problem. I will arranqe follow-up care as instructed above. I acknowledge receipt of the written instructions as outlined on this and any pre 'pus page(s). I will read and review these instructions. X 'atient (or Leqal Guardian) Siqnature Staff itness) ignature Aqe/DOB: Medical Record: 1028323 Disposition: MEDICAL Cf NTE0. 246 Parker St. Carlisle, PA 17013 Ph:717-249-1212 IENT'S NAME AUNT NO. BLACK, DAVIDSON 9271553 CONDITIONS OF TREATMENT AND ADMISSION ATTENDING PHYSICIAN CORDLE, RANDOLPH J DATE & TIME OF ADMISSION 12/30/2003 15:29 (SENT TO HOSPITAL CARE AND TREATMENT A PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND I VOLUNTARILY CONSENT TO THE RENDERING OF SUCH iE, INCLUDING DIAGNOSTIC TESTS AND MEDICAL TREATMENT, BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL, AND BY ITS MEDICAL ,FF, OR THEIR DESIGNEES, AS MAY IN THEIR PROFESSIONAL JUDGEMENT BE DEEMED NECESSARY OR BENEFICIAL TO MY WELL BEING. 'KNOWLEDGE AND UNDERSTAND THAT MANY OF THE PHYSICIANS ON THE STAFF OF THIS HOSPITAL, INCLUDING THE ATTENDING PHYSICIAN(S) DIED ABOVE, AND RADIOLOGISTS, ANESTHESIOLOGISTS, PATHOLOGISTS AND EMERGENCY PHYSICIANS, ARE NOT EMPLOYEES OR AGENTS OF THE ;PITAL, BUT RATHER ARE INDEPENDENT CONTRACTORS WHO HAVE BEEN GRANTED THE PRIVILEGE OF USING THE HOSPITAL FACILITIES FOR THE IE AND TREATMENT OF THEIR PATIENTS. I AGREE TO ACCEPT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPITAL. VDERSTAND THAT THE EXAMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY BASIS IS NOT INTENDED AS A SUBSTITUTION OR 'LACEMENT FOR COMPLETE MEDICAL CARE. 4SENT TO RELEASE INFORMATION _REBY AUTHORIZE THE HOSPITAL TO DISCLOSE TO INSURANCE COMPANIES, INCLUDING WORKERS COMPENSATION CARRIERS, OR OTHER PARTIES aT MAY BE LIABLE FOR ALL OR PART OF THE HOSPITAL CHARGES, ALL OR PART OF MY HOSPITAL RECORDS AS MAY BE NECESSARY (INCLUDING ANY :ATMENT FOR ALCOHOL OR DRUG ABUSE OR DEPENDENCE), TO DETERMINE BENEFITS ENTITLEMENT AND PROCESS PAYMENT CLAIMS FOR HEALTH IE SERVICES PROVIDED. DICARE CERTIFICATION RELEASE =RTIFY THAT THE INFORMATION GIVEN BY ME IN APPLYING FOR PAYMENT UNDER THE TITLE XVIII AND TITLE XIX OF THE SOCIAL SECURITY ACT IS RRECT. I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS ERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM. I REQUEST THAT PAYMENT OF AUTHORIZED JEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSIGNMENT. ISONAL EFFECTS AND VALUABLES NDERSTAND THAT THE HOSPITAL SHALL NOT BE LIABLE FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES (MONEY, JEWELRY, 4SSES, DENTURES, DOCUMENTS, CLOTHING, ETC.) UNLESS SUCH ITEMS ARE DEPOSITED IN THE HOSPITAL SAFE. THE HOSPITAL WILL NOT BE LIABLE EXCESS OF $50 FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE. OUT YOUR BILL NDERSTAND THAT I WILL RECEIVE A BILL FROM THE HOSPITAL FOR PROVISION OF THE HOSPITAL SERVICES, INCLUDING STAFF AND EQUIPMENT, AND R ANY SUPPLIES OR MEDICINES UTILIZED. I WILL ALSO RECEIVE A BILL FROM ANY PHYSICIAN WHO PROVIDES PROFESSIONAL CARE TO ME. FOR