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HomeMy WebLinkAbout01-5511IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. 2001 -S'KII Civil Action - (XX) Law ( ) Equity JURY TRIAL DEMANDED SARA L. WORMAN and JARED N, WORMAN 522 Springhouse Road Camp Hill, PA 17011 GIANT FOOD STORES, INC. a/k/a GIANT FOOD STORES, LLC 1149 Harrisburg Pike Carlisle, PA 17013 Plaintiff(s) & Address(es) Defendant(s) & Address(es) PRAECIPE FOR WRIT OF SUMMONS TO THE PROTHONOTARY OF SAID COURT: Please issue A Writ of Summons in the above-captioned action. X WritofSummonsShallbeissuedandforwardedto( )~ / W. Scott Hennin.q, Esquire 1300 Linqlestown Road P.O. Box 1177 Signature ofAttor eyr~.~ ~ Harrisburq, PA 17108 NI (717) 238-2000 Supreme Court ID No. 32298 Name/Address/Telephone No. of Attorney Date: 9/17/2001 WRIT OF SUMMONS TO THE ABOVE NAMED DEFENDANT(S): YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFF(S) HAS/HAVE COMMENCED AN ACTION AGAINST YOU. Prothonotary Date: .~?¢ t~ ,~- I . ~_ t"~t:~' ! b Y~,,.~.~. ~ ~_.:~ o__ ~'~' -- -- ~ ~ I~ep uty ( ) Check here if reverse is used for additional information 1ROTHON. - 55 SHERIFF'S RETURN - REGULAR CASE NO: 2001-05511 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND WORMAN SARA L ET AL VS GIANT FOOD STORES INC ET AL KENNETH GOSSERT , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within WRIT OF SUMMONS was served upon GIANT FOOD STORES INC the DEFENDANT , at 1520:00 HOURS, on the 26th day of September, 2001 at 1149 HARRISBURG PIKE CARLISLE, PA 17013 HAVEN FISH, LEGAL ADMIN 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 3.25 Affidavit .00 Surcharge 10.00 .00 31.25 Sworn and Subscribed to before me this /~- day of A.D. O. rothonotary So Answers: R. Thomas Kline 09/27/2001 PLANDLER HENNING & ROSENBERG~, By, .,~~/ ~ MARTSON DEARDORFF WILLIAMS &e OTTO DWS O TEN EAST CARLISLE, PENNSYLVANIA 17013 SARA L. WORMAN and JARED N. WORMAN, Plaintiffs GIANT FOOD STORES, 1NC., a/k/a GIANT FOOD STORES, LLC, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 2001-5511 JURY TRIAL OF TWELVE DEMANDED PRAECIPE TO THE PROTHONOTARY OF CUMBERLAND COUNTY: Enter the appearance of MARTSON DEARDORFF WILLIAMS & OTTO on behalf of Defendant, GIANT FOOD STORES, LLC, in the above matter and issue a role upon the Plaintiffs to file a Complaint within twenty (20) days from service thereof or suffer judgmem of non pros. Defendant hereby demands a twelve juror jury trial in the above captioned action. MARTSON DEARDORFF~WILLIAMS Gd~rg~ B. Fal]~e~, Jr.,'~uh, ex I.D. No. 49813 Ten East High Street Carlisle, PA 17013 (717) 243-3341 & OTTO Attorneys for Defendant Giant Food Stores, LLC Dated: October 5, 2001 RULE t~4~.. 0~' 2001, a Rule is issued upon the Plaintiffto file AND NOW, thisJ day of , a Complaint within twenty (20) days from service hereof. ProthZono-tary ~ , -/ CERTIFICATE OF SERVICE I, Melinda A. Hall, an authorized agent for Martson Deardorff Williams & Otto, hereby certify that a copy of the foregoing Praeeipe was served this date by depositing same in the Post Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows: W. Scott Henning, Esquire HANDLER, HENNING & ROSENBERG 319 Market Street P.O. Box 1177 Harrisburg, PA 17108 MARTSON DEARDORFF WILLIAMS & OTTO BYMdin~dak~.~allL~ ~//~- ~ -~ Ten East High Street Carlisle, PA 17013 (717) 243-3341 Dated: October 5, 2001 HANDLER HEI G& ROSF, NBERG ATTORNEYS AT LAW · P. O. Box 1177 ° Harrisburg, PA 17108 · (717)238-2000 148A Eost King Slreet, Lancaster, PA 17602 · (717)431-401m SARA L. WORMAN, Plaintiff V. : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, PENNSYLVANIA : : CIVIL ACTION-LAW : : No. 2001-5511 GIANT FOOD STORES, INC. : a/k/a GIANT T FOOD STORES,: LLC : Defendant : JURY TRIAL DEMANDED NOTICE You have been sued in court. If you wish to defend against the claims set f°rth 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 OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 Liberty Avenue Carlisle, PA 17013 Telephone 717-249-3166 or 800 990-9108 HANDLER, HENNING & ROSENBERG BYw. Scott Henn,r~J',/ Es/. I.D. #32298~ ' / 1300 Linglestown/Road Harrisburg, PA 1/7110 (717) 238-2000 Attorney for Plaintiff SARA L. WORMAN, Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION-LAW V. : : GIANT FOOD STORES, INC., : a/ida GIANT T FOOD STORES,: LLC : Defendant : No. 2001-5511 JURY TRIAL DEMANDED COMPLAINT AND NOW, comes the Plaintiff, SARA L. WORMAN by and through her attorneys, HANDLER, HENNING & ROSENBERG, by W. Scoff Henning, Esquire, and brings forth this Complaint against Defendant GIANT FOOD STORES, INC., a/k/a GIANT FOOD STORES, LLC and aver as follows: 1. Plaintiff, Sara L. Worman, is an adult individual currently residing at 522 Springhouse Road, Camp Hill, Cumberland County, PA 17011. 2. Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, is a corporation registered and established under the laws of Pennsylvania, with a location at 700 Camp Hill Shopping Plaza, Camp Hill, Cumberland County, PA 17011. 3. Defendant Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, is a corporation registered and established under the laws of Pennsylvania, with a registered office 1149 Harrisburg Pike, Carlisle, Cumberland County, PA 17013. 4. At all times material hereto, Plaintiff, Sara L. Worman, was a business invitee upon said Premises. 5. At all times material hereto, Defendants, who had exclusive control of said Premises, had allowed a squashed red pepper to remain on the floor in the produce area. 6. At all times material hereto, there were no warning signs posted on the Premises warning of the possibility that produce was on or remained on the floor. 7. On or about October 12, 1999, at about 10:30 AM, Plaintiff, Sara L. Worman, was on the Premises shopping. While shopping in the produce aisle, Plaintiff was caused to slip and fall harshly and roughly to the ground due to a squashed red pepper, that was allowed to remain on the floor, causing personal injuries upon the Plaintiff as detailed more specifically hereinafter. COUNT I- NEGLIGENCE Sara L. Worman v. Giant Food Stores, Inc. a/k/a Giant Food Stores LLC length. 9. Paragraphs 1 - 7 are incorporated herein by reference as if fully set forth at At all times material to hereto, Plaintiff, Sara L. Worman, believes and therefore avers, that Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, was in ownership, possession, management and control of the Premises and was responsible for maintaining the safe condition of the property known as a Giant Food Stores located at 700 Camp Hill Shopping Plaza, Camp Hill, Cumberland County, PA 17011. 2 10. The occurrence of the aforementioned incident and the resulting injuries to Plaintiff, Sara L. Worman, were caused directly and proximately by the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, by its agents, servants, workmen or employees, acting in the scope of their authority and employment, generally and more specifically as set forth below: (a) in causing or permitting the floor at Premises to become littered with a squashed red pepper and/or other produce, thereby posing an unreasonable risk of injury to the Plaintiff and to other persons lawfully upon the premises; (b) In failing to make a reasonable inspection of said Premises which would have revealed the existence of the dangerous condition posed by the squashed red pepper, and thereby allowing the same to be and remain a dangerous condition when the Defendant knew or should have known of it; (c) In failing to ensure the floors at said Premises were maintained in a safe condition to prevent injury to the Plaintiff and other persons lawfully upon the Premises; (d) In failing to post a warning sign or device in the area to notify of the dangerous condition on the floor of said Premises; 3 (e) In failing to clean the squashed red pepper from the floor of said Premises so as to avoid the situation in which the Plaintiff slipped and fell; and (f) In failing to maintain the common floor in a reasonably safe condition that would prevent a customer from slipping and falling. 11. Defendant, Giant Food Stores, Inc. a/ida Giant Food Stores LLC, had actual knowledge or should have known through the exbrcise of ordinary care and diligence that there was a squashed red pepper on the floor in the area where Plaintiff, Sara L. Worman, fell. 12. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/Ida Giant Food Stores LLC, Plaintiff, Sara L. Worman, sustained serious injuries including, but not limited to, extreme trauma to her left wrist, neck and rib area. She suffered a comminuted T-shaped fracture to the distal radius of the left arm. 13. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/Ida Giant Food Stores LLC, Plaintiff, Sara L. Worman, has undergone great physical pain, discomfort and mental anguish and she will continue to endure the same for an indefinite period of time in the future, to her great detriment and loss, physically, emotionally and financially. 14. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/Ida Giant Food Stores LLC, Plaintiff, Sara L. Worman, has been, and will in 4 the future be, hindered from attending to her daily duties to her great detriment, loss, humiliation and embarrassment. 15. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/k/a Giant Food Stores LLC, Plaintiff, Sara L. Worman, has, and will in the future, suffer a loss of life's pleasures. 16. As a direct and proximate result of the negligence of Defendant, Giant Food Stores, Inc. a/ida Giant Food Stores LLC, Plaintiff, Sara L. Worman, has been compelled, in order to effect a cure for the aforesaid injuries, to expend large sums of money for medicine and medical attention, and will be required to expend large sums of money for the same purposes in the future, to her great detriment and loss. WHEREFORE[, Plaintiff, Sara L. Worman, seeks damages from Defendant Giant Food Stores, Inc. a/Ida Giant Food Stores LLC, in an amount in excess of Twenty-Five Thousand Dollars ($25,000.00), exclusive of interest and costs, which is an amount in excess of jurisdictional amounts requiring compulsory arbitration. Respectfully submitted, HANDLE~ W. Scott H.~,~fi~ng / I.D. # 32,2'98 / 1300 Lin'g'l'~s'~wn R( & ROSENBERG / P.O. Box 1177 Harrisburg, PA 17!/08-1177 (717) 238-2000 Attorney for Plaintiff 5 VERIFICATION The undersigned hereby verifies that the statements in the foregoing document are based upon information which has been furnished to counsel by me and information which has been gathered by counsel in the preparation of this lawsuit. The language of the document is of counsel and not my own. I have read the document and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information and belief. To the extent that the contents of the document are that of counsel, I have relied upon my counsel in making this Verification. The undersigned also understands that the statements made therein are made subject to the penalties of 18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities. Sara~'~-rrr~a~ I ' Date: SARA L. WORMAN, Plaintiff GIANT FOOD STORES, INC., a/k/a GIANT T FOOD STORES, LLC Defendant : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, PENNSYLVANIA : : CIVIL ACTION-LAW : No. 2001-5511 .' : JURY TRIAL DEMANDED CERTIFICATE OF SERVICE On this 6th day of November, 2001, I hereby certify that Plaintiff's Cmplaint with Notice to Defend was served upon the following by U.S. mail, certified delivery: George B. Failer, Jr., Esquire MARTSON, DEARDORFF WILLIAMS & OTTO Ten East High Street Carlisle, PA 17013 Date: 11/6/2001 W. S/~-'~nn~g, _Es/~u. ire 130(~Lingle~own R/bad Harris-'b-~g, PA 17//110 (717) 238-2000 / ATTORNEY FOR PLAINTIFF · IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY WORMAN VS. GIANT FOOD STORES NO. 2001 5511 CERTIFICATE PREREQUISITE TO SERVICE OF A SUBPOENA PURSUANT TO RULE 4009.22 As a prerequisite to service of a subpoena(s) for documents and things pursuant to Rule 4009.22 GEORGE FALLER, ESQUIRE certifies that: 1. A Notice of Intent to Serve the Subpoena(s) with a copy of the subpoena(s) attached thereto was mailed or delivered to each party at least twenty days prior to the date on which the subpoena(s) is sought to be served, 2. A copy of the Notice of Intent, including the proposed subpoena(s) is attached to this certificate, 3.No objection to the subpoena(s) has been received, and 4. The subpoena(s) which will be served is identical to the subpoena(s) which is attached to the Notice of Intent to Serve the Subpoena(s). Date: 11/21/01 GEORGE FALLER, ESQUIRE MARTSON DEARDORFF WILLIAMS TEN EAST HIGH STREET CAP. LISLE, PA 17013 717-243-3341 ATTORNEY FOR DEFENDANT INQUIRIES SHOULD BE ADDRESSED TO: MEDICAL LEGAL REPRODUCTIONS, 4940 DISSTON STREET PHILADELPHIA PA 19135 (215) INC. By: Christine Janiszewski File #: M280652 ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY WORMAN Vs. GIANT FOOD STORES No. 2001 5511 TO: W SCOTT HENNING NOTICE OF INTENT TO SERVE A SUBPOENA TO PRODUCE DOCUMENTS AND THINGS FOR DISCOVERY PURSUANT TO RULE 4009.21 DEFENDANT intends to serve a subpoena(s) identical to the one(s) attached to this notice. You have twenty (20) days from the date listed below in which to file of record and serve upon the undersigned an objection to the subpoena. If no objection is made the subpoena may be served. Date: 10/31/01 GEORGE FALLER, ESQUIRE MARTSON DEARDORFF WILLIAMS TEN EAST HIGH STREET CARLISLE, PA 17013 ATTORNEY FOR DEFENDANT INQUIRIES SHOULD BE ADDRESSED TO: MEDICAL LEGAL REPRODUCTIONS, 4~40 DISSTON STREET PHILADELPHIA, PA 19135 (215) 335-3336 INC. By: Christine Janiszewski Enc (s): File #: Copy of subpoena(s) Counsel return card M280652 · co--TH OF pI~thqYLVANIA WORMAN Vs. GIANT FOOD STORES COUNt~ OF ~ Fi le No. 2001 5511 TO: SUBPOENA TO PROOU(~ DOOJMENTS OR 'Pr'Il NGS FOR DISCOVERY PURSUANT TO RULE 4009.22 HOLY SPIRIT HOSP, 503 N 21ST ST, CAMP HILL PA 17011 ATTN: MEDICAL RECORDS DEPT (Name of Person or Entity) within twenty (20) days afte~ service of this subpoena, you a~e ordered by the court to produce the fo1 lowing docunent.