AMPLE, I MAY RECEIVE A SEPARATE BILL FROM ONE OR MORE OF THE FOLLOWING TYPES OF PHYSICIANS WHO RENDER SERVICES TO ME: MY TENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN, RADIOLOGIST, ANESTHESIOLOGIST, PATHOLOGIST, OR ANY OTHER ECIALIST. ;URANCE ASSIGNMENT iEREBY ASSIGN TO AND AUTHORIZE THE HOSPITAL AND PHYSICIANS INVOLVED IN CARE DURING THIS PERIOD OF ILLNESS OR TREATMENT REINAFTER "PHYSICIANS"), OR THEIR DULY AUTHORIZED ASSIGNS TO TAKE ALL NECESSARY STEPS, WITHOUT LIMITATIONS, TO ENSURE THAT ANY ;URANCE BENEFITS OTHERWISE PAYABLE TO ME OR MY ESTATE ARE PAID DIRECTLY TO THE HOSPITAL OR PHYSICIANS. THIS ASSIGNMENT OF ;URANCE BENEFITS INCLUDES BUT IS NOT LIMITED TO BILLING INSURANCE, FILING PETITIONS, FILING SUIT, IN MY NAME OR ON BEHALF OF THE ISPITAL OR PHYSICIANS, FILING PROOFS OF CLAIM, FILING PROBATE CLAIMS AND FILING GRIEVANCES AND ALL OTHER SIMILAR PROCEDURES, AS kY BE AMENDED FROM TIME TO TIME WITH THE STATE DEPARTMENT OF INSURANCE. I ALSO AGREE TO PROVIDE AND SIGN ANY OTHER DOCUMENTS AT MAY BE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES. ATEMENT OF FINANCIAL RESPONSIBILITY INDERSTAND THAT I AM FINANCIALLY AND LEGALLY RESPONSIBLE FOR CHARGES NOT COVERED IN FULL BY ANY THIRD PARTY. I FURTHER AGREE IAT SHOULD 1 NOT PAY THE BALANCE WITHIN THIRTY (30) DAYS AFTER THE DATE OF DISCHARGE, MY ACCOUNT WILL BE CONSIDERED DELINQUENT. I TREE TO PAY COSTS OF COLLECTION, INCLUDING REASONABLE ATTORNEY'S FEES AND COSTS, COLLECTION AGENCY FEES AND COSTS, AND rEREST WHICH SHALL ACCRUE AT THE MAXIMUM RATE ALLOWED BY LAW. AUD JY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY, OR FILES A STATEMENT OF CLAIM )NTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE SUBJECT TO PROSECUTION UNDER APPLICABLE LAW. )VANCE DIRECTIVE (FOR ADMISSION TO HOSPITAL ONLY) I AM TO BE ADMITTED TO THE HOSPITAL, I HAVE BEEN GIVEN WRITTEN MATERIALS ABOUT MY RIGHT TO ACCEPT OR REFUSE MEDICAL TREATMENT. I NVE BEEN INFORMED OF MY RIGHTS TO FORMULATE ADVANCE DIRECTIVES. I UNDERSTAND THAT I AM NOT REQUIRED TO HAVE AN ADVANCE RECTIVE IN ORDER TO RECEIVE MEDICAL TREATMENT AT THIS HOSPITAL. I UNDERSTAND THAT THE HOSPITAL AND MY CAREGIVERS WILL FOLLOW iE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW. JITIAL THE FOLLOWING OPTION THAT APPLIES) HAVE EXECUTED AN ADVANCE DIRECTIVE AND WILL PROVIDE A COPY OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME. INIT. HAVE NOT EXECUTED AN ADVANCE DIRECTIVE AND DO NOT WISH TO DO SO. INIT. (FOLLOW-UP DONE BY DATE WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITA IZATIO INIT. ;ERTIFY THAT ?,ti?E READ (O E BEEN READ) THE ABOVE CONSE "CERTIFICATIONS AND UNDERSTAND AND AGREE WITH THEM. 4TE' x-r+_ Ini-ti 1 MONTH i /DAY YEAR SIGNATURE OF PATIENT OR LEGALLY AUTHORIZED REPRESENTATIVE )1B 9271553 VIII ill ll IIIIII III IIII I IIII II (IIII Ili II 11111 Iil ll Iilll 11111 IIII IIII PRINT NAME OF PERSON ABOVE 0001028323 I IIIIII Iilll VIII VII I IPII VIII III II V) II VIII III II III I II I) • 3 Page OFFICE RECORD MIfRA ORTHOPEDICS BLACK, DAVIDSON M. Name DpB;_1,118/45 /5/04 OFFICE VISIT: 'his is a 58-year-old self-employed carpenter who was generally well until he was attacked by a St. lernard at a client's home on or about December 16th that bit his left hand and threw him to he ground on !J's left side. After that he went to the emergency room, had sutures done and he ays he took out his own stitches because he heals fast. Because he had some discomfort develop in is left arm similar to that which he had when he was told he had rotator cuff disease many years ago y Dr. Plank he went to the emergency room on 12/30/03, they x-rayed his shoulder and told him that e may need ar, MRI that he probably has recurrent rotator cuff problems and sprain associated with its fall. He describes it as a dull ache from the deltoid region to the fingertips, which is pretty much teady. He had some difficulty raising his arm initially but not really now. He said that he had the pain end rotator cuff problem in the 80's and it took about 2 years to quiet down and it has been pretty lood until now. He denies any neck pain and it is a low-grade discomfort for which he takes occasional over-the-counter medication. He finds that heat helps also. .XAMINATION: He has good range of motion with no impingement sign. There is no atrophy. He alks and demonstrates freely moving his arms around. His external rotation with resistance is good is well as abduction. Internal rotation is good. There is no distal atrophy. Intrinsics are intact. Biceps s intact. There is no tenderness around his shoulder area. Neck range of motion and posture are food. I reviewed x-ray of his left shoulder, which shows some reactive change at the greater uberosity consistent with chronic rotator cuff disease. The subacromial space is well preserved. He ilso had an x-., ::iy of his left hand here for review from 12/16/03, which shows some degenerative :hanges of the i' joints but otherwise no abnormalities. MPRESSION: Left shoulder sprain with probable mild recurrence of some rotator cuff tendonitis, left shoulder. IECOMMENDATION: I told him that I think he has no crepitus or weakness and good range of notion to suggest, that he any significant rotator cuff problem. I think that over time it should return to, its baseline or so and he should give it time. I don't see any evidence that he has an injury from this iccident including lacerations, which would be likely to cause him any long-term problems in my opinion. He seemed to be reassured and wanted to know this and he will call as needed. AJM/kas 31ack, Mr. Davidson M. Case Type: DB DOI: 12/16/2003 LimDate: 12/15/2005 Ase #: 209070 Class: Assigned: WSH Date Opened: 12/29/2003 11/8/2007 09:29 AM Value Code Dates of Service Value Summary Report Total Amount Total Paid Date Paid Payment Amount Page 1 of 1 Reduction Deduct From Client Paid By/To Lien IED 12/16/2003 - 12/30/2003 2,754.91 0.00 2,754.91 0.00 / Carlisle Regional Medical Center AED 12/16/2003 - 