~ ADDENDU i ~g%~ ~940 DISSTON ST., PHILA., PA MEDICAL LEGAL REPRODUCTIONS~A s You may deliver or mail legible copies of the doctrnents or produce things requested this subpoena, together with the certificate of coTpliance, to the party making thi~ 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, days after its se~vlce, the party serving 'this subpoena may seek a court order' O.~l~elling you to co,~ly with it. TH I S SUBPOENA WAS ADDRESS: ISSUED AT THE RE(ZJESTf~THEFOLLOHINGPERSOfl: GEORGE FALLER, ESQ MARTSON DEA/{DORFF WILLIAMS TELEPHONE: ~REME COI,~T ID ~ ATTORNEY FOR: ~ ~o~ ~ PA 17013 215-33b-3212 49813 DEFENDANT M280652-01 DATE: Seal of the Oourt BY ~ COURT: Prothonotary/~l'e~k~ Civil Oivisioo I>e~uty (Eff. 7/97) ADDENDUM TO SUBPOENA WORMAN VS. GIANT FOOD STORES NO. 2001 5511 CUSTODIAN OF RECORDS FOR: HOLY SPIRIT HOSP Any and all hospital records, including microfilm, microfiche emergency room reports, x-ray r~ports, out-patient records physical therapy records, and any other information pertaining to: DATE NAME: ADDRESS: 0F BIRTH: SSAN: SARA L WOPdW3~N 522 SPRING HOUSE RD 04/16/38 161323713 CAMP HILL PA ALL FEES MUST BE APPROVED PRIOR TO RECORDS BEING FORWARDED. RECORD CUSTODIAN COMPLETE AND RETURN ] RECORDSAREATTACHED HERETO:I hereby certify as custodian of records that, to the best ?f my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NO DOCUMENTS AVAILABLE:I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): RECORDS ( ) PATIENT BILLING X-RAYS ( ) RECORDS / XRAYS have been destroyed Date CUMBERLAND M280652-01 Authorized signature for HOLY SPIRIT HOSP *** SIGN AND RETURN THIS PAGE *** ~TH OF p~X%ISYLVANIA WORMAN GIANT FOOD STORES Fi le No. 2001 5511 TO: SUBPOENA TO PROOUCE DOCIJHE~S OR THINGS FOR DISCOVERY PURSUANT TO RU1.E 4009.22 ORTHO INST OF PA, 875 POPLAR CHURCH RD, C~P HILL PA 17011 (N~e of Person o~ Entity) Within twenty (20) days afte~ service of this subpoena, you a~e ordered by the court to pr~uce the foll~in9 ~tm~ ~~ u~ng~----~--~ at DISS os SILA., MEDICAL LEGAL REPRODUCTIONS,(A s You may deliver or mail legible co~ies of the doctrr~.nts or produce things requested bt this subpoena, together with the certificate of co',oliance, to the party making this request at the address listed 'above. You have the risht to seek in advance the rea~onabl~ 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' orm%oelling you to cu,Oly with it. THIS S~IK~NA WAS ISSUED AT THE RE(~ST OF THE FOLLONING PERSON: NAME: GEORGE FALLER, ESQ ADORESS: MARTSON DEARDORFF WILLIAMS TELEPHONE: SUPREPE COURT ID ~ AI'TORNEY FOR: 215-335-3E12 49813 DEFENDANT M280652-02 DATE: Seal of the ~ourt BY THE COURT: Prothonotary~/~e~k, Civil D~vision (Elf. 7/97) ADDENDUM TO SUBPOENA WORI~kN VS. GIANT FOOD STORES NO. 2001 5511 CUSTODIAN OF RECORDS FOR: ORTHO INST OFPA ANY AiqD ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMOP~ANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: DATE NAME: ADDRESS: 0F BIRTH: SSAN: SARA L WORMAN 522 SPRING HOUSE RD 04/16/38 161323713 CAMP HILL PA CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN COMPLETE AND RETURN [ ] RECORDSAREATTACHEDHERETO:I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NODOCUMENTSAVAILABLE:I hereby certify that a thorQugh search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date CUMBERLAND M280652-02 Authorized signature for ORTHO INST OF PA *** SIGN AND RETURN THIS PAGE *** WORM_AN VS. GIANT FOOD STORES CO~TH OF p]~YLVANIA COONTY OF O3MBERLAND Fi le No. 2001 5511 TO: SUBPOENA TO PROEX3CE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 CAPIT_A_L AREA SURGICAL, 890 POPLAR CHURCH RD #200, CAMP HILL PA 17011 (Name of Person o~ Entity) Within twenty (20) days after service of this subpoena, yo~ are ocde~ed by the court to produce the fol lo in docu t. DEND Tvi MEDICAL LEGAL REPRODUCTIONS,(A~C~ss%940 DISSTON ST., PHILA., PA You may deliver o~ mail legible copies of the documents o~ produce things requested this subpoena, together with the certificate of comoliance, to the party making thi~ request at the address listed above. You have the right to seek in advance the rea~onabl~ cost of preparing the copies or producing the things sought. If you fail to produce the doctrnents o~ things required by this subpoena within twenty (20) days after its service, the party serving this subpoena may seek a court orde~- o~ellir~j you to cu,~ly with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOtLO~ING PERSON: NAME: GEORGE FALLER, ESQ ADORESS: MARTSON DEkRDORFF WILLIAMS TELEPHONE: SUPREME COURT ID ~. ATTORNEY FOR: CA/~LISLE, PA 17013 215-~35-321~ 49'813 DEFENDANT M280652-03 11'/o /0 DATE: Seal of the Court (Elf. 7/97) ADDENDUM TO SUBPOENA WORMAN VS. GIANT FOOD STORES NO. 2001 5511 CUSTODIAN OF RECORDS FOR: CAPITAL AREA SURGICAL ANY AND ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: NAME: ADDRESS: DATE 0F BIRTH: SSAN: SARA L WORM_AN 522 SPRING HOUSE RD 04/16/38 161323713 CAMP HILL PA CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN COMPLETE AND RETURN [ ] RECORDSAREATTACHED HERETO:I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NODOCUMENTSAVAILABLE:I hereby certify that a thorough ~earch has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) x-RAYS ( ) RECORDS / XRAYS have been destroyed Date CUMBERLAiqD M280652-03 Authorized signature for CAPITAL AREA SURGICAL *** SIGN AND RETURN THIS PAGE *** WORMAN VS. GIANT FOOD STORES c~TH OF pI~]NSYLVANIA : Fi le No. 2001 5511 TO: SUBPOENA TO PROOUCE DO:3JMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 PENN REHAB ASSOS, 2151 LINGLESTOWN RD #240, HARRISBURG PA 17110 (Name of Person or Entity) within tweoty (20) days afte~ service of this subpoena, you a~e ocdered by the court to ADDENDUrvi 94o n ss os M DZC L s You may deliver o~ mail legible copies of the doct~nents o~ produce things requested this subpoena, togeth~ with the certificate of cu,uliance, to the pa~tymaking thiz request at the address listed above. You have the risht to seek in advance the reasonable cost of preparing the copies or ~oducin9 the things sought. If you fail to produce the doc~nents o~ things required by this subpoena within twenty, (20) days afte~ its service, the party serving 'this subpoena may seek a court orde~' o~m~ellin9 you to co~]y with it. THIS St~POENA WAS ISSUED AT THE REQUEST OF THE FOtLONING PERSON: NAME: GEORGE FALLER, ESQ ADORESS: __ DORFF WILLIAMS TELEPHONE: SUPREME COURT ID ~.__ ATTORNEY FOR: CARLICLE, PA 17013 215-335-3212 49813 DEFENDANT M280652-04 DATE: Seal of the Cou~t BY T~ Prothonotary/G~e~{~, Civil Division Deputy (Elf. 7/97) TO SUBPOENA ADDENDUM WORI~L~q VS. GIANT FOOD STORES NO. 2001 5511 CUSTODIAN OF RECORDS FOR: PENN REHAB ASSOS ANY AND ALL OFFICE RECORDS, 'INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: DATE NAME: SARA L WORMAN ADDRESS: 522 SPRING HOUSE RD OF BIRTH: 04/16/38 SSAN: 161323713 CAMP HILL PA CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN - COMPLETE AND RETURN RECORDS AREATTACHED HERETO:I hereby certify as custodian of records that, to the best 9f my knowledge~ information and belief all documents or things above mentIoned have been produced. [ ] NODOCUMENTSAVAILABLE:I hereby certify that a thorough s~arch has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date CUMBERLAND M280652-04 Authorized signature for PENN REHAB ASSOS *** SIGN AND RETURN THIS PAGE *** WORMAN VS. GIANT FOOD STORES c~TH OF p~NSYLVANIA 'Fi le No. 2001 5511 TO: SUBPOENA TO PROOU(~ DOOJMENTS OR TH I NGS FOR DISCOVERY PLRSUANT TO RULE 4009.22 WEST SHORE ENDOSCOPY, 423 S 21ST ST STE 102, CAMP HILL PA 17011 (Name of Person or Entity) Within twenty (20) days after service of this subpoena, yo~ are ordered by the court to produce the fo1 lowing doc~ment.~ o in T t ENDUr,[ at MEDICA~. LEGAL REPRODUCTIONS, s Yc~ may deliver or mail legible copies of the doctrnents or produce things requested this subpoena, together with the certificate of coq%olience, to the party making thi~ request at the address listed above. You have the right to seek in advance the rea~onabl~ cost of preparing the copies or producing the things sought. If you fail to produce the docurents or things required by this subpoena within twent} (20) days after its service, the party serving 'this subpoena may seek a court erd+' ~,~elling you to cu,~ly with it. THIS SUBPOENA WAS ISSUED AT THE REQ(3~ST OF THE FO~LOWIN~ PERSON: NAME: GEORGE FALLER, ESQ ADORESS: MARTSON DEA~RDORFF WILLIAMS TELEPHONE: SUPREME COURT ID ~ ATTORNEY FOR: C ........ ... 17013 215-335-3212 49813 DEFENDANT M280652-05 DATE: Seal of the Court BY ~ COURT: Prothonotary/Oink, Ci~ill Division ~' ' Deputy (Elf. 7'/97) ADDENDUM TO SUBPOENA WORMAN VS. GIANT FOOD STORES NO. 2001 5511 CUSTODIAN OF RECORDS FOR: WEST SHORE ENDOSCOPY ANY AND ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: NAME: ADDRESS: DATE OF BIRTH: SSAN: SARA L WORMAN 522 SPRING HOUSE RD 04/16/38 161323713 CAMP HILL PA CERTIFIED PHOTOCOpIEs WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN - COMPLETE AND RETURN [ ] RECORDSAREATTACHED HERETO:I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NO DOCUMENTS AVAILABLE:I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date CUMBERLAND M280652-05 Authorized signature for WEST SHORE ENDOSCOPY *** SIGN AND RETURN THIS PAGE *** WORMAN VS. GIANT FOOD STORES ~TH OF p]~qNSYLVANIA : File No. 2001 5511 TO: SUBPOENA TO PROOLICE DCO. I"IENTS OR 'II-lINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 JOYNER SPORTS MED INST, 6301 GP. AYSON RD STE 138, HARRISBURG PA 17111 (Name of Person cc Entity) Within twenty (20) days afte~ service of this subpoena, yo~ a~e ccdered by the court to produce the fol lowing docz~n~nt.~ oi~in~TAC~{ED ADDEndUM at MEDICAL LEGAL REPRODUCTIONS,(~S~940 DISSTON ST., PHILA., PA You may deliver cc mail legible co~ies of the doctrnents cc produce things requested this subpoena, together with the certificate of c~,'~liance, to the pa~ty making thiz request at the address listed above. You have the right to seek in advance the reasonab)~ cost of preparing the copies or producing the things sought. If you fail to produce the docunents cc things required by this subpoena within twcnt~ (20) days afte~ its se~vlce, the party serving 'this subpoena may seek a court orde,- ~'m~elling you to cu,~ly with it. THIS SUBPOENA WAS ISSUED AT THE RE(~3EST 06 THE FOELO~ING PERSON: NAME: GEORGE FALLER, ESQ ADORESS: MARTSON DEARDORFF WILLIAMS TELEPHONE: SUPRI3"~ COURT ID ~ A'rFORNEY FOR: ~ ~o~ ~ ~ 17013 215-335-3212 49813 DEFENDANT M280652-06 ~1/~'/01 DATE: Seal of the Court BY THE O3~T: Prothonota~y/Ole~k, Civil Divisio~ / / Deputy (Eff. ADDENDUM TO SUBPOENA WORMAN VS. GIANT FOOD STORES NO. 2001 5511 CUSTODIAN OF RECORDS FOR: JOYNER SPORTS MED INST ANY AND ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: NAME: ADDRESS: DATE OF BIRTH: SSAN: SARA L WORMAN 522 SPRING HOUSE RD 04/16/38 161323713 CAMP HILL PA CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN COMPLETE AND RETURN [ ] RECORDSAREATTACHED HERETO:I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NO DOCUMENTSAVAILABLE:I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date CUMBERLAND M280652-06 Authorized signature for JOYNER SPORTS MED INST *** SIGN AND RETURN THIS PAGE *** WORMAN VS. GIANT FOOD STORES c~TH OF p]~YLVANIA File No. 2001 5511 TO: SUBPOENA TO PROOUCE DOCt. ItENTS OR TH I NGS FOR DISOOVERY PURSUANT TO RULE 4009.22 GR~-NDVIEW SURGERY CTR, 205 GRA_NDVIEW AVE, CAMP HILL PA 17011 (Name of Person or Entity) within twenty (20) days after service of this subpoena, you are ordered by the co,Jrt to produce the fol lowing docLrnents ~-,~ins~;~,~..