12/30/2003 592.00 0.00 0.00 8/17/2006 592.00 Lima bil ty / P rovider Central Penn Medical Group Emergency AED 1/5/2004 - 1/5/2004 105.00 0.00 105.00 0.00 / Mira, M.D., Dr. Alan J. .otals $ 3,451.91 $ 592.00 $ 2,859.91 -lens $ 0.00 There are no unvalued items on this report. Subtotals: MED $ 3,451.91 Paid By: Liability ,[ $ 592.001 Jon Bar- & Associates, Inc. >c - ONJBAI I O 216 LePhimp Ct ? Concord NC 28025-2954 PO Box 1022 1-800-230-5892 Wixom MI 48393-1022 ADDRESS SERVICE REQUESTED MAIL ALL CORRESPONDENCE TO: July 10, 2007 #BWNHRMD 0336055 0014018 #0710 1612 0014 0185# 4542961-14 1tul111n11n11n1lll1un111111111nl1tlnl1111nl11n111111 Scott Henning 1300 Linglestown Rd Harrisburg PA 17110-2838 t< <. , 200 JON BARRY & ASSOCIATES INC PO Box 748 Concord NC 28026-0784 Re: Davidson Black Account #: 4542961 Balance: $2754.91 '"`* Detach UpperlsoAion And Itetunl With Yuur Respcins?'a' ****TO MAKE PAYMENTS ON LINE VISIT WWW.PAYJBA.COM**** Security No.: 1021938816 Re: Davidson Black Account No.: 4542961 Balance: $2754.91 Dear Scott Henning, It is our understanding you represent the above individual(s). Please contact our office today in order for us to resolve this matter. Original Creditor: Carlisle Regional Medical Center 2160.36 Carlisle Regional Medical Center 594.55 Please Call: 1-800-230-5892 Upon settlement, please forward all payments to Jon Barry & Associates at the above address. This is an attempt to collect a debt and any information obtained would be used for that purpose. Debt Collectors Since 1986 NC Department of Insurance Permit #885. 20MBA110M JON BARRY & ASSOCIATES INC ? 2/6 LePhillip Ct ? Concord NC 28025-2954 # 1-800-230-5892 APPROVED M8 N 38-0279 3 PATIENT CONTROL NO. PARKER ST Z L I S LE PA 17 013 E M ENT COVERS PERIOD 7 COV D. 8 N-C D. 9 C-I O. 10 L-R D 5 FED. TAX NO. 6 STA 11 JEPHOIv2 (717) 218-8852 O M . FR - ENT NAME 13 PATIENT ADDRESS =, DAVE 25 PENNY LANE ENOLASLE PA 17025 THDATE 15 SEX 16 MS ADMISSION 17 DATE 18 HR 19 TYPE 20 SRC 21 D HR 22 STAT 23 MEDICAL RECORD NO. 24 CONDITIpN CODES 2B 26 30 31 OCCURRENCE DATE 34 OCCURRENCE CODE DATE 36 CODE OCCURRENCE SPAN FROM THROUGH 3 A B .UK, L)AVE VALUE C 5 3 VALUE CAM 4 ? AMOU C ODE 000E PENNY LANE 4 5 a b s )LASLE PA 17025 : d s I. CO. 43 DESCRIPTION 44 HCPCS / RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 i8 IV SOLUTIONS 121603:1 2 8:2'':.73. 10 MED-SUR SUPPLIES 121603 3 L 89:.49 0 DX: X'.-RAY 73130RT` 121603 1 220i..33 i0 EMERG ROOM 12002LT 121603 1 3961.93 i0 EMERG ROOM 90471 " 1.2:1603 1 3961..93 ; i0 EMERG ROOM 90788 121603 l _3961.' 93 i 0 EMERG- ROOM 9 9 2;8:4.2 5 1216 03 1 3'9'6:. 93 16 DRUGS OTHER 90718 121603 1 76166 1 TOTAL:. CHARGES ` 2.1.6 Oi:.:.3 6 . PAGE 1 OF h (ER 51 PROVIDER NO. - 5, PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 ic).LAIE HEALTH INS 2578ts 7146 : x 2160i. 36 • 21601. 36-1 URED'S NAME 59 P.REL 60 CERT. - SSN - HIC. - ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. 