~_~_ ADDEndUM at --MEDICAL LEGAL REPRODUCTIONS, I~C, 4940 DISSTON ST., PHILA., PA (Adddess) You may deliver or mail legible copies of the documents or produce things requested bl this subpoena, together with the certificate of co','~liance, to the party making this request at the address listed above. You have the right to seek in advance the rea~onabl~ cost of preparing the copies or producing the things sought. If you fail to produce the docur~nts or things required by this subpoena within twent~ (20) days after its service, the party serving 'this subpoena may seek a court o~de.' c~elling you to cu,~ly with it. TH I S SU~,POENA WAS NAME: ADORE,SS: ISSUED AT THE RECkLIESTOFTHEFOLLONINGPERSOH: GEORGE FALLER, ESQ MARTSON DEARDORFF WILLIAMS TELEPHONE: SUPREI~ COURT ID ~ ATTORNEY FOR: 215-335-3212 49'813 DEFENDANT M280652-07 DATE: Seal of the Court BY THE COURT: Prothonotary/Cl~k, '~ivi 1 Olvisi6n ~ ~ Deputy (Eff. ~/97) ADDENDUM TO SUBPOENA WORMAN VS. GIAIqT FOOD STORES NO. 2001 5511 CUSTODIAN OF RECORDS FOR: GRANDVIEWSURGERY CTR ANY AND ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: NAME: ADDRESS: DATE 0F BIRTH: SSAN: SARA L WORMAN 522 SPRING HOUSE RD 04/16/38 161323713 CAMP HILL PA CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN COMPLETE AND RETURN [ ] RECORDSAREATTACHED HERETO:I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NO DOCUMENTSAVAILABLE:I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date CLTMBERLAAID M280652-07 Authorized signature for GP3kNDVIEW SURGERY CTR ** * SIGN AND RETURN THIS PAGE *** WORMAN VS. GID~NT FOOD STORES CO{~4DNWEAL~ OF p]~qNSYLVANIA : File No. 2001 5511 TO: SUBPOENA TO PRCOUCE BCC:LIHENTS CR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 DR. GEPJ%LD DINCHER, 2704 MA_RKET ST, CAivIP HILL PA 17011 (Name of Person or Entity) within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following document.~ ADDENDUi'v MEDICAL LEGAL REPRODUCTIONS'(I~{C's4940Addre s) DISSTON ST., PHILA., PA You may deliver or mail legible copies of the docunents or produce things requested this subpoena, together with the certificate of c~lience, to the party making thi~ 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 prcx~uce the docunents or things required by this subpoena within twenty (20) days after its service, the party serving 'thi~ subpoena may seek a court order' ~,~elling you to co,~ly with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: GEORGE FALLER, ESQ ADORESS: M~TSON DEARDORFF WILLIAlVjS TELEPHONE: SI.IPRI~'.~ CC~RT ID ~t ATTORNEY FOR: ~n~ ~o~ ~ ~ 17013 21b-33b-3212: 49813 DEFENDANT M280652-08 11/0~/01 ' DATE: Seal of the Oo~rt BY THE CO,~T: Prothoootary/Cl~r'k,~ Civil Division (£ff. ~/97) ADDENDUM TO SUBPOENA WORMAN VS. GIANT FOOD STORES No. 2001 5511 CUSTODIAN OF RECORDS FOR: DR GERALD DINCHER ANY AND ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-RAY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXAMINATION OR TREATMENT RENDERED TO: NAME: ADDRESS: DATE 0F BIRTH: SSAN: SARA L WORMAN 522 SPRING HOUSE RD 04/16/38 161323713 CAMP HILL PA CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN COMPLETE AND RETURN [ ] RECORDSAREATTACHED HERETO:I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NO DOCUMENTS AVAILABLE:I hereby certify that a thorough search has been made and that no record of the following documents~have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date CUMBERLAIqD M280652-08 Authorized signature for DR GERALD DINCHER *** SIGN AND RETURN THIS PAGE *** WORMAN VS. GIA/qT FOOD STORES CO~4~D~TH OF p~%LqYLVANIA File No. 2001 5511 TO: SUBPOENA TO PROCXJCE DOOJMENTS OR THINGS FOR DISCOVERY PLRSUANT TO RULE 4009.22 vISITING NURSE ASSN, 3315 DERRY ST, HARRISBURG PA 17111 ATTN: PERSONNEL DEPARTMENT (Name of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the fol lowi~ do~t.~ ADDE U 'vl {4o =iSSTON ST., P ILA., PA MEDICAL LEGAL REPRODUCTIONS, s You may deliver or mail legible copies of the docunents or produce things requested this subpoena, together with the certificate of cc~liance, to the party making thiz request at the address listed above. You have the right to seek in advance the reasonabl~ cost of preparing the copies or producing the things sought. If you fail to produce the doct~nents or things required by this subpoena within twenty (20) days after its service, the party serving thin sJopoenamay seek a court order' c~elling you to ccrr~ly with it. THIS SUBPOENA WAS ISSUED AT THE REQ~JEST OF THE FOLLOWING PERSO6h NAME: GEORGE FALLER, ESQ ~ESS: MARTSON DEA_RDORFF WILLIAMS TELEPHONE: ~AJPREI'~ COURT ID ~.__ ATTORNEY FOR: 215-335-3212 49813 DEFENDANT M280652-09 DATE: 11/os:/d1 Seal of the Court BY THE Prothonotary/~:l~rk, Civil Division ~ ! Deputy (Eff. 7/97) ADDENDUM TO SUBPOENA WORMAN VS. GIANT FOOD STORES NO. 2001 5511 CUSTODIAN OF RECORDS FOR: VISITING NURSE ASSN ANY EMPLOYMENT APPLICATIONS, EARNINGS, LEDGER SHEETS, TIME CARDS REVIEWS, ATTENDANCE SHEETS, ANY AND ALL MEDICAL RECORDS AND REPORTS AAVD PRE-EMpLOYMENT PHYSICALS, WORKMEN'S COMPENSATION CLAIMS MADE, ANY W-2 WITHHOLDING TAX FORMS, AND ANY OTHER INFORMATION PERTAINING TO: NAME: ADDRESS: DATE OF BIRTH: SSAN: SARA L WORMAN 522 SPRING HOUSE RD 04/16/38 161323713 CAMP HILL PA CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN COMPLETE AND RETURN ] RECORDS ARE ATTACHED HERETO:I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. [ ] NO DOCUMENTSAVAILABLE:I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X- P~AYS ( ) RECORDS / XRAYS have been destroyed Date CUMBERLAND M280652-09 Authorized signature for VISITING NURSE ASSN *** SIGN AND RETURN THIS PAGE *** WORMAN VS. GIANT FOOD STORES Fi le No. 2001 5511 TO: DR BRIAN QUIRK, SUBPOENA TO PROOUCE DOOJI~NTS OR TH I NGS FOR DISCOVERY PURSUANT TO RULE 4009.22 4713 LOCUST LN, HARRISBURG PA 17109 (Name of Person or Entity) within twenty (20) days after service of this subpoena, you are erdered by the court to ADDENDLTv[ DISSTON ST., P ILA., PA MEDICAL LEGAL REPRODUCTIONS, s Yc~ may deliver cc mail legible copies of the documents or produce things requested b) this subpoena, together with the certificate of cc~liance, to the party making this request at the address listed above. You have the right to seek in advance the rea~onabl~ cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required by this subpoena within twent~ (20) days after its service, the party serving 'this subpoena may seek a court orde.' o3~,~elling you to co,~ly with it. THIS SUBPOENA WAS ISSUED AT THE RE(;~JEST OF THE FOLLOWING PERSON: NAME: GEORGE FALLER, ESQ ADORESS: MARTSON DEARDORFF WILLIAMS TELEPHONE: SUPRE~ CO JRT ID ~__ ATi'ORNEY FOR: 17013 215- 3-~ 49813 DEFENDANT M280652-10 DATE: Seal of the Court BY TI~ COURT: Prothc~qotary~erk, Civil Division (Elf. 7/97) ADDENDUM TO SUBPOENA WORMAN VS. GIA1TT FOOD STORES NO. 2001 5511 CUSTODIAN OF RECORDS FOR: DR BRIAN QUIRK ANY ~ ALL OFFICE RECORDS, INCLUDING NOTES, CORRESPONDENCE, MEMORANDA, X-P~AY REPORTS, HISTORY NOTES, INDEX CARDS AND ANY OTHER INFORMATION RELATING TO ANY EXPJ4INATION OR TREATMENT RENDERED TO: ADDRESS: DATE OF BIRTH: SSAN: SAP~% L WORMAN 522 SPRING HOUSE RD 04/16/38 161323713 CAMP HILL PA CERTIFIED PHOTOCOPIES WILL BE ACCEPTED IN LIEU OF YOUR PERSONAL APPEARANCE. RECORD CUSTODIAN COMPLETE AND RETURN [ ] [ RECORDS AREATTACHEDHERETO:I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. NO DOCUMENTS AVAILABLE:I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) 'X-RAYS ( ) RECORDS / XRAYS have been destroyed Date CUMBERLAND M280652-10 Authorized signature for DR BRIAN QUIRK *** SIGN AND RETURN THIS PAGE *** WORMAN Vs. GID1NT FOOD STORES co--TH OF PENNSYLVANIA COUNTY OF O3MBERL~ND : Fi le No. 2001 5511 TO: SUBPOENA TO PROCXJC~ DOCUHSNTS C~ THIN'3S FOR DISCOVERY PURSUANT TO RULE 4009.22 HF_~TH ASSURANCE, PO BOX 2610, PITTSBURGH PA 15230 (Name of Person or Entity) Within twenty (20) days after service of this subpoena, yo~ are ordered by the court to produce the fo] lcwing docunent.~ c~.~j~in~s~.__.~...~.. ADDENDUrvl at stSC0 DiSSTo, ST., PRIL ., PA M)~DICAL LEGAL REPRODUCTIONS, s You may deliver or mail legible copies of the docuaents or produce things requested this subpoena, together with the certificate of cc~]iance, to the party making thi~ request at the address listed above. Yo~ 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 doctrnents or things required by this subpoena within twenty days after its service, the party serving 'thin subpoena may seek a court order' o~,~elling you to cu,~ly with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FCLLOWlNG PERSON: NAME: GEORGE FALLER, ESQ ADORESS: MA_RTSON DEARDORFF WILLIAMS TELEPI-K)NE: SUPREME COURT ID ~ ATTORNEY FOR: 215-33b-3Z1Z 49'813 DEFEND~uNT M280652-11 DATE: Seal of the O~urt BY THE CO. IRT: Prothonotary/(~4~r~% Oi¥il Divisio~ _ ~ ' ~ty (Eff. 7'/97) ADDENDUM TO SUBPOENA WOPaV~kN VS. GIANT FOOD STORES NO. 2001 5511 CUSTODIAN OF RECORDS FOR: HEA~TH ASSURANCE ANY AND ALL RECORDS, MEDICAL AND OR ACCIDENT CORRESPONDENCE, NOTES, RECEIPTS, BILLS, ETC., AND ANY OTHER INFORMATION PERTAINING TO: NAME: ADDRESS: DATE OF BIRTH: SSAN: SARA L WORMAN 522 SPRING HOUSE RD 04/16/38 161323713 CAMP HILL PA ALL FEES MUST BE APPROVED PRIOR TO RECORDS BEING FORWARDED. RECORD CUSTODIANCOMPLETE AND RETURN [ ] [ ] RECORDSAREATTACHED HERETO:I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. NODOCUMENTSAVAILABLE:I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-RAYS ( ) RECORDS / XRAYS have been destroyed Date CUMBERLAND M280652~11 Authorized signature for HEALTH ASSURANCE *** SIGN AND RETURN THIS PAGE *** CO--TH OF p~qNSYLVANIA WORMAN VS. GIANT FOOD STORES File No. 2001 5511 TO: SUBPOENA TO PROOUCE DOO,.JHENTS OR TH I NGS FOR DISCOVERY PURSUANT TO RULE 4009.22 PA BLUE SHIELD, 1800 CENTER ST, CAMP HILL PA 17011 ATTN: LEGAL DEPT (Name of Person or Entity) Within tweoty (20) days after service of this subpoena, you a~e o~'dered by the court to produce the fol lowin~j docurent.~ o in TACHED ADDENDUM at You may deliver or mail le9ible copies of the documents or produce thinss requested b~ this subpoena, togethe~ with the certificate of coroliance, to the party making this request at the address listed above. You have the right to seek in advance the rea~onabl~ cost of preparing the copies or producing the thin§s sought. If you fail to produce the docuT~nts or things required by this subpoena within twenty days after its service, the party serving 'this subpoena may seek a court orde~' ~,~elling you to co,wly with it. TH I S SUBPOENA WAS NAME: ADDRESS: ISSUED AT THE REQUEST O~ THE FOLL(~I NG PERSON: GEORGE FALLER, ESQ MARTSON DEARDORFF WILLIAMS TELEPHONE: SUPREh~ COURT ID :~ ATTORNEY FOR: 49~13 DEFENDANT M280652-12 1 /o /Ol DATE: Seal of the O~rt BY THE (XX3RT: rothonotary/6~le~k, Civil Division Deputy (Eff. 7/97) ADDENDUM TO SUBPOENA WORMAN VS. GIANT FOOD STORES NO. 2001 5511 CUSTODIAN OF RECORDS FOR: PA BLUE SHIF. LD ANY AND ALL RECORDS, MEDICAL AND OR ACCIDENT CORRESPONDENCE, NOTES, RECEIPTS, BILLS, ETC., AND ANY OTHER INFORMATION PERTAINING TO: NAME: ADDRESS: DATE OF BIRTH: SSAN: SARA L WORMAN 522 SPRING HOUSE RD o4/16/38 161323713 CAMP HILL PA #QBD161323713 ALL FEES MUST BE APpROVED PRIOR TO RECORDS BEING FORWARDED. RECORD CUSTODIAN COMPLETE AND RETURN [ ] RECORDS AREATTACHED HERETO:I hereby certify as custodian of records that, to the best of my knowledge, information and belief all documents or things above mentioned have been produced. ] NODOCUMENTSAVAILABLE:I hereby certify that a thorough search has been made and that no record of the following documents have been located (CHECK THE APPROPRIATE BOX): ( ) RECORDS ( ) PATIENT BILLING ( ) X-P~AYS ( ) RECORDS / XRAYS have been destroyed Date CUMBERL~LND M280652-12 Authorized signature for PA BLUE SHIELD *** SIGN AND RETURN THIS PAGE *** SARA L. WORMAN and JARED N. WORMAN, Plaintiffs GIANT FOOD STORES, INC., a/k/a GIANT FOOD STORES, LLC, Defendants 1N THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW 2001-5511 JURY TRIAL OF TWELVE DEMANDED DEFENDANT'S ANSWER TO PLAINTIFFS' COMPLAINT 1. After reasonable investigation, Defendant is without knowledge or information sufficient to form a belief as to the troth or falsity of the averments contained in this paragraph. The averments are therefore deemed denied and proof is demanded. 2. Denied as stated. To the contrary, Giant Food Stores, LLC is a Delaware corporation which has a retail establishment at 700 Camp Hill Shopping Plaza, Camp Hill, Cumberland County, Pennsylvania 17011. 3. Denied. To the contrary, Giant Food Stores, LLC is a Delaware Corporation with a registered office at 1149 Harrisburg Pike, Carlisle, Cumberland County, Pennsylvania 1701 I. 4. Denied pursuant to Pa. R.C.P. 1029(e). 5. It is admitted that the Defendants operated a retail grocery establishment at 700 Camp Hill Shopping Plaza, Camp Hill, Cumberland County, Pennsylvania and had possession and control of the premises. The remaining averments of this paragraph are denied pursuant to Pa. R.C.P. 1029(e). 6-7. Denied pursuant to Pa. R.C.P. 1029(e). COUNT I-NEGLIGENCE Sara L. Worman v. Giant Food Stores, Inc. a/k/a Giant Food Stores, LLC 8. Paragraphs 1 through 7 of this Answer are hereby incorporated by reference. 9. It is denied that the Defendant Giant was the owner of the premises. It is admitted that Defendant Giant operated the retail grocery establishment and possessed and controlled the premises. 10. It is denied that this incident occurred as a result of the negligence of the Defendant Giant by or through its agents, servants, workmen, or employees acting within the scope of their authority and employment. (a-f). Denied pursuant to Pa. R.C.P. 1029(e). 11-16. Denied pursuant to Pa. R.C.P. 1029(e). WHEREFORE, Defendant Giant Food Stores LLC demands judgment in its favor and dismissal of Plaintiffs' Complaint with prejudice. Date: MARTSON DEARDORFF WILLIAMS & OTTO BYGe~e ~/~//~ ~ ge-B~Fatt~e,~r.~, E~/quire I.D. Nmber49813 ~ Ten East High Street C~lisle, PA 17013-3093 (717) 243-3341 Attorneys for Defendant VERIFICATION I, TIMOTHY REARDON, Vice President-Risk Management and Support Services of Giant Food Stores, LLC, acknowledge that I have the authority to execute this Verification on behalf of Giant Food Stores, LLC and certify that the foregoing Defendant's Answer to Plaintiff's Complaint is based upon information which has been gathered by my counsel in the preparation of this lawsuit. The language of this Answer is that of counsel and not my own. I have read the document and to the extent that this Answer is based upon information which I have given to my counsel, it is true and correct and to the best of my knowledge, information and belief. To the extent that the content of this Answer is that of counsel, I have relied upon counsel in making this Verification. This statement and Verification are made subject to the penalties of 18 Pa. C.S. § 4904 relating to answom falsification to authorities, which provides that if I knowingly make false averments, I may be subject to criminal penalties. Dated: Giant Foo~ S~s~LLC T'lmOtl~/ifi~.eardon Vice l~sident - Risk Mgt. & Support Services BECF~VFU NOV ~ 0 2001 MDW~ CERTIFICATE OF SERVICE I, Nichole L. Myers, an authorized agent of Martson Deardorff Williams & Otto, hereby certify that a copy of the foregoing Defendant's Answer to Plaintiffs' Complaint was served this date by depositing same in the Post Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows: W. Scott Henning, Esquire HANDLER, HENN1NG & ROSENBERG 1300 Linglestown Road P.O. Box 1177 Harrisburg, PA 17108-1177 Dated: MARTSON DEARDORFF WILLIAMS & OTTO By ~(~ (~ ~/~ Nichole L. Myers Ten East High Street Carlisle, PA 17013 (717) 243-3341 ,¢ WILLIAM R. BUNT CHRYSTAL L. PROSSER ATTORNEYS AT LAW 109 S. Carlisle Street New Bloomfield, Pa. 17068 Tel. (717) 582-8195 FAX (717) 5~2-7521 JAYME L. GARNER, Plaintiff JEFFREY L. GARNER, Defendant : iN THE COURT OF COMMON PLEAS : OF THE 9TH JUDICIAL DISTRICT : OF PENNSYLVANIA : :IN DIVORCE : NO. 01-5510 AFFIDAVIT OF SERVICE Before me, a Notary Public, appeared Chrystal L. Prosser, Esquire, who being duly sworn according to law, deposes and says that service of a Complaint in Divorce along with a Notice to Defend and Claim Rights and Notice of Right to Counseling was made on the Defendant by depositing the same in an envelope addressed to Mr. Jeffrey L. Garner, 1060 West Foxcroft Drive, Camp Hill, Pennsylvania 17011, in the United States Mail and by mailing the same Certified Mail, Restricted Delivery # 7000 1670 0012 8350 5823 on September 25, 2001 from the New Bloomfield Post Office, Perry County, Pennsylvania. The original PS Form 3800 and PS Form 3811, marked Exhibit A, are attached hereto and incorporated herein by reference thereto. Sworn and subscribed to before me this r~t:~ day of March, 2002. WILLIAM R. BUNT CHRYSTAL L, PROSSER AITORNEYS AT LAW 109 S. Carlisle Street New Bloomfield, Pa. 17068 Tel, (717) 582-5195 FAX (717) 582-7521 Postage Certified Fee Return Receip! Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Required) $ 7,/¢ Co~'4~ete Items 1, 2, and 3. Rem 4 If Re~ Detlv~ ia deelmd. lB Print your name and addree~ on the reverse so thet we can return the card to you. · A~ this card to the back of the mailplece, or on the front If space permits. I~r. Jeffrey L. Garner 1060 West Foxcroft-.Drive Camp Hill, PA 17011 7000 1670 0012 8350 5823 Form 3811, July 1999 ~,. ~gr~tum ~Jf YES, e.ter dellve~ addre~ below: [] No 3. Service lype ~3[Ce~1~ed Mm~ [] Express MeJ~ 0 Re~temd ~etum Receipt for Ivlem, hendl~ [] Ir~umd Mail [] C.O;D. 4. Restricted Deliver? ~ Fee) ~'Yee Exhibit A WILLIAM R. BUNT CHRYSTAL L. PROSSER ATTORNEYS AT LAW 109 S. Carlisle Street New Bloomfield, Pa. 17068 Tel, (717) 582-8195 FAX (717) 582-7521 JAYME L. GARNER, Plaintiff JEFFREY L. GARNER, Defendant : IN THE COURT OF COMMON PLEAS : OF THE 9TH JUDICIAL DISTRICT : OF PENNSYLVANIA :IN DIVORCE .' NO. 01-5510 AFFIDAVIT OF CONSENT 1. A Complaint in divorce under § 3301(¢) of the Divorce Code was filed on September 21, 2001. 2. The mardage of Plaintiff and Defendant is irretrievably broken and ninety days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final decree of divorce after service of notice of intention to request entry of the decree. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. Date: Ja~rne~.. ~"~rn~, Plaintiff WILLIAM R. BUNT CHRYSTAL L, PROSSER ATTORNEYS AT LAW 109 $. Carlisle Street New Bloornflekfl, Pa, 17068 Tel. (717) 582-8195 FAX (717) 582-7521 JAYME L. GARNER, Plaintiff JEFFREY L. GARNER, Defendant : IN THE COURT OF COMMON PLEAS : OF THE 9TH JUDICIAL DISTRICT : OF PENNSYLVANIA :IN DIVORCE : NO. 01-5510 AFFIDAVIT OF CONSENT 1. A Complaint in divorce under § 3301(c) of the Divorce Code was filed on September 21, 2001. 2. The mardage of Plaintiff and Defendant is irretrievably broken and ninety days have elapsed from the date of filing and service of the Complaint. 3. I consent to the entry of a final decree of divorce after service of notice of intention to request entry of the decree. I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. J~fl~ey~.. Gar~er, Defendant WILLIAM R. BUNT CHRYSTAL L. PROSSEI A1TORNEYS AT LAW 109 S. Carlisle Street New Bloomfield, Pa. 17068 Tel. (717) 582-8195 FAX(717)582-7521 JAYME L. GARNER, Plaintiff JEFFREY L. GARNER, Defendant : IN THE COURT OF COMMON PLEAS : OF THE 9TH JUDICIAL DISTRICT : OF PENNSYLVANIA :IN DIVORCE : NO. 01-5510 WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER §3301(c) Of THE DIVORCE CODE 1. I consent to the entry of a final decree of divorce without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce is granted. 3. I understand that I will not be divorced until a divorce decree is entered by the Court and that a copy of the decree will be sent to me immediately after it is filed with the Prothonotary. I verify that the statements made in this Affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. § 4904 relating to unsworn falsification to authorities. Date: Ja~'me'L. ~ar'n~r, Plaintiff WILLIAM R. BUNT CHRYSTAL L. PROSSER ATTORNEYS AT LAW 109 $, Carlisle Street New Bloornfle~d, Pa. 17068 Tel. (717) 582-8195 FAX (717) 582-7521 JAYME L. GARNER, Plaintiff JEFFREY L. GARNER, Defendant : IN THE COURT OF COMMON PLEAS : OF THE 9TH JUDICIAL DISTRICT : OF PENNSYLVANIA :IN DIVORCE : NO. 01-5510 WAIVER OF NOTICE OF INTENTION TO REQUEST ENTRY OF A DIVORCE DECREE UNDER §3301(c) OF THE DIVORCE CODE 1. I consent to the entry of a final decree of divorce without notice. 2. I understand that I may lose rights concerning alimony, division of property, lawyer's fees or expenses if I do not claim them before a divorce is granted. 3. I understand that I will not be divorced until a divorce decree is entered by the Court and that a copy of the decree will be sent to me immediately after it is filed with the Prothonotary. I verify that the statements made in this Affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. § 4904 relating to unsworn falsification to authorities. ~ff~ey~. ~'arner, Defendant SARA L. WORMAN, Plaintiff GIANT FOOD STORES, INC. a/Ida GIANT FOOD STORES, LLC, Defendant : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 2001-5511 : CIVIL ACTION - LAW RULE 1312.1. The Petition for Appointment of Arbitrators shall be substantially in the following form: PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: W. Scott Henning, Esquire, of Handler, Henning& Rosenberg, LLP, counsel for the Plaintiff in the above action, respectfully represents that: The above-captioned action is at issue. The claim of the Plaintiff in the action is $ 25,000.00. The counterclaim of the defendant in the action is N/A. The following attorneys are interested in the case as counsel or are otherwise disqualified to sit as arbitrators: W. Scott Henning, Esq., Handler, Harming & Rosenberg, LLP, 1300 Linglestown Road, Harrisburg, PA 17110 and George B. Failer, Jr., Esq., Martson, Deardorff, Williams & Otto, Ten East High Street, Carlisle, PA 17013. WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. Respectfully submitted, HANDLER, HENNING & ROSENBERG, LLP ~0 Lirf~lest~wn Roa~ Harrisbur~-P'A 1711~ (717) 238-2000 / Attorney for Plaint~t ORDER OF COURT ,~~~ilAND NOWy.~ ~.f/.d_~ in consideration of the foregoing petition, /'/,2003, Cb SARA L. WORMAN, Plaintiffs V. GIANT FOOD STORES, INC. a/Ida GIANT FOOD STORES, LLC, Defendants : IN THE COURT' OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA NO. 01-5511 CIVIL TERM CIVIL ACTION - LAW _, 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: 2, 3. 4, 5. 6. 7. 8. Medical Records from Orthopedic Institute of Pennsylvania - Dr. Dailey 10/15/99 through 7/7/00 Medical Records from Holy Spirit Hospital; 10/12/1999 Medical Records from Herd Chiropractic Clinic; 1/14/00 through 7/31/00 Grandview Surgery Center; 4/18/00 Narrative Report from Dr. Dailey dated 2/5/01; Supplemental Narrative Report from Dr. Dailey dated July 19, 2001; Medical expense billing summary (with corresponding billing statements); Incident Report. Date: September 25, 2003 Respectfully Submitted, W. Scott Henn/i~ I.D. #32298/' 1300 Ling~st~ Harrisburg'71:',~ (717) 238-20~ ~// ~J~ERG, LLP ~/7ad 110 Attorney for Plaintiff ORTHO~mDIC INSTITUTE OF PENNSYLVaniA (717) 761-5530 Patient: Sara L. Worman Chart ~: 11524206 DOB: 04/16/38 SSN: 161 32 3713 Page # 12 6/16/2000 STEPHEN W. DAILEY, M.D. -CONTINUED- LEVEL THREE REVIEW 0F SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed. PHYSICAL ELAM: On examination there is no swelling, ecchFmosis, deformity or atrophy in the hand. There is some tenderness in the area of the A-1 pulley, the right middle finger. No active triggering. Ail joinzs of the hand have a full and pain free range of motion both passively and autively. Ail joints of the hand and fingers are stable. Sensory, motor, reflsx and vascular exams of that extremity are within normal limits. All tendon functions are intact. There are no skin lesions. Examination of the ~rist, elbow and shoulder are normal. DIAGNOSIS: !. Improvement status post left endoscopic carpal t,~nnel release. 2. Mildly symptomatic right carpal tunnel. 3. Right middle finger triggering which is coming back. PLAi~: I ncld her at this point it makes sense lust to wait and see how she does with her right middle finger trigger. She will come to see me on an as needed basis ~f the righm middle finger continues to trigger and gets worse ec the po!nE where she would consider another lnjectlon cr surgical release. cc~ Brian Quirk, M.D. vla fax 7/07/2000 STEPHEN W. DAILEY, M.D. LEVEL FOUR Trind!e Road Office CHIEF COMPLAINT: Triggering right middle f!nger HISTORY CF her r~ght day as well and ~iNT: Sara Worman returns. c _inter trigger, it is occur actually get snuck in increased mroblems with everyday and later in the a flexed position. · .~-~==~ C,F SYSTEMS: ~tient's rev! cf syssems, past: med~-cai history, lstory oeen re-eva!uaEed and reviewed. -~-_g=~ i hand have a full and pain free range of me5aon bo5h passy;ely and ~ lozn5s of ~he hand and fingers are .~ tendon functio~re intact. There are no skin ncrmal !eslons. ExaminaElc~f 5he wrist, e!b~ an~der ace normal. / ORTH~.~DIC INSTITUTE OF PENNSYLW=_.=A (717) 761-5530 Patient: Sara L. Worman Chart ~: 11524206 DOB: 04/16/38 SSN: 161 32 3713 Page ~ 11 5/19/2000 STEPHEN W. DAILEY, M.D. -CONTINUE~- LEVEL TWO CHIEF COMPLAINT: HISTORY OF COMPLAINT: Sara returns. She did great fcr the firsl two weeks after her left endoscopic carpal tunnel release and then with increase in activities and strengthening exercises in started to be aggravated. The right carpal tunnel syndrome is not ihat symptomatic at this point and she is not having numbness and tingling every day. She is bo!herod by her right middle finger triggering which has recurred after the last injecmion. REVIEW OF SYSTEMS: The patient's review cf systems, past medical history, family history and social history have been re-evaluaued and reviewed. PHYSICAL EXAM: The incision is well healed an the ~- wrist. ~ is minimal tenderness and minimal scar lissue. On the right hand there is Ienderness over the A-1 pulley of txe middle finger and triggering with passive motion of the finger. DIAGNOSIS: 1. Doing well S/P endoscopic left carpal !unne! release with aggravation probably by trying ec do too much icc soon. told her this and she'll slow down her activities and let pain be her guide. 