'ex, :ATMENT AUTHORIZATION CODES 64 ESC - - 65 EMPLOYER NAME 66 EMPLOYER LOCATION 9 SELF, DAVE BLACr R=711.m 25 PENNY LANE ENOLA i. DiAC. c0. oDE OTHER DIAG. CODES 70 CODE 72 CODE 74 CODE 76 ADM. DIAG. CD. 77 E-CODE 78 51 80 ,o EINCIPAL PROCEDORE 0 E DOTHER PR CED IRE E 82 ATTENDING PHYS. ID OTHER PROCEDURD CODE I ATE CODE DATE 83 OTHER PHYS.ID NARKS A OTHER PHYS. ID IAmi)uuoouun LLSTATE HEALTH INS 1655 VA LLEY CTR PKWY 200 85 PROVIDER REPRESENTATIVE 86 DATE BETHLEHEM PA 18017 lD ?o US-1 4bU OCR/OR I G 1 NAL I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PANT HEREOF. )5/06/04 PAGE 001 HEALTH MANAGEMENT ASSOCIATES DA17 COID: 858 CARLISLE REGIONAL MED CENTER AS OF 05/05/04 PATIENT: BLACK, DAVE F/C: P P/T: E DSC CODE: 01 UC: 9270 --- 162 ---- ---- ----- ADMISSION: 12/16/03 DI -------------------------------------- SCHARGE: --------- 12/16/03 ------ ------ ;HG DATE DPT REV BAT# HCPC M1M2 CHGCD ------------ DESCRIPTION --------------------- QTY --------- ---- AMOUNT --------- -2/16/03 ---- 412 ---- 250 ----- 5206 ----- 04210 BUPIVACAINE 0.5% 30M 1 ---------- 75.27 .2/16/03 412 250 5206 05610 CEFAZOLIN 1GM INJ 1 28.16 .2/16/03 412 636 5206 90718 36300 TET DIP TOX ADULT 0. 1 76.66 -2/16/03 412 250 5206 05610 CEFAZOLIN 1GM INJ 1 28.16 -2/16/03 416 258 5206 49140 WATER STERILE 10ML I 1 11.15 -2/16/03 416 258 5400 02760 SODIUM CHLORIDE 0.90 1 71.58 L2/16/03 418 270 5400 00493 SET CONTINU FLO 0.22 1 31.31 L2/16/03 418 270 5400 26890 TRAY LACERATION 5288 1 43.49 L2/16/03 428 320 8 73130 RT 73130 HAND MIN 3V 1 220.33 L2/16/03 418 270 5 25167 SUTURE TYPE I 2 46.00 L2/16/03 480 450 5 99284 25 00517 ER DEPT EXTENSIVE VI 1 653.40 L2/16/03 480 450 5 97001 ER PROCED INTERMED 1 770.96 L2/16/03 480 450 5 90471 97005 DT INJECTION 1 81.68 L2/16/03 480 450 5 90788 97503 INJ ANTIBIOTIC IM 1 81.68 CONTINUED... 3_EL,EfT_- RFV= * DEPT= * CHG-CD= * -DATE/-MDCY-- * TO/MDCY= * 'MD:I=DAR,2=PAT 4=SUMMARY,S=TOP,6=END,7=RETURN,8=BACKWARD ENTER=FORWARD V 15/06/04 PAGE 002 HEALTH MANAGEMENT ASSOCIATES DA17 COID: 858 CARLISLE REGIONAL MED CENTER AS OF 05/05/04 PATIENT: BLACK, DAVE F/C: P P/T: E DSC CODE: 01 /C: 9270 162 ADMISSION: 12/16/03 DISCHARGE: 12/16/03 - ----- -- .-------- :HG DATE -------- DPT REV - ------ BAT# ------ ------ - ---------------------- HCPC M1M2 CHGCD DESCRIPTION -- ---------------------------- - ------------------- QTY AMOUNT --------- I -------- ,2/16/03 ------- 412 250 3558 - - ---- 05610 CEFAZOLIN 1GM INJ ---------- 1- 28.16- .2/16/03 418 270 3558 00493 SET CONTINU FLO 0.22 1- 31.31- ------------------------------------------------------------------------------- TOTAL CHARGES 2,160.36 'OTAL: CASH > 0.00 ADJUSTMENTS > 0.00 BALANCE > 2,160.36 ;ELECT: REV= * DEPT= * C.H.GCD= * DATE/MDCY= * TO/MDCY= * ENTER=FORWARD 4=SUMMARY,S=TOP,6=END,7=RETURN,8=BACKWARD -LJ.iaJ..Ir, nr?v1V1VHJJ L•1LlJ r?1v _ 3 PATIENT CONTROL NO. ? s - 5 PARKER ST r R L I S L E • PA 6 STATEMENT COVERS P 17013 fED 7 COV D ` TAX NO R u 8 N-C D. 9 C-1 D. 10 L-R D. 11 LEPHONE (717) 218 . . GH iI iRO -8852 - 'IENT NAME 13 PATIENT ADDRESS ACK, DAVIDSON 25 PENNY LANE ENOLASLE PA 17025 iTHDATE 15 SEX 16 MS 17 DAIE ADMISSION 18 HR 19 TYPE 20 SRC 21 D HR 22 STAT 23 MEDICAL RECORD NO. 24 CONDITION' CODES I_ _I 26 28 80 31 OCCURRENCE 34 OCCURRENCE 36 OCCURRENCE SPAN '- T R UGH 37 A DATE O H CDC, DATE CODE- :FROM 39 VALUE CODES 41 VALUE CODES r CODE AMOUNT CODE AMOUNT. PENNY LANE a 4 15:.0 b DLASLE PA 17025 d .1 L :V. CD. 43 DESCRIPTION 44 HCPCS /RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 -0- X-RAY DX 7303OLT 123003 1 220:.33 50 EMERG ROOM 992>>8225 12300.3 1 374:.22` 01 TOTAL CHARGES 594;.55 PAGE 1 OF 1 AYER 51 PROVIDER NO, 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 - A • 5 94: ISURED'S NAME 59 P.REL 60 CERT. - SSN - HIC. - ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. EHM' REATMENT AUTHORIZATION CODES 64 ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION r DAVE BLACK XE.PA-I-R_ 2!:, PENNY L ANE EN 0 IjA IIN. DIAG. CD. 68 CODE OTHER DIAG. CODES 70 CODE 72. CODE 74 CODE 'i' " 76 ADM. DIAG. CD. 77 E CODE 78 8409 lE9UbU 80 PRINCIPAL PRO CEDURE 8 1 OTHER PR OCEDURE 82 ATTENDING PHYS ID CODE DATE CODE DATE . CODE PRO CEDURDATE CODE OTHER PRU UEDURF DATE 83 OTHER PHYS.ID IEMARKS ALLSTATE INS 1655 VALLEY CTR PKWY 200 BETHLEHEM PA 18017 OTHER PHYS. ID 12 CMS-1450 OCR/ORIGINAL I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF. RR n? /1 S2 /na Central Penn Medical Grou ;mergency P. O. Box 619 East Petersburg, ?-A 17520-0619 Phone 866-247-3141 Fax 1-405-607-1326 TAX ID# 23-3013255 patientinquily@,mjca.net visit us online at www.mjca.net BLACK, DAVIDSON C/O W. SCOTT HENNING ATTY. 1300 LINGLESTOWN HARRISBURG, PA 17110 160.00 NUMBER 9271553 STADIA EE- 06/11/04 PATIENT BLACK, DAVIDSON P'"XTO R ; NAMC C UA RAYTO BLACK+ DAVIDSON _FROVIDEA LASEK M.D., ROBERT SERVICCS "NDUEOAT CARLISLE REGIONAL MEDICA CARLISLE, PA IF PAYING RY VISA. MASMCARD. OR AMERICAN ILCPRM FILL OUT RFA.OW ? Vetl ? ?. CARDNUMBER AMOUNT SIGNATURE EXP DATE PLEASE DETACH AND RETURN THIS PORTION WITH REMITTANCE ------------------'-------------'------ --^- --__'-_-- ---------------------------------------- PLEASE ICFFp THIS PORTION FOR YOUR RECORDS DATE TREATING PROVIDER DESCRIPTION OF SERVICE CHARGES/CREDITS BALANCE 12/30/03 9901 STROUP EMERGENCY DEPT VISIT TO DATE, WE HAVE RECEIVED NO RESPONSE FROM YOUR INSURANCE COMPANY REGARDING SERVICES PROVIDED BY EMERGENCY PHYSICIAN. PLEASE FOLLOW UP WITH YOUR INSURANCE COMPANY TO DETERMINE THEIR REASON FOR IN PAYING THIS CLAIM. OTHERWISE, PLEASE PAY THE INDICATED ON THIS STATEMENT. THANK YOU. Referred by LASEK M.D., ROBERT 160.00 THE DELAY BALANCE 160.00 Please Remit Payment to: If you have questions regarding this bill please call CENTRAL PENN MEDICAL GROUP EMERGENCY PO BOX 619 1-866-247-3141 (toll free) or email EAST PETERSBURG, PA 17520-0619 patientinquirya,mica.net. THANK YOU. FOR YO UR CONVENIENCE, YO U MAY PAY ONLINE AT www. Mjca. net Central Penn Medical Gror 'mergency P. O. Sox 619 East Petersburg, r A 17520-0619 Phone 866-247-3141 Fax 1-405-607-1326 TAX ID# 23-3013255 patientinguiry@,Mjca.net visit us online at www.mjca.net BLACK, DAVIDSON C/O W. SCOTT HENNING ATTY. 1300 LINGLESTOWN HARRISBURG, PA 17110 K RAM 0 INAL, I I 432.00 7 ACCOUNT NUMBER 9270162 SIATYD/" DATE 06/11/04 PATIENT. BLACK, DAVIDSON PATIENT/ GUARANTOR R NAME BLACK1 DAVIDSON PROVIDER CORDLE MD, RANDALL SERVICILS RENDERED AT CARLISLE REGIONAL MEDICA CARLISLE, PA IF PAYING By NSA, MASTERCARD, OR AMERICAN E.IPRUII, FILL OuT BEIAW ? VISA ? ?,. CARD NUMBER AMOUNT SIGNATURE EXPDATE PLEASE DETACH AND RETURN THIS PORTION WITH REMITTANCE ---------------------------------------- ------------------------------------------ P-LEASE ----KEEP---THTI--IS'P-OR--ON ---FOR -- YO-URR---EC-O--RDS DATE TREATING PROVIDER DESCRIPTION OF SERVICE CHARGES/CREDITS BALANCE 12/16/03 1113 CORDLE EMERGENCY DEPT VISIT 160.00 160.00 12/16/03 1113 CORDLE REPAIR SUPERFICIAL WOUND(S) 272.00 272.00 TO DATE, WE HAVE RECEIVED NO RESPONSE FROM YOUR INSURANCE COMPANY REGARDING SERVICES PROVIDED BY THE EMERGENCY PHYSICIAN. PLEASE FOLLOW UP WITH YOUR INSURANCE COMPANY TO DETERMINE THEIR REASON FOR DELAY IN PAYING THIS CLAIM. OTHERWISE, PLEASE PAY THE BALANCE INDICATED ON THIS STATEMENT. THANK YOU. Referred by CORDLE MD, RANDALL Please Remit Payment to: If you have questions regarding this bill please call CENTRAL PENN MEDICAL GROUP EMERGENCY PO BOX 619 1-866-247-3141 toll free or email EAST PETERSBURG, PA 17520-0619 patientinquiry(a,mica.net. THANK YOU. FOR YO UR CONVENIENCE, YO U MAY PAY ONLINE AT www. mjca. net FEB 0 9 2004 nm%fisr V r.Aw* yi. ART" BLDG., SUITE 20 , :,I.E.; PA 1.701.: 19-7400 t1. II) -3...211.%81-) Itemi.; d SJ(;.';J,;;m"nt Ci1/0: /204;4 ._ 01.10' P004 (c) M.J...5y Prlnted,? 0?/05/ZM4 7;47 E'M V ?K, rAIVIDIS(W Mt Pat ID: PENNY I.PAE Di?bo 01/18/1.945 )(P., PA 1.7025 Age; 59 '/691-01.99 warlcc, Company Policy H Group 9 ?LLSTATE IRUPME 51.52493916 7)5 VALICY C fR PKWY SUITti 200 BETI II.OAP.M, PA 18017 'e oa.te(s) Patient Flame Code Description Gua rantor 004J8< °0001. SP S.'-7, AcctID., 8904 BLACK, 0AVIDS(PI M. t'A 1t>?- ?-:31..ti 25 PENNY I.APIE MIA, PA 1.7025 717/6"1-0199 Other Info I-VAder Effective D,?th(s) H04 BLACK, DAVIDS01 M. City/Src Charged Open Prov. Place Caseg r04 BLACK, DAVIDSON r. 9')203 OV NN PAT. W)D. SLV. 1.00 1.05,N IV6.00 MIRA OF DiagP: 840.9 SPRAIN Sfan:IL1LDI:R U4 SPECIFIED D.,;,.g8. 8&? '0 WIVU 14410 W/O COMPLICATION it B, lancos It B.'lance 11?k".00 wi],a1.1 1.!5.00 la) i'alancf- 105.0') once Ra_Luc:e n 0.00 t Ei?.s)arlC(' 0.00 Tot ).s From 0]./0`1/2004 Thru 01/0:5/2004 Ch .rges MAO -tion Ralancr 0100 91 40 W. Scott Henning, Esquire I.D.