2. Right .carpal tunnel syndrome. PLAN: in terms of her right carpal zunne! syndrome i dcn'i think we need ~$ do any~hlng ae this point. For her righ~ middle trzggering finger i offered her injection again !oday and chis was undertaken slerile!y. She understands that if it does recur after !his in~ecticn ie is proba£iy a gccd idea nc consider trigger finger release, i'ii see her hack in ihree weeks. SWD/kir Paxed to: Brian Quirk, M.D. 6/16/2000 STEPHEN W. DAILEY, M.D. LEVEL THREE Trindie Road Office her left hand and ~hai is actually .... -~ ~c which has ieveio~ed cu~ce ~ga~n '~ ~'=~- rign~ ce= is having some ~__gge middle finger. The inlec~ion helped fcre wni!e ~uu Li LS rcmLx~ sack ORT~ _~DIC INSTITUTE OF PENNSYL%._.ZA (717) 761-5530 Patient: Sara L. Worman Chart ~: 11524206 DOB: 04/16/38 SSN~ 161 32 3713 Page ~ 10 4/12/2000 STEPHEN W. DAILEY, M.D. -CONTINUED- LEVEL TWO distal radius fracture. I told her that 5he carpal tunnel takes precedence and when she recovers from that if she is still having Dersisnen5 problems in her wrist we will evaluate that at tha5 time. SWD/kmp CC: Brian Quirk, M.D. via fax 4/18/2000 STEPHEN W. DAILEY, M.D. GRANDVIEW SURGICAL CENTER April 18, 2000 G~NDViEW SURGERY CENTER DIAGNOSIS: Left carpS1 tunnel syndrome PROCEDURE: Left endoscopic carpal tunnel release SWD/kmp CC: Brian Quirk, M.D. via fax 4/26/2000 A~EXANDER KALENAK MD GLOBAL SERVICE VISIT Trindle Road Office Eight days status-post endoscop!c left carpal tunnel release by Dr. Daiiey. She is actually ecstatic aborn her resuius. She states there is very !itmle swelling. She is able to use Ehe fingers witnouu provocation almosu immediately pos~ op. She can mold a cell phone which she was unable to do. PHYSIC.AL E~AM: Incision healing well. No drainage. Minimal swelling and zenderness. PL~N: Continue all acuivizies as toieraued. Judicious use for any hea~Qz acuivizies. Return to see Dr. Dai!ey in lhree weeks er so. AK/kir Faxed lo: Brian Quirk, M.D. 5/15/2000 STEPHEN W. DAILEY, M.D. REQUEST FOR RECORDS Office no,es copied, billed sy ~uadramed and mat!ed t~ H~NDLER, ROSENBERG, ATTORNEYS AT LAW. e!b HENNiNG & 5/19/2000 STEPHEN W. DAILEY, M.D. LEVEL TWO Trindle Road Office 0RTHL.-,'.DIC INSTITUTE OF PENNSYLV~,IA (717) 761-5530 Patient: Sara L. Worman Chart #: 11524201 DOB: 04/16/38 SSN: 161 32 3713 Page ~ 9 2/04/2000 STEPHEN W. DAILEY, M.D. -CONTINUED- LEVEL TWO DIAGNOSTIC TESTS: EMG and nerve conduction studies as above. DIAGNOSIS: 1. Bilateral carpal tunnel, right worse than left. 2. Triggering right middle finger. pLAi~ I discussed the diagnosis and treatment options with the patient. She would like to proceed with endoscopic carpal tunnel release and this is to be scheduled for her right wrist. Also her right middle finger was injected today with 1/2 cc. of Celes~one and 1/2 cc. of 1% Lidocazne without epinephrine. She will see how this works for her and will let me know whether we will release her finger or inject it again at the time of surgery. She was given a prescription for Flexeril 10 mgs., #20 with no refills. SWD/kir Faxed to: Brian Quirk, M.D. 3/17/2000 THOMAS J. YUCHA MD CANCELLED The appointment was cancelled by the patient. This was ail old post-op appointment as the patient's surgery was post-poned. tjs 4/12/2000 STEPHEN W. DAILE¥, M.D. LEVEL TWO Poplar Church Road Office CHIEF COMPLAINT: Sara Worman returns. She returned from her trip and zs having more problems actually with her left hand now. Tile injection helped out with the trigger finger and actually took away all of her symptoms on the right side. She is having increased numbness and tingling on the left side. It does wake her up at night. She has a prevmous EMG/NCS which was consistent with bilateral carpal tunnel s!rndrcme which is moderate to severe.. REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed. PHYSICAL EXAM: The left wrist has a positive Tinel's and positive compression. She is unable tc do Phalen's do to her past wrist injury. DIAGNOSIS: Bilateral carpal tunnel syndrome, with the left now being more symptomatic than the right. PLAN: She zs already scheduled for the right side to be ~one April 18 and we are going to switch this to the left side now. We will 5rrange this today. Of note, she has also had persistent pain in her left wrist residual from her ORT~.2EDIC INSTITUTE OF PENNSYL¥~IA (717) 761-5530 Patient: Sara L. Worman Chart #: 11524201 DOB: 04/16/38 SSN: 161 32 3713 Page $ 8 1/14/2000 STEPHEN W. DAILEY, M.D. -CONTINUED- LE%'EL THREE negative. Tinel's and compression tests are positive bilaterally. Phalen's is positive on the right. She is unable to do a Phalen's on the left due to the stiffness from her distal radius fracture. She also has some nodular swelling in the area of the flexor tendons of the right middle finger at the A-1 pulley. There is no significant tenderness and no ~ctive triggering today. Tinel's sign at the elbows and elbow flexion tests are negative. Sensory, motor, reflex and vascular exams of that extremity are within normal limits. There are no skin lesions. Examination of the elbows and shoulders are grossly within normal limits. WRIST X-RAYS(RIGHT AND LEFT): Radiographs reveal the bony architecture is intact without evidence of fracture or dislocation. No significant soft tissue abnormality is seen. DIAGNOSIS: Possible bilateral carpal tunnel syndrome. Possible right middle finger trigger. PLAN: Continue with her medications. Wrist splints at night. We ordered an EMG nerve conduction study today which will be obtained and I will ~-ee her back after that to discuss the results. SWD/raf cc: Brian Quirk, M.D. via fax RADIOLOGY RESULTS WRIST X-R3tYS(RIGHT AND LEFT): Radiographs reveal the bony architecture is intact without evidence of fracture or dislocation. No significant soft tissue abnormality is seen. IMPRESSION: SEE ABOVE STUDY. SWD/raf 2/04/2000 STEPHEN W. DAILEY, M.D. L~TEL Trindle Road Office CHIEF COMPLAINT: Sara Worman returns. She is still havzng problems with numbness and tingling in both hands, right worse than left. They are numb and tingly almost constantly, it does wake her up at nzght. Splints have not helped. She also has a right triggering middle finger which bothers her as well. She had EMG and nerve conduction studies which are consistent with mildly severe bilateral carpal tunnel, right worse than left. REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed. PHYSICAL EXAM: ORT~,~EDIC INSTITUTE OF PENNSYL¥~qIA (717) 761-5530 Patient: Sara L. Worman Chart #: 11524206 DOB: 04/16/38 SSN: 161 32 3713 Page % 7 11/19/1999 STEPHEN W. DAILEY, M.D. -CONTINUED- P. ADIOLOG¥ RESULTS IMPRESSION: SEE ABOVE STUDY. SWD/raf 11/23/1999 JAMES R. HAMSHER MD CANCELLED The appointment was cancelled by the patient. Rescheduled for 12-10-99. sam 12/10/1999 STEPHEN W. DAILEY, M.D. GLOBAL SERVICE VISIT Trindle Road Office CHIEF COMPLAINT: Sara Worman returns. She is still having some pain in her hand. She also has some numbness and tingling that comes occasionally as well. She has been wearing her cock-up wrist splint. PHYSICA~L EXAM: She has some stiffness. 30 degrees of dorsiflexion end 10 degrees of palmer flexion. She has a positive Tinel's at the wrist and positive compression test mildly. DIAGNOSIS: Probable median nerve irritation from her healing fracture. PLAN: D/C the immobilization. Work on her range of motion activities and follow up in one month for re-evaluation. SWD/raf cc: Brian Quirk, M.D. via fax 1/14/2000 STEPHEN W. DAILEY, M.D. LEVEL THREE Trindle Road Office CHIEF COMPLAINT: Sara Worman returns today. She is having numbness and tingling in both hands especially in the night. She also describes some locking of her right middle finger. She has been wearing the cock-up wrist splint at night and this has not helped significantly. She has also been prescribed a pain medication by ano[her physician. REVIEW OF SYSTEMS: The patient's review of systems, past medical h~story, family history and social history have been re-evaluated and reviewed. PHYSICAL EXAM: On examination there is no swelling, eccnymosis, deformity or tenderness about ~he right and left wrists. The wrists nave a full and pain free range of motion without crepitation. There is no distal radial ulnar joint instability. Scaphoid shift and lunotriquetra! "snuck" tests are ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Sara L. Worman Chart ~: 11524206 DOB: 04/16/38 SSN: 161 32 3713 Page ~ 6 11/05/1999 STEPHEN W. DAILEY, M.D. -CONTINUED- GLOBAL SERVICE VISIT Therefore, I would like her to see one of my partners for an exam out of plaster with radiographs on 11/23/99. SWD/kir Faxed to: Brian Quirk, M.D. RADIOLOGY RESULTS LEFT WRIST: Radiographs today reveal maintenance of the alignment of the fracture. IMPRESSION: SEE A~OVE STUDY. SWD/kir 11/17/1999 STBPHEN W. DAILEY, M.D. REQUEST FOR RECORDS p~ Office notes copied, billed by Quadramed and mailed to M~C RISK MNGMNT, elb INC. 11/19/1999 STEPHEN W. DAILEY, M.D. GLOBAL SERVICE VISIT Trindle Road Office CHIEF COMPLAINT: Sara Worman returns early. She is having problems with her whole left upper extremity. She returns earlier than i wanned her ~o for possible removal of the cast. PHYSICAL EXAM: On physical exam she has full range cf moticn of nhe fingers. She is not tender over the fracture site after 5he shore arm case was removed. DIAGNOSTIC TESTS: Radiographs obtained noday, 2 views of the wrisu, show healing of the fracture. DIAGNOSIS: Healed distal radius fracture. PLAN: Cock-up wrist splint to be worn for the next 1-2 weeks. She will follow up in 3 weeks time. SWD/raf cc: Brian Quirk, M.D. P, ADIOLOG¥ RESULTS via fax LEFT WRIST X-RAYS: Radiographs obtained neday, 2 views cf the wrist, show healing of the fracture. ORTHO=EDIC INSTITUTE OF PENNSYLVA~IA (717) 761-5530 Patient: Sara L. Worman Chart #: 11524206 DOB: 04/16/38 SSN: 161 32 3713 Page % 5 10/22/1999 STEPHEN W. DAILEY, M.D. -CONTINUED- GLOBAL SERVICE VISIT comfortable at this point. PHYSICAL' EXAM: On physical exam the cast is in good shape. Fingers are neurovascularly intac/ and she has good range of motion. DIAGNOSTIC TESTS: Radiographs, two views of the wrist obtained today, reveal maintenance of the alignment of the fracture which is acceptable. DIAGNOSIS: Post left distal radius fracture and contusion left ribs. PLAN: Continue with the moist heat to her ribs. Continue the short arm cast. She can stDrt weaning herself from the sling. I'll see her back in two weeks at which time we'll get x-rays. I told her it would be a total of approximately six weeks immobilization for the distal radius to heal. SWD/kir Faxed to: Brian Quirk, M.D. RADIOLOGY RESULTS LEFT WRIST (2V) : Radiographs, two views of the wrist obtained today, reveal maintenance of the alignment of the fracture which is acceptable. IMPRESSION: SEE ABOVE STUDY. SWD/kir 11/05/1999 STEPHEN W. DAILEY, M.D. GLOBAL SERVICE VISIT Trindle Road Office CHIEF COMPLAINT: Sara Worman re/urns. She is doing quite well with her fracture. She is having some discomfort with the cast au the proximal end and underneath in the area of the ulnar styloid. PHYSICAL EXAM: The cast is in good shape. There is no erythema of the skin at the proximal end. She has good range of motion of the fingers and she is neurovascular!y in/act. DIAGNOSTIC TESTS: Radiographs today reveal maintenance cf the alignment of the fracture. DIAGNOSIS: Doing well pos5 fracture left distal radius. PLAN: Continue the cast for anc5her 2-1/2 weeks at which ~me ~he fracture should be healed and the cast w±ll be removed. The patlent is headed out cf town early morning of Nove~er 24th and, therefore, I won'~ be able to see her at that time and would prefer not to remove 5he cast the Friday. ORTHOPEDIC INSTITUTE OF PENNSYLVANIA (717) 761-5530 Patient: Sara L. Worman Chart #: 11524206 DOB: 04/16/38 SSN: 161 32 3713 Page ~ 4 10/15/1999 STEPHEN W. DAILEY, M.D. -CONTINUED- RADIOLOGY RESULTS wrist, show maintenance of the distal radius alignment. Length is ulnar neutral and there is approximately 1-2 degrees of dorsal angulation which is acceptable. IMPRESSION: SEE ABOVE STUDY. SWD/raf INITI~tL F P. AC~"JRE Trindle Road Office CHIEF COMPLAINT: She is a 61-year-old right hand dominant female who was an the Giant Supermarket on Tuesday, slipped on a pepper.going down on£o her left side with pain in her left chest area and her left distal radius. She was seen at Holy Spirit Hospital where x-rays were negative for any rib fractures. She had a comminuted intraarticular left distal radius fracture which was reduced and casted in the ER. She was sent for our definitive car%~ REVIEW OF SYSTEMS: The patient's review of systems, past medical history, family history and social history have been re-evaluated and reviewed. PHYSICAL EXAM: On physical exam the cast is in good shape. There is some swelling of the hand. It is neurovascularly intact. The case does incorporate the ring finger, but there is some space to move the finger and it is neurologically intact. DIAGNOSTIC TESTS: Repeat radiographs obtained ~cday, AP and iaeerai of the wrist, show maintenance of the distal radius alignment. Leng£h is ulnar neutral and there is approximately 1-2 degrees of dorsal anguiatlsn which is acceptable. DIAGNOSIS: Distal radius fracture interarnicu!ar!y comminused wznh accepta£!e closed reduction at this time. PLAN: Ice and elevation. Continue with the immobilization. 1 week with x-rays on arrival. SWD/raf i will see her in CORRESPONDENCE (Ref) QUIRK, M.D., BRIAN 10/22/1999 STEPHEN W. DAILEY, M.D. GLOBAL SERVICE VISIT Trindle Road Office CHIEF COMPLAINT: Sara Worman re5urns. She's had more problems wish her contusion to her ribs on the left side than her left wrist whick is feeling PATIENT INFORMATION SHEET ESTABLISHED PATIENT/NEW PROBLEM Chart Number: Patient Name: ~ Last Birth Date: z./ -/~-..