#32998 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 (717) 238-2000 Attorneys for Plaintiffs DAVIDSON M. BLACK, Plaintiff V. ROSE E. BREHM and JAMES BREHM, Defendants : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA NO. 05-6388 CIVIL ACTION - LAW JURY TRIAL DEMANDED CERTIFICATE OF SERVICE On November 8, 2007, 1 hereby certify that a true and correct copy of Plaintiffs Arbitration Exhibits (Rule 1305) was served upon the following by depositing in U.S. Mail, post pre-paid: Donald L. Carmelite, Esquire Marshall, Dennehey, Warner, Coleman & Goggin 4200 Crums Mill Road, Suite B Harrisburg, PA 17112 Respectfully Submitted, HANDLER, HENNI G & OSENBERG, LLP Date: 11/8/07 By: W. Scott Hennin_ . q re ?? ? _ ? _ ?. ?, •?: ? i'_? r ?? ; ,C "? r:- ?...? ? l? : .. W. Scott Henning, Esquire I.D.#32998 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 (717) 238-2000 Attorneys for Plaintiffs DAVIDSON M. BLACK, Plaintiff V. ROSE E. BREHM and JAMES BREHM, Defendants : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA NO. 05-6388 : CIVIL ACTION - LAW : JURY TRIAL DEMANDED PRAEC/PE TO THE PROTHONOTARY OF CUMBERLAND COUNTY, PENNSYLVANIA: Please mark the above captioned matter settled and discontinued. Date: - V-0-w K HANDL HENNING 8 R SENBERG, LLP By W. Scott Henni qu' e Attorney I.D. # 2'X880/ 1300 Linglestown R ad Harrisburg, PA 17 10 (717) 238-2000 ATTORNEY FOR PLAINTIFF s W. Scott Henning, Esquire I.D.#32998 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 (717) 238-2000 Attorneys for Plaintiffs DAVIDSON M. BLACK, Plaintiff V. ROSE E. BREHM and JAMES BREHM, Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 05-6388 CIVIL ACTION - LAW JURY TRIAL DEMANDED CERTIFICATE OF SERVICE On February 4, 2008, 1 hereby certify that a true and correct copy of Plaintiff's Answers to Interrogatories of Defendants was served upon the following by depositing in U.S. Mail, post pre-paid: Donald L. Carmelite, Esquire Marshall, Dennehey, Warner, Coleman & Goggin 4200 Crums Mill Road, Suite B Harrisburg, PA 17112 Respectfully Submitted, HENNING &/FZQSENBERG, LLP Date: 2/4/08 By: ui N c O ? Q7 film c ? t Yi + Z5 W following award: (Note: If damages for delay are awarded, they shall be separately stated.) A' )OA Imo , llL `'L G fi[?? thin !? ?(' J, Defendant -/ Oath laZ401 16?9~ q6?G( 207-19-bciLI2 ao98 Award* 188x3 a We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the J LI Address Address Address L"5 k ,,41 f 7 U4rel- I /-t City, zip city, zip City, zip ' A??? fP Plain ' In The Court of Common Pleas of Cumberland County, Pennsylvania No._ I!LZ Civil Action - Law. We do solemnly swear (or affirm) that we will support, obey and defend the Constitution of the United- States and the Constitution of this Commonwealth and that we will discharge the duties of our office Name (Chairman) with fidelity. Signature F / ut?,aaaau?Y .?PSS4N A• KIGGI Name Law Firm Law Firm . Arbitrator, dissents. (Insert name if applicable.) Date of; earng: z Date of Award: I / 11:2id P 2 //d Notice of Entry Now, the d5lN' day of r 20 07 , at A: C19 P .M., the above award was entered upon the docket and notice thereof given by mail to the parties or their attorneys. Arbitrators' compensationjo be paid upon appeal: $ 350.00 By: Prothonotary Deputy rv t 'a 'T3 co CD M pie's µenn'n 9e?;te, o OEM WG• o0natd 01 1a) 0 4d 44&'OJq •V;)S slros7??'!7'f' /oJroL? llH+b '-o/8z/-c/ s-