~ Problem: ~ Date: /0 -/..~ - ? ~ First Age: Is the condition that you are being seen for the result of an injury? ~ Date of Injury: /~-/.¢ -~ Type of injury: Work Auto Other :~ If the condition is not the result of an injury, date symptoms first appeared: Description of accident: ,~.~. ~"~,z~--~-J' If Workers' Comp: Employer: Occupation: Address: Insurance: If Auto: Insurance: State: Insurance: Family Physician: Send letter to: Family Physician: Revised 9/1/99 mee Referring Physician: _¢',,~-¢2 ,¢ Referring Physacian: ~/~ Neither: / HSH ER FORM ~E~ DATF: 10/12/9~ 11:38 PT#: iADE~6S: 522 SP~{INGHDUSE RD /~AMP HILL /FA/17011 PHtt: 717-7&1-18~? RET-VISITIN~ NURSE A OCCdPATtON: VI~TING NURSE / / / PH#: 71/-233-1035 F'RESBYT~;~IAN-SILVER SP~IN~S A~B: HA~'~EN EMS i~)AME: EMERGENCY CONTACT INFOi~ATIO~! WORMAN ,dARE~ REL TO PT: H W~K PH #: ~2~ SF'~INBMDUBE RD /CAMP MILL /PA/17011 ~ #: 717-7~1-183~ PTi N6~K PH ~: / / PH #: 'AYFN]D 0~: lll~3& SHAI~MA RAdANA ADMIT DX: iCOMF'LAItJT~ FALL,L3 WRIST INdUR¥ AND LT RI HOSP SE;RV: ER3 FII~NCIAL CLS~ g ICD-~ DX~ ~ PAI~ AC[.II3ENT INFO~MA1 ION OA~E/~IME: i0/12/~ 10:20 ACC IN]D: 0 ,JO~ R~I_ATEI3a N LOCATION: DESCRIP]IO)'~: P1 SLIPr'EZ; [3N A PEPPER A'[ GIA NT AND INJURL'D HEFe LT I~RIBT NAIq~: ADDRESS: A~ID~ESS: 5~ S~R)ND~ObSE ~5 /S~P HiLL /PA/iT011 RE T -- CONTACT ~lffE ~' I ~L(RA~E I~ORMATI 0~ PLAN iNSU~ANCE CO [;OB POt. ICY ~ GROUP ~ORMAIq , ~ARA S Y Y 4 AFIEN¥ D. IAM~: ~RHAN ,SARA L lJ~ PH #: 717-23S-1035 PT#= I40~8081 ~R#: 20~82 // Date:. ~" ,~ ' · ' Log-m Time /D: ~'~' I Name..~-./.~ ~,~. ,.~. , . ~;e',~. ~1' , TnageT~ ' FMD Q' ~ ~'~ ' T~metoExamR~m //~ ~ ~af Amv~l ~ls~ [ ~BLS [ ]~ ( ]M~t~m~d ~ d~IEF COMPLAINT: ~ · ~ [~ ~ ~: ~ ~ ~' ~ INmAL TRIAGE: ~ ~ Place injury occurred [ ] Heine [ 1 Incluatry [ ] Recrea~on ( ] Other OblecUve: Last Dose Last tA~seasment completed at by ~ R,N. Data oDtalned by: ~ M.A Holy Spirit Hospital Camp Hill, PA ECU Nursing Assesament Re~ JD MD BR CHART COPY CONSENT TO MEDICAL TREAt MENT ' ' ' I HEREB~Y CONS, ENT AND AUTHORIZE Ho~y ~o~rlt Hcaprta}, iI,~ agenla, and employee~, to the randenng of medl~ll c.~e, which may Include re.ne alagnost~c prcoequres and such meq~a~ tr~atmen! as my attand~ng or ~on,~J~ng phy~c~an conmdem to be necaesary I also under- stand d ~$ customary, absent emergency or extraordinary arcumstencas, that no substantial proneduma w~ll be performed upon me unless or unhl I have had an c~oportun~y to d~scuss them w~th a p~ys~c~an or other healtfl care profasmonal to my aa~__,:'~_n If I am a c~npamnt adult, have the right to co~sent Or refuse to consent I undemtm~d that the practice of r~ed~me and surgery ~a ~ot a~ exe~-'t scter~e and that diane- sm and treatment may ~nvolve risks of ~njury Or even death and acknowledge that no guarantee has been made to me as to the reeulle of any examination or treetme~ In this Hcapttst I undsmtsnd many of the phyactans o~ the staff of Holy Gpmt f-~ta~ am not emp~me~ ~ agen~ of 'the Hcal:v, tsl, ~ rather me ~ndepandant conlractom who ha'.~ been grante~ the pnvdege of using these fa=hbea for the care end treatment of their patmrds Fur~er, I tashze this Ho~ m a teacha~g t-lssp~l and at t~e Hcaprml am haslth care bemonnet ;n trmn~ng who, unless expressly requested othemnae, may pa~:q3ato or may be present dunng my care as part of their educatlOrl Still or motion p~cture~ and ctoeed c~rcult mon~onng of pabant cam may also be used for equcat~onal purposes, unless I expressly request otherv~ae. I understand that ~n order to ensure a safe enwronmmlt for pebents, ws~tore and staff aJI property on the premises of _l~[e~ ~)l. rltJosprtaJ subject to reasonable search and/or smzure at any brae w~thout further nebce RELEASE OF MEDICAL INFORMATION I authorize Holy Sprat Hosp;tal to release to requesting haaNh ~nsurence carrier(a), their representabvas and auditors, and any refernng health cars providers, such diagnostic and therapeutic mforma~on [motudmg any ~nfermatmn reta'~ng to treatment for ~ and/or treetmerff of osvchmtnc dmerdem, and/er conhdantmJ HIV misled ;ofo~Tnatfon. as may be necessary for them to determine benefit flemant, to process payment claims for health care services prov]deq dunng this hosp~tahzat~orVtreatmant episode, and for continuing cam/treatment A photocopy or carbon copy of this euthor~zahon shall be considered as offset;ye and vehd es the ong~nal The undersigned also authorizes Medw. are, when applicable, to release to another ~nsurence career, upon their request, medicaJ Information needed to make payment upon that c, ia~.n I undarstartd and consent that the manufacturer of ~ay ~mplanfuble devoe ~nasrted by my phya~an dunng the course maY be Pr°Vlde~d~/v~l~h mY ldantlflCahOn. Trmatlon, InClud'ng Scolal secunty number, as mandated bY Federat Law ~.~/~,,.*.-~ __/~...) INSUFh~NCE ~IG~MENT O~ BENEFIt'S I authonze payment d~recl~y to Holy Sprat Ho~pital and my treating physicians of all benefits payable under my ~nsu~qretand ~FATEMENTTO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS, PHYSICIANS RNB'PATIENT - I request payment of Author~ze~t Mecltcare benefits to me er on my behalf for any services furr.~hed ma by or m Hofy ~p1~t Hospital MEDICAL ASSISTANCE RECIPIENT My s~gnetorss cerises that I recawed e service or ~tams from Holy Spirit Hospital and Dr on the date listed below I underetand that payment for thm serwce or item wdl be from Feclerel end S~ate funds, and that any taise ctafma, statements, or documents, or congealment of mata~al rely be prosemged undec abplmable Fedefat and State !.~ws Date 81gn~um. HOLY SPIRIT HOSPITAL, CAMP HILL, PA CONSF. J~ FOR TREA'I'MEI~/ ~:~ ~ASE OF INFOP. MATION INSURANCE ASSIGNMENT CHART COPY / Obje,c~ve ......... / / [],,,.~ []s~s []ALS HMO~pr[ ]y~ [ P'rei~snit~ [IED [IF)lC . []OnC~ []L,M~Re~' []~C~ce WONMi~ ,$1Ri L L,.,,~ ,~j~ WOZ ~042~24710~ IO/LZ/gQ FX~ 'X~24, ADH. 24 complaining of pain and d~scomfort in her left wrist after she fell e~rlzer ~oday in the grocery store area comxng out of the grocery s~ore. She fell and sustained an znJury on her outstretched left wrist and nsurovascularly intact. She was seen an~ initially evaluated. X-rays shows a comminu~sd T-shaped fracture of the distal radius w~th minimal displace~nt at best at this time. Neuro~ascular intact. Good pulse, moderate swelling. ! have discussed with Sara et length the prognosis and treatment. If over the next several 10 days to 2 weeks of this fracture Olsplaoes or shortens, then all bets are off and we have to proceed w~th a pins and plaster fixatxon and or an externa~ flxator to hold tt tn good alignment. However the a~ignmen~ right now ls very acceptable. I have gone ahead and placed her in a short arm lfght fi~erglass cast to keep her completely tmn~Dllized, ice and elevation and ! have given her prescription for Darvocet-N 100 for pain. She xs going to be using AOvil in the ~n~er~m as well and elevation and she will see Dr. Yucha who she has seen in the past for the next 2-3 days follow up in the office and close ~nitorin9 o£ the fracture the next 10 day~. It is going to ~ake approximately 6-8 weeks to completely heal an~ she is otherwise ~o~ng very well. She will follow up as sobeauleO. displaced but needs to weeks. radius ~n~erart~ouiar fracture mtnimal~y be watched closely over the next several Franc~s Homer PA-C FH/Js D~ 10/12/1¢J9~ T: 10/12/1999 9198 cc Dr. Yucha Page 1 HOLY SPIRIT HOSPITAL NA~: I~ORNAN, HR~: 201982 ROOK#: ~ ~a.: Homer CC~ULTATIOli 1~ SARA ED/HOUSE PHYSICIAN FINDINGS' ED CHART COPY ED/HOUSE PHYSICIAN CHARGE NURSE RADIOLOGIST DEPARTMENT OF RADIOLOGY ' HOLY SPmlT HOSPITAL PRELIMINARY K-RAY INTERPRETAT~,ON AG~ ~'' / LOCATION RADIOLOGIST FINDINGS, Holy Spirit Hospital Department of Radiology and Diagnostic Imaging PATIENT: WORMAN, SARA L MRfl: 201982 SeC SEC' 161-32-3713 ORD DR: RAJANA SHARMA M D PT TYPE: E ADM DATE: 10/12/1999 LOCATION: ER3- Camp Hill, P. ennsylvannla 1701t (717) 763.2600 DICTATION DATE: Oct 12 1999 1 16P TRANSCRIPTION DATE: Oct 12 1999 2 21P ARRIVAL. DATE: 10112J199g HOSP SERVlCE: FR3 ***Final Report*** EXAMINATION: LEFT FOREARM (2v), UNILATERAL LEFT RIBS (3v), CHEST ('Iv) 73090 - Oct 12 t999 COMMENTS' INDICATION - ~njur-/,~'auma There is no prewous chest radiographs avmlable for compar~s~)n at the time of the d~ctation Both lungs ere clear of air space or ~nterstlbal opacities The card~ac s~lhouette and med~asbnal structures are unremarkebie Pleurat effusions or pneumothorax are not seen There is no fractures ~denbfied There ~s no fracture identified in the left ribs Osteoblasflc or osteolytlc changes are not seen The lungs ;~re unremarkab{e Pleural effusions are not seen There ~s a commmu~ed fracture ~nvolwng the articular suiface of the distal radius. There am no fractures ;denbfied m the ulna The ahgnment of the carpal bofle ~s unremarkable CONCLUSION: Normal chest and left nbs Commlnuted fracture of the d~stal radius DICTATED BY: NOBUO NAKAGAWA M D t DG DATE OF EXAM: Oct 12 1999 SIGNED BY: NOBUO NAKAGAWA M D DATE/TIME. Oct 12 1999 $10P -----~abnormai but no actfon mdmated. File Imaging Services Consultation Page 1 Holy Spirit Hospital Department of Radiology and Diagnostic Imaging PATIENT, WORMAN, SARA L MRS: 201982 SOC SEC: 161-32-3713 ORD DR: RAJANA SHARMA M D PT 'tYPE: E ADM DATE: 10/12/1999 LOCATION. ER3- Camp Hill, P. ennsylvannla 17011 (71~ 753~600 DICTATION DATE:, Oct 12 1999 1 18P TRANSCRIPTION DATE: Oct 12 t999 2 10P ARRIVAL DATE: '10/12/t gg9 HOOP SERVICE: ER3 ***Final Report*** EXAMINATION: LEFT WRIST (6VI 73110 - Oct '12 t999 COMMENTS INDICATION * fell S~x views of the left wnst radiograph ~s obtained There is a comm;nuted fracture involv~ng the d;stal radius The fracture Imes appear ID be involving tile articular surface of the radlocarpai joint Mlid ;mpactlon ami angulabon ~s noted There ~s no fracture identified in the distal ulna The radlo-ulnario;nt space Is widened CONCLUSION: Comm~nuted f~"actura of the d~stal rad[us DICTATED BY: NOBUO NAKAGAWA M D / DG DATE OF EXAM: Oct 12 1999 SIGNED BY: DATE/TIME: NOBUO NAKAGAWA M D Oct 12 1999 3 10P Imaging Services Consultation Page 1 Phone: Home ~ ~ I - ~ ~ ~C{ Work X-Ray if { ~IAY ! MAY 3 0 JUN o 6 zOOO JUN i JUN g 3 2000 JUL 0 6 ZOO0 ~ERD CLI~C Camp Hill, PA PE~ONAL INJURY QUESTIONNAIRE ~verlOther Vehicle Have you retained an attorney? Phone Agent's Name ' ~o Ins. Co. ,, , Policy ( ~ )~Y'~ s~l~') Name. ~.._..~_ Were there any .,tnessess? (~) Yes ( ) No Name(s) ~ NATURE OF ACCIDENT: Were you: ( } Driver ( ) Passenger ( ) Front Seat ( ) Back Seat ~NumOer of peDDle in your vehicle?. Other vehicle? ~Whet direction were you headed? ( ) North ( ) E~st ( ) South ( )West on (name of street) ~G~, What direction was other vehicte headed? on (name of street) ( )North ( }East South ( )West ~_ were_you struck from: ( ) Behind ( ) Front ( ) Left side ) Right side 7. Wereycuknockedunconecious? ( )Yes (/~)No. Ifyes, for how long? 8 Were p01Jce not ted? ( )Yes ~lNo/ . 10, ~ ~o~ ~ ,~hysic,I corn. Iai.ts BEFORE THE ACCIDENT? ( ) Yes {~ NO' m~ y,s. pie,se deecribe in 11. Please describe how you felt: b. IMMEDIATELY A~ER the accident; c. ~TER THAT DAY: d. THE NEXT DAY:. ~_. ' -' ,-, '-' )l . - J .. . --~-~, ~ ~ ..... , [ ~ ~ .', - ~,~. 13. Do you have any congenital (frbm birth) factors which relate to this problemt- describe: )Yes (4No. II yes, please 15. Have you ever been involved !n an accident before? ( ) Yes (X) No. If yes, please describe, including date(s) and type(s) ct accidents, es well as injury(les) re~eived. 16. Wherev'~,ereyoutakenaftertheaccident? ~,.~.;p/hJ~'kf,/-dl ( I~'.~(p.(~,_,J"",~t'". 't~ ~ ..... · --- ,,.. .... ~4~,~tq I )(~ '(~. ' ) No. yes, please hsJ doctor s name 18. Since this injuP/ occurred, are your symptoms: ~. Last gay Worked: b. Type of Emmoyment: d. Areycu;uemg eomcens~',tedtar time lost from worx? ( )Yes you are receiving: OATE PATIENT'S CERVICAl. DIAGNOSIS SHEET ~ ~ DATE~-~" /~ ,.--~'~"~ LUMBAR. SACROILIAC. & COCCYX 723.2 729.2 723.4 353.0 724.9 723.5 728.8 738.4 336.9 847.0 722.0 723.2 722.4 CervicocraniaJ Syndrome Cervical Disc Syndrome Oervicobrachlal Syndrome Cervical Myalgia Cervicalgia Cervical Neuralgia, Neuritis, Radicular Neuralgia Cervical Disorders, Brachiai Neuritis or Radiculitis Cervical Plexus Compression Compression of Spinal Nerve Root Cervical Torticollis Cervical Myofascitis Cervical Spondytosis Cervical Neurovascular Compression Cervical Sprain/strain Cervical Disc Syndrome Cervioocranial Syndrome Degeneration of Cen/icai Inter- vertebral Disc 722,2 724.6 724.70 724.71 724.4 724.3 353.4 846.0 722.10 729.5 724.0 839.0 722.52 Displacement of Intervertebral disc Disorders of the Lumbosacral or Sacroiliac Joint Unspecified Discrder/Coccy'x Hypermobility of Coccyx NeudtJs or Radiculltis, Lumbosacra .4..umbar Sciatica, Sciatic Neuritis Lumbago, (Iow back pain) Displacement of Lumbar lntervertebral Disc w/o Myeicpathy Lumbar Plexus Disorder Lumbar Sprain/Strain Prolapse, Protrusion, Rupture or Herniation of Disc Inflammation of the Hip Joint Other & Unspecified Disorders/Back Subluxation Degeneration of Lumbar/Lumbosacral Intervertebrai disc THORACIC 724.1 722.11 724.4 786.5 786.0 785.1 353.3 722.51 Pain in Thoracic Spine Displacement of Thoracic Int. Disc Nffuritis or Radiculitis Thoracic Chest Pain Dyspnea Palpitations Nerve Root Irritation/Degeneration Degeneration of Thoracic tnt. Disc WRIST. HAND AND FINGERS C 59.3 g55.4 955.9 354.0 842.1 726.4 Injuryto Wrist Injul7 to Hand lnjul¥ to Nerve in Hand or Wrist Can3ai Tunnel Syndrome SpranJStrain of Hand Synovitis, Bursitis, Tenosnovitis Wdst & Carpus ANKLE. FOO'r AND TOE!~ LEG AND KNEll 719.46 Pain in Lower Leg 844.8 Sprain/Strain of Knee or Leg 959.7 845.0 723.7 355.5 lnj~'y to Ankle or Foot Sprain/Strain of Ankle Cacaneal Spur T a~31 Tunnel Syndrome SHOULDER AND ELBOW OTHER 959.2 996.3 726.3 726.10 injury to Shoulder Injury to Elbow Synovitis, Bursitis, & Tenosnovitis Elbow Synovitis, Bursitis, & Tenosnovitis Shoulder OTHER 830.0 TMJ Subluxation 717.9 Paravertebra Myofascitls 780.7 Fatigue 493.9 Asthma, Bronchial 782.3 Edema 346.9 Migraine Headaches 780,4 Vertigo (Neumpathic) Dizziness 470 influenza 786.2 Bedwefling 729.82 Menstrual Pan/Cramps 625.4 PMS 780.51 Insomnia 787.9 Gl Complants 112.5 Candida 995.3 Allergies, Unspecified 693.1 Food Allergies 737.0 Curvature of Spine 079.0 Viral Infection, Unspecified 477.9 Respiratoq/Allergy 712.0 Arthritis 956.1 Sbondylosis 551.3 Hialal Hernta 355.0 Sinus ROENTGENOLOGICAL REPORT Cervical Spine Negative for recent fracture or gross osteepathoiogy as visualized. Loss of ( ) Severely decreased ( ) Mildly decreased cervical lordotic curve. Negative for discogenic lesion. Apparent cervical myospasm. ( ) Mild ) Moderate Severe. Destro- scoliosis. ( ) Mild ) Moderate Severe Lave'- scoliosis. ( ) Mild ) Moderate Severe z)~arrowed, o disc spac_so between (~croachment of th, neuroforami~bgtw~ ~--~ ~steoarthritis of ~ ~-~, ~ ~ ~/- - Other ~ Apexed at Apexed at Thoracic Spine Negative for recent fracture or gross osteopathoiogy as visualized. Kyphotic curve appears normal. Apparent myospasm. ( Mild ( Moderate Negative for discogenic lesion. Dextro - scotiosis. ( Mild ( Moderate Lave - scoiiosis. ( Mild ( Moderate Narrowed disc spaces between Osteoarthritis of Severe. Severe. Severe. ADexed at_ Apexed at_ Other Lumbar Spine ( }.Negative for recent fracture or gross osteo[~athology as visualized. ( ) Loss of ( ) Severely decreased (/I Mildly decreased lumbar lordotic curve. ) A~parant lumbar myospasm ( )~i/d (~?' Dextro - scoiiosos. Lave- scoliosis, .,( ) Mild ~mN-~rrow disc space between Articular facets appear to be ~ -- % // Spondylolistheses, grade ( ) 1 ( ) 2 Right ilium rotated Left ilium rotata¢ -k-~ther ./¢/2~ ,'/~'t/' ) Moderate ( ) Severe. ) Moderate ( ) Severe. ) Moderate ( ) Severe. Apexed at Apexed at Extremities ( ) ( ) Other ( ) ( ) Overview of X-Ray Findings HERD CHIROPRACTIC CLINIC, P.C. 2704 MARKET STREET / CAMP HILL, PENNSYLVAh, IA 170,1 t [7'17] 737-,168,1 FAX [7'17] 73,1-'1648 Initiali Report danuaw 26,2000 To: MAC Risk Management Pa~ent:SaraWorrrmn Date of InjUry: 10-12-99 1. Incident of Injury: Fell at GIANT food stores on a "red pepper," 2. Patient's Complaints: Low back pa.~, neck arid wnst pain with numbness. 3. Objective Findings (Examination): (+) orthopeclio test, and decreased range of motion. 4. X-my Analysis Summary: Consistent wrth diagnosis 5. Diagno~is: 723,3; 729.1; 724.2; 959.3 6. Disability Data: N/A HERD CHIROPRACTIC CI.,INIC, P.C. 2704 MARKET STREET / CAMP HILL, PENNSYLVANIA ~ 70 t ~ {7t71737-~68~ FAX(717) 731-1648 MONTHLY PATIENT: Sara Won'nan DATE OF THIS REPORT: March 31, 2000 PROGRESS REPORT THE ABOVE CAPTIONED PATIENT: ( 9,/~ under active care. ( ) has been released from care. ( ) has reached a state of maximum medical improvement for this condition and has been released from active care. He / She has been advised to return on an as needed basis for the control of pain and exacerbations. THIS IS NOT MAINTENANCE CARE. HIS I HER CONDITION AT THIS TIME: ( ) ,j~improving with the present course of treatment. ( ,)/remains stalic ( ) is retrogressing. INTERIM AGGRAVATIONS OR ACCIDENTS: ,~e~xtended standing, sitting or stooping. I ,.)/~bousehold duties. duties related to the patient's regular employment. o[her (please speoifi/) PRESENT SUBJECTIVE COMPLAINTS: / PROGNOSIS: TREATMENT PL~.' This patient is to be seen time(s) a week for the next ..__ week(s), and will then be re- evaluated after days for his / her existing health status. This patient is / is not disabled from work at this time because [~f this injury. GERALD M. DINCHER, D.C. SS# f88-44-4403 IRS# 23-2'!f0925 HERD CHIROPRACTIC CLINIC, P.C. 2704 MARKET SYREET / CAMP HILL, PENNSYLVANIA '170'1~ (7t7) 737-t681 FAX (717) 73~-1648 MONTHLY PROGRESS REPORT PATIENT: Sara Won'nan DATE OFTHI$ REPORT: February 29, 2000 THE ABOVE CAPTIONED PATIENT: ( ) has been released from care. ( ) has reached a state of maximum medical improvement for this condition and has been released from active care. He / She has been advised to return on an as needed basis for the control of pain and exacerbations. THIS IS NOT MAINTIr. NANCE CARE. HIS I HER CONDITION AT THIS TIME: ( ) ,,is'improving with the present course of treatment. (~ remains static. ( ) is retrogressing. INTERIM AGGRAVATIONS, OR ACCIDENTS: ( ."~/extended standing, sitting or stooping. ( ~ .)~::x~sehold duties. ( ~ duties related to the patient's regular employment ( ) other (please specify) / TREATMENT I~N: This patient is to be seen o~'-., time(s) a week for 1he next _~ week(s), and will then be re- evaluated after ,~/~) days for his / her existing health statbs. This patient is I is not'disabled from work at this time because of this injury. GERALD M. DINCHER, D.C. SS# f88-44-4403 IRS# 23-2ff0925 HERD CHIROPRACTIC CLINIC, RC. 2704 MARKET STREET / CAMP HILL, PENNSYLVANI ~, t70t t [7~7]737-168t FAX(717]731-1648 MONTHLY PATIENT: Sara Worman DATE OF THIS REPORT: APRIL 30, 2000 PROGRESS REPORT THE ABOVE CAPTIONED PATIENT: (.~is under active care. ( ) has been released from care. ( ) has reached a state of maximum medical improcement for this condition and has beeH released from active care. He / She has been advised to return on an as neecied basis for the control of pain and exacerbations. THIS IS NOT MAIN?ENANCE CARE. HIS / HER CONDITION AT THIS TIME: (.~'/is improving .wi~.~h the present course of treatment. ( .)' remair~ static. ( ) is. retrogressing. INTERIM AGGRAVATIONS OR ACCIDENTS: (¢). extended standing, sitting or stooping. ( )'.household duties. ( -)' duties related to the patient's regular employment. ( ) other (please speoify) PRESENT 8UB,JECTIVlE COMPLAINTS: PROGNOSIS: TREATMENT PLA~: This patient is to be seen __ time(s) a week for the next ____ week(s), and wilt then be re- evaluated after days for his / her existin~ health statu.,~ 'this patient is / is not disabled from work at this time because of this injury. ~ERALD M. DINCHEF~, D.C, SS# '188-44.,4403 IRS~ 23-2ff0925 GRANDVIEW SURGICAL CENTER OPERATIVE REPORT DATE DICTATED: 4/I 8/00 DATE TRANSCRIBED: 4/18/00 PATIENT: Sara Woman 21428 DATE: 4/18/00 SURGEON: Stephen W. Dailey, M.D. ANESTHESIOLOGIST: PRE-OP DX: See below. POST-OP DX: See below. PROCEDURE: See below. DESCRIPTION PREOPERATIVE DIAGNOSIS Left carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS Same. PROCEDURE Left endoscopic tunnel release. ANESTI-[ESIA MAC. INDICATIONS The patient is a 61-year old female with moderately severe bilateral carpal tunnel s~vndrome. She was originally scheduled to have the right side released, and that started feeling better. The left side was worse for her symptomatically preoperative and, therefore, we proceeded with a left endoscopic carpal tunnel release. OPERATIVE PROCEDURE The pattern was taken to the Operating Room and placed on the operating table in the supine position, and the let~ upper extremity was sterilely prepped and draped in the usual manner. 1% Xylocaine with epinephrine with sodium bicarbonate was used to infiltrate across the palmar aspect of the wrist and between the thenar and hypothenar eminences. Approximately 6 cc of local anesthesia was infiltrated. A marking pen was then used to outline the skin incision.just proximal to the wrist flexion crease overlying the median nerve, and also to outline the axis oftbe ring finger metacarpal. The arm was then exsaagulnated with the Esmarch bandage, and the pneumatic tourniquet about the right proximal upper extremity inflated to 250 mm of mercury. A transverse skin incision was made at the wrist. Coursing longitudinal veins were electrocoagulated and divided. The palmaris longte~ tendon was identified and retracted radialward. PATIENT: DATE: PAGE: Sara Worman 4/l 8/00 2 The forearm fascia was opened transversely with the scissors, and then a flap of fascia developed and retracted distally and palmarly with a skin lmok. Scissors were first passed into the carpal canal superficial to the median nerve and deep to the transverse carpal ligamem in line with the ring finger metacarpal. Following th/s, the synovial stripper, then the canal dilators were introduced. The scope was then introduced into the carpal canal, and the transverse fibers of the carpal ligament identified clearly. The distal most aspect of the transverse carpal ligament was clearly seen. Using the thumb, it was possible to palpate in the palm and to demonstrate the fat at the distal aspect of the transverse carpal ligament. The knife was then elevated approximately one-third of its height, and the distinct most aspect of the transverse carpal ligamem (approximately 1 em) divided. The knife was then retracted. Visualization of the distal aspect of the transverse carpal ligament then identified a few fibers still intact distally. The knife was elevated partially again and these fibers divided. The knife was then fully elevated and withdrawn fi.om the wrist, dividing the transverse carpal ligament. With the knife retracted, the scope was reinserted, and the: division of the transverse carpal ligament was inspected. It was noted that a rectangular d:Msion of the ligament had been accomplished. This having been performed, the scope was removed from the wrist. Under direct vision, the remaining few fibers of the transverse carpal ligament distal to the skin incision were divided sharply with scissors, and then the forearm fascia divided proximal to the skin incision for a distance of approximately 2.5 cm. The wound was then irrigated with normal saline and closed with a running 4-0 nylon subeuticular suture. A sterile dressing incorporating Xeroflo, 4 x 8's. Kerlix and Kling was then applied. The tourniquet was deflated, and excellent capillary refill returned to the fingertips. The patient was transported in good condkion to the Recovery Room having tolerated the procedure well. Stephen W. D~'~v.M.D. Date SWD/TK:clk/139886 Gr. and~iew Surgery & La$~,~ Pre-Dp Dx. Pre-Dp Dx. Post-Dp Dx. =DSt-Dp Dx. 'enter #05-0091 ' Operating Room N~,'ses' Notes 3rocedure Procedure / PATIENT IN O.R. , OUTO,R. TYPE OF ANESTHESIA' m B er B oc~ ANESTHESIA ~ OPERATION I r~ ~ , ' -- START I END i STARTi END 1 [] Regional // ~' Local S~and-By PATIENT IDENTIFIED CONSENT SIGNED ©P SiTE IDENTIFIED BY PATIENT PRE-DP ASSESSMENT REVIEWED ALLERGIES: KNEE STRAP LEGS r iWOUND N/A SECUREB? I ,~CROSSED? OR BED I CLASSIFICATION --r YES EYEL ' ER I ~ NO ) -- NO : NA [- ~STRETCHER i~11 ]H POSITION OF PATIENT ~-- Legholder R or L -- BeanBag ~upine -- Li~otomy ~ Shoulder Roil ' _~ Prone ~ Jack-Knife ] Arms :ucxed at -- Lateral ~ Beach Chair ~, _ri Ta~ie R Ulnar Pads -] Pillow , Head ~rm Bcar~r L ~1~ Donut _~ Head Cradle -- Pillow . Knees Other -- Heel Pad INJECTION NEEDLES BLADES SURGEON: ASSISTANT: OTHER: /~ LOCAL MONITOR:/~ ORIGINAL COUNT RAYTEC LAP OTHER SPONGES SPONGES ?P'ONGES ATR. NEEDLES REG. NEEDLES Nurses' Notes: PrEP SOLUT1CN USED: __-- N/A ~. Betadine -- Phi$onex ~biclens -- Other (S~ec~ ~i GEOUNDING PAD SITE: PCWER LEVEL: OCAG Signatures: .~ .~__~ circ: ~ ~/~--. relief: scrub: ~ '~ ~ ~ ( ~ relief: time: time: Grandview Surgery & Lar Practitioner Intraoperat,.e Order Section -;enter #05-0091 DOSE TIME ROUTE Piaster ' SiTE Packs : N/A~ Specimens: tissues E cultures [] frozen [] N/A [~ 2, 5. 6. 8. 9. Tourniquet: # /. ., '~N/A [] Tourniquet checked pre-op ~ [] Right Arm ~=Y~eff Arm ~ RightLe~ / ~ ~ Left Leg Pressure: Pressure:~___~___ ~'-~ /~'-'~ln flared Inflated @: De . Deflated @: ~ · ~/ Total ~me: Catheter inserted: N/A ~ Foley ~ Straight E Removed @ / Drainage Amt. + Color implants: Type,: Size: Company: ID #: Lot #: Stickers: Surgeon Signature: Date: BALINT BALOG, M.D. RICHARD J. BOAL, M.D. ROBERT R. DAHMUS, M,D. STEPHEN W. DAILEY, M.D. WILLIAM W. D~MUTH. M,D., F.A.C.S. JOHN R. FRANKENY IL M.D., F.A.C.S. MARK IL GRUBB, M.D. RICHARD H. HALLOCtL M.D. GREGORY A. HANKS, M.D. ALEXANDER KALENAF, M.D., F.A.C.S. ROBERT R. IL~NEDA. D.O., F~.C.O.S. JASON J. LITTON~ M.D. TELEPHONE: (717) 761-5530 (800) 834-4020 FAX: (717) 737-7197 www.orthoinstituteofpa.com Pebruary !5, 2001 W Scott Henning, Attorney-at-Law P.O. Box 1177 Harrisburg, PA 17108 FEB 2 0 2001 RE: Sara L. Worman 161 32 3713 Dear Mr. Hennlng: Sara Worman ms a patient that I had the privilege of taking care of. I first saw her on 10/15/1999. At that time, she had ju~E recently slipped at the Giant Supermarket and fell on a pepper going down en her left side. Her initial complaint was left sided chest pain and left wrist pain. She sustained a left distal radius fracture which wa~ reduced and casted. The reduction was in accep£able position and this was treated with zmmohi!ization. After a period of immobilizatlon for approximately six weeks, she had improvement of the pain that she ~as experlenc!ng and the fracture hea~ed appropriately. When she was seen on 12/10/99, she still had some discomfort in the hand and she also had complaints of numbness and tingling in the left hand. Subsequenu EHG and neFce conduction study was consistent with lefl carpal tunnel syndrome. Her exam was conslstenm with enis diagnosis as well. She subsequently underwent left endoscopic carpal tunnel release on 4/18/2000 and had improvement of her symptoms. It is my sp~nmon that the carpal tunnel is direcziy related to the injury she sustained when she fell on 10/12/99. The specific injuries related to this would be the left distal radius fracture, that is the side she had fallen on, anO left carpal tunnel syndrome. It is also my spinion that at this point, the payment has reacneu maximum=~': --~ improvement. .... ~¼~ should not have significant long term sequelae in her lefz upper extremity from th~s in]ury. Of course, with any fracture nhaE goes znno a joznm, there is the possibility of pose trmumaE!c arthritis at some point mn the future With her fracture, this ms not likely, however. There ms also the possibility of recurrence of carpal Eunne! syndrome. I don't suspect zhe matient will need further treatment mn the foreseeable future for zhe left upper extremlty. The percentage of disability according ~c she ~ guidelines, page 36, zs 13 percent for uhe left upper extremity. If you have any further questions on Sara Worman, don't hesitate to call me. ADDRESS ALL CORRESFONDENCI~ TO: 875 POPLAR CHURCH ROAD, CAMP HILL, PA 17011 RE: WORMAN, SAR~ L. PAGE 2 February 5, 2001 SWD/mee Sincerely, SEephen W. Dailey, M.D~ ORTHOPEDIC INSTITUTE OF PENNSYLVANIA GREGORY A. HANKS, ALEXANDER KALENAK, M.D,, F~t C.S. RONALD W. LIPPE, M.D., F.A.C.S, JA.SON J. LITTON, M,D. ERNEST R. RUBBO, ?I.D. WILLIAM J. FOLACHECK, JR., M.D. STEVEN B. WOLF, M.D. THOMAS ,J. YUCHA, M.D TELEPHONE: (717) 761-5530 · (800) 834-4020 FAX: (717) 737-7197 www.orthoinstituteofpa.com July 19, 2001 W. Scott Henning Handler, Henning & Rosenberg Attorneys At Law P. O. Box 1177 Harrisburg, PA 17108 RE: Sara L. Worman 161 32 3713 Dear Mr. Henning: This letter is in regards to Sara Worman who is a patient of mine. She was treated for injuries to her left upper extremity associated with injuries she sustained 10/12/99. She developed problems with her right upper extremity involving right carpal tunnel syndrome and right trigger finger. These were treated surgically by me. I do not feel that there is a cause of relationship between her right upper extremity orthopedic problems and her in]ury which did in fact affect her left upper extremity. If you have any further questions, please do not hesitate to contact me. Sincerely, SWD/lmn Stephen W. Dailey, M.D. ADDRESS ALL CORRESPONDENCE TO: 875 POPLAR CHURCH ROAD, CAMP HILL, PA 17011 MEDICAL EXPENSE SUMMARY Provider Dates of Service Holy Spirit 10/12/99 Orthopedic 10/15/99 thru Institute 7/7/00 Herd Chiropractic 1/14/00 thru 7/6/00 Grandview 4/18/00 Surgery Prescriptions 1/20/00 West Shore 4/18/00 Anesthesia Teufel Orthotic 11/19/99 Amount Paid .Due $721.00 $*696.00 $0.0 $25.00 $1,990.08 $'1,904.20 $0.0 $**85.88 $2,826.00 $0.0 $2,826.00 $3,221.57 $* $ $40.00 $**40.00 $0.00 $390.00 $'192.00 $ $45.00 $*36.00 $ TOTALS $9,188.65 SUBROGATION CLAIM: Healthcare Recoveries $2,992.92 (amount pending final accounting for related charges - total lien being asserted is $6,665.99 C 16 HCI S$ 1 17011 A HOLY SPIRIT HOSPITAL $05 N 21ST ST CAMP HILLt PA CYCLE 10/26/99 717 765-2141 BIRTH-DATE OUTP. FEI ~ 23-1512747 04/16/58 590004 Q E NORMAN ,SARA L 14098081 F 61 I0/12/~9 SARA L WORHAN 2 HEAkTH AMERICA 20428247102 522 SPRINGHOUSE RD CAMP HILL,PA 17011 SHARMA RAJANA DETAIL OF CURRENT CHARGES, PAYMENTS AND ADJUSTMENTS !0/12 CAST SCOTCH 4 0117204459 29.00 2';,00 !0/12 CAST SCOTC? 5 0217204454 64.00 64.00 1~/12 UNILAT LFT RIBS015G101145 i97.00 lg7.0C 10/12 LEFT FOREARM 0156101301 82.00 82.00 10/12 LEFT WRIST 0136!01327 110.00 110.00 10/12 ED VISIT LEVEL 0117103011 259.00 259.0C BALANCE FORWARD 0.00 SUMMARY OF CURRENT CHARGES M/S SUPPLIES 270 93.00 9~.00 DX X-RAY 320 389.00 389.00 EMERGENCY ROOM 450 259.00 259.00 SUB-TOTAL OF CURR. CHARGES 721.00 721.00 DIAGNOSIS: E849.6 PAYMENT IS DUE UPON RECEIPT OF THIS STATEMENT'. YOU MAY SUBMIT THIS FORM TO YOUR INSURANCE CARRIER FOR REIMBURSEMENT. T 0 T A L S 721.00 721.00 14098081 PAY THIS AMOUNT 0.00 HOLY SPIRIT HOSPITAL CAMP HILL, PA Page No. ]. Account Numi~er: ]. ~ n ~) 8 0 8 1 PatientName:WORHAN , SARA L Service Start: 1 0 / 1 2/9 9 Service Ena: Statemert Date: 0 1/0 I~ / 0 0 Last Statement Date: 10/2&/99 QUESTIONS? Please Call: 717-7&$-2158 Contact: ACCOUNT BALANCE I ESTIMATED INSURANCE DUE I TOTAL PATIENT CREDITS 25°00 .00 I I TRANS DATE 10/12/99 10/12/99 10/12/99 Z0/I2/99 I0/12/99 10/I2/99 12/25/99 12/25/99 DESCRIPTION PREVIOUS BALANCE CAST SCOTCH ~ CAST SCOTCH $ UNILAT LFT RIBS LEFT FOREARM LEFT NRIST D VISIT LEVEL III A~ER PYMT-OP AMER C/A HOS-OP QO2 HEALTH AMERIC Q02 HEALTH AMERIC AMOUNT 29 197 82 110 259 216 O0 O0 O0 O0 O0 O0 O0 70- $0- 0 R HO SG i 000025587 iACCOUNTBA~NCE ] 25.00 THIS BILL REPRESENTS THE AMOUNT NOT PAID BY YOUR INSURANCE' REHIT PAYMENT TODAY OR CALL 765--9620 IF YOU HAVE QUESTIONS' Q02 HEALTH AMERZC .00 PLEASE DISREGARD THIS STATEHENT IF YOU HAVE PAID' ~SL DBA ORTH~INSTITUTE OF PA ~3916'TR1NDLE::'ROAD- CAMP~ HILL PA 717--761-5530' TA~-~D'#~ 23~1~75547 05-15-00 SARA L WORMAN 1~5242 522 SPRIN6HOUS~-ROAD ..... GA~ Ii-Z~9~G~ATER-' OI-~4v00~C~ATE~--~ 01-14~00-99~13 01-14-00'7'~100-LT 01-14-00.7~100-52 02-04-00 CLATER ' 02-04-0~ ~921~ TOTAL' CHARGES HEALTH .~A~iERICA PAYMENT ~' PERSONA[~ CHECK HF..ALTH~AE;SURANCE PAYMENT HEALTH ~AMERICA ADJUSTMENT HEALTH AE;SURANCE ADJDSTME TOTAL BALANCE DUE DIAGNOSES: 847.1 ~E849.0 E~85 726.19 E849.6 E880.~ 813.41 SPRAIN AND STRAIN THORACIC PLACE OF. OCCURRENCE;' HOME~' FALL ON SAME LEYEL~ FROM SLIPPING, TRIPPING, OR STU MBLING OTHER SPECIFIED DISORDERS OF THE E;HOULDER PLACE OF OCCURRENCE;'~PUBLIC' BUILDING FALL ON OR'FROM STAIRS-OR~ STEPS; OTHER COLLES'-'FRACTURE, CLOSED .00 .00 50.00 60.00 40 i60~00 '~60~00 .13.00 .00 .00 .00 ,00 50.00 60.00 60~00 .00 40.00~, 24~.50 40i88 -259.50 -85.11 ,00 OSL DBA ORTH iNSTITUTE OF PA 3916 TRINDLE ROAD CAMP HILL PA 17011 FAX ID #: 23-1~75547 0b-15-00 SARA L WORMAN 11524Z 522 SPRINGHOUSE ROAD -t~-AMP~HILL PA ~17011 DAT~ ' ~ROC D~G~tO~; 0~-00 CLATER CHA~G~ LA:~ER~' ~WD¢ 05 04~i2-00 -99~2 O~FiCE'O~, ~tSiT. ~W~ 05 ~4--18-00' 29G4G-LT ENDOSCO~Y~'?W~IS.~, ' 04-26-00 99024 OPFICE' OALL 01 TOTAL BALANCE.DUE DIAGNOSES: E84~0 E885~ 726.19 E849.~ E880.9 354.0 727.03 SPRAIN AND ,:~TRAiN~?rHORACiC FALL~,,ON-, B~kME LE~EL--FROM~L~P~ING~-~IP~ING~ OR O'~HER-' SPECIFIED *' D~ORD~RS' OF' THE SHOULDER FALL O~ OR,FROM,STAIR~ ~R STEPS; COLLES' FRA~Ua~-CLO~ PLEX, CAR~AL TUNNEL SYNDROME TRIGGER FINGER (ACQUIRED) CHARGES .00 40,00 1028.00 .00 15~00 F.~EE TEXT'MESSAGE, 1 F~EE'TEXT MESS;{GE LINI:. 2 'FREE---TEX7~ ~E~SAGE LiNE's4- OSL DBA ORTH INSTITUTE OF PA 875 POPLAR CHURCH ROAD CAMP HILL PA 17011 7!7-781-5530 TAX ID ~: 23-1875547 PATIENT: 115242 WORMAN ,SARA L PAl BAL: ?--" ~c INS BAL: 1083. i~]~! OTH BAL: ,00 SERV C INS A LINE INVOICE RUNNING DATE INV RP~ ~ DR PROC DESC COMMENT CO CmA PL AMOUNT' BALANCE _A=ANC= "' I 2~ 04=609 ALEXANDER 051900 30 STEPHEN W 051900 31 STEPHEN W 060700 092600 31 092600 092600 31 ~51900 STEPHEN W i~92600 32 ;~92600 ~51900 STEPHEN W 092600 092600 061600 34 STEPHEN W STEP'HEN W STEPHEN W 072600 37 082100 37 082100 37 082100 37 090600 37 090600 37 080100 38 STEPHEN W 101300 38 101300 101300 38 E9=000 38 081600 39 STEPHEN W 081600 40 STEPHEN W i ~;-' 90000 OC KALENAK MD DIAG: 354.0 i ..~I 90000 OC DAILEY MD DIAG: 354.0 1 31 99212 OFFICE OUT 9284 12Y 01 40.00 40~00 DAILEY MD DIAG: ~=~. ~o i PC PERSONAL ! 1~7 l:i 05 -15.00 ;iS. 00 i HASS HEALTH ASS.~ ...... ¢ ~ ~ =~' ~ ..... := ;7~ -..~.,': " *,~,~- :~ ~Z~. ~'7 i HASJ H. ASS. ADJ i $15.00 COPAY '!:2 DAILEY MD DIAG: HASS HEALTH ASS ....... :: ~ ~ -~ ~- ~ ~ ':' }284 Si ~0¢0~ CELESTONE DAILEY MD DIAG: 727.03 ~ HASS HEALTH ASS ? ..... " HASJ H. ASS. ADJ 12~.~';~ -=.= ~=": ,~ .:ZiO _~ CLATE CHGE LATER DAILEY MD DIAG: 7~7. 03 DAIL?f' MD DIAG: ¢=7.03 -~__ 99214 OFF,CE OUT 7234 DAILEY MD DiAG: 727.03 :'C PERSONAL i 2 ~9 HASS HEALTHH~c~ 367G00 .:5 .,.':~ . Z~O S3.00 '~ HASJ H. ASS. ADJ , =~ ,,~ -. =. ~0 - ~ ~ =,. ..:~]E~. ' ~.~-,I GLOBAL SURGERY ",.5 i HASS DENIED-iNCLUDED 'i REF REFUND TO PT. i;]5 .~.~=~,. ~Z~O I CHECK NO. 23783 I 31 26055 TRIG FtNG DAILEY MD DiAG: 727.03 i HASS HEALTH ASS i HASJ H. ASS. ADJ 1 $47.38 MEMBER CO-INS 1 PC PERSONAL 509 1 31 90000 OC DAILEY MD DIAG: 727.03 I 31 99212 OFFICE OUT DAILEY MD DIAG: 7~6.32 9284 378i0i · ~ ~ ,~ 828.00 828. i~70 16 L~5 -i89. 54 G38.48 18 05 -591.08 ~.'~ 38 16 16 05 -15.00 ~c_.?'-' 38 ~,~'-' 38 05 , 00 . 00 ~=.?'-' 38 9284 17Y 05 40.00 7~. 38 INS C~HARGES ONLY ITEMIZE[) ST A T ~ M E NT CLAIM: [lATE. 0511512000 INSURE[): STEPHANIE BRADLEY PATIENT: SARA L. WORMAN 130497 522 SPRINGHOUSE ROAD CAMP HILL PA 17011 8S#161-32-3713 POL#(~L99~9192 DATE/INJ: 10/12/1999 GRP# TO: MACRISK MANAGEMENT P O BOX 9227 BOSTON MA 02299-9935 IRS#~ 232110925 EMPLOYER: YNA OF HBG HERD CHIROPRACTII] CLINII] 2704 MARKET STREET CAMP HILL PA 1701t-4531 717/7<17-1681Fax:7!7/73!-164H D I AGNOS I s: 72X.3 CERVICOBRACHIAL SYNDROME 729,t CERVICAL MYALGIA 724.2 LUMBAGO w%9.3 INJURY TO WRIST ~(7~ PER-INJURY [)ATE oF LAST BILL: 05/11/2000 PR# 1Z10~6KPK ID# 121006 DATE CPT DESCRIPTION * POS TON # AMOUNT 01/14/20~0 98941 CMT, SPINAL, THREE TO FOUR RE(~IONS 11 2 ] 40.o~ 01/14/2000 97014 ELECT, STIMULATION-UNATT~ 1! 1 0]/]4/2000 7~O40 CERVICAL SPINE A-P AN[) LATERAL ~1/14/2000 721o~ LUMBOSACRAL A-P AN[) LATERAL 0]/15/2000 98941 CMT, SPINAL, THREE TO FOUR RI~I(DNS ]1 2 ] 40.0~ ~1/15/2000 97014 ELECT. STIMULATI£~-UNATT. 1t 1 20.0~ Ol/17/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 ~1/!7/2000 97014 ELECT. STIMULATIf~-UNATT. 11 1 20.0~ 0111812000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40.0~ 0!/18/200~ 97014 ELECT. STIMULATION-UNATT. 11 1 20.0~ 01/19/200~ 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 ! 40.0~ 0]/19/2000 97014 ELECT. STIMULATION-UNATT, 11 1 20.0~ 01/19/20~ 97035 ULTRASOUND 11 ] 15.00 ~1/21/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS !1 2 1 01/21/200~ 97035 ULTRASOUND 11 1 15.0o 01/~412~00 98941 CMT~ SPINAL~ THREE TO F¢)UR R~GIONS 11 2 1 40.00 ~1/24/2000 97035 ULTRASOUND 11 1 15.00 01/2612000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40.00 0112612000 97014 ELECT. STIMULATION-UNATT, 11 i 20.00 01/26/200~ 97035 ULTRASOUND 11 1 15.00 0112812000 98941 CMT, ~PINAL, THREE TO FOUR RE~IONS 11 2 ] 40.00 01/28/2000 97014 ELECT. STIMULATION-UNATT, 11 1 20.00 01/2~/200~ 97~35 ULTRASOUND 11 1 15.0~ 02/02/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40.00 02/02/2000 97035 ULTRASOUND 11 ~ 15.00 ~2/04/2000 98941 CMT, SPINAL, THREE TO FOUR REGIONS 11 2 1 40.0~ 02/04/2000 97014 ELECT. 8TIMULATION-UNATT. 11 1 20.0~ C(DNTINUED SUBTOTAL: 806.0~ INS CHARGES ONLY I T ~, M I ?, E[I ~T~TEMEMT CLAIM [)ATE: 05/15/20~ INSURE[), STEPHANIE BRADLEY PATIENT, SARA L~ WORMAN 522 SPRINGHOUSE ROAD {7AMP ~ILL P~ IRS#: 232110925 EMPLOYER~ VNA ()P HER[) CHIROPRA{?TIC CLINIC Z7~4 MARKET STREET {?AMP HILL R~ i7o!i-~n~ D!A{~N{)SIS, -" :,. } (.ERVL_.)BRACHIAL SYNDR(-)M~, ' ! i ~MBAGO e2/~7/2eee 98941 ]MT. SPINAL, THREE TO FOUR REC~IONS 11 2 (42/e7/2eoe 97~L~ 5 ULTRASOUND !1 ! ~ 5.e~' ~2/~7/2~ 97~).4 ELECT. STIMJLATION-UNATT. !'I e2./eq/2ese qbe4! ('.MT~ SPINAL, THREE TO POUR REGIONS 'i! 2 i 4e-ce e2/~R/2~e 97~14 ELE(iT. STIMULAT!ON-UNATT. 1! ! ~}2/~n/2e~e 97e~5 HLTRASOUND !! ! 15,ee e2/~9/2e~e 9753e KINETIC ACTIVITY RE~ABtLITATK} 1! ~2/it/2eee 98941 CMT, SPINAL~ THREE To POUR R{GIONS !1 2 e2/!i/2eee 97~!4 ELECT. STIMULATION-UNATT, '!! 1 ~}2/!1/2eee 97e35 ULTRASOUND 11 ! 15.ee ~2/i~ /2~ 9753~ KINETIC ACTIVITY REHABtLITATIO e2/1B/2eee 98941 CMT ,_PINAL, THREE TO POUR REGIONS 11 2 e2/'! 5 / 2~ 97e35 ULTRASOUND 11 ] 15.ee ~}2/'!~/2e~ 9753~ KINETIq ACTIVITY 9BHABILITATIO !! 1 :3e.ee ~/.! ,/2~ 9894"i C~T, SPINAL, THREE TO FOUR RE(.I(_)N~ 1i M 1 4~.~ ~)2/-~7/2eee 97e'!4 ELE-T. gTIMllLATION-UNATT. I1 e2/17/2~e 97e~5 ULTRASOUND '!1 1 15.ee ~2/!7/2~e 9751~ KINETIC ACTIVITY REHABILITATIO 1i ~2/23/2~ 9894] CMT, SPINAL, THRE~ TO ~(i)UR RE(~Ifi)N8 il 2 1 4~.~ ~2/23/2~ Q7~i4 ELE .T. STIMULATION-UNATT. $2/23/2~ 97535 LTRA SOIIND ]1 p ' 2 THREE TO FOUR REGIONS !! 2 1 45.~ ~2/25/2~ 98941 (.MT, ,_PINAL, ~2/25/20~ 97~i4 ELE(]T~ STIMULATION-UNATT. 11 1 2~,~ ~2/25/2~ 97~35 l [LTRASOUND ~2!28/2~ 98941 CMT, SPINAL, THREE TO FOU~ REGIONS 11 2 1 4~.~ ~2/28/2~ 97~14 ELE..T, STIMULATION-UNATT. ~2/28/2~ 97~[~5 ULTRASOUND ]'~ l~~ i5.~ CONTINUED SUBTOTAL: 1,5~6.~0 INS CHARGES ONLY ITEMIZE[) H T h T ~ M E N T CLAIM: DATE: ~5/]5/2~0~ INSURE[): STEPHANIE BRADLEY PATIENT: SARA L. WORMAN !3~a~v 322 SPRINGHOHSE ROAD ~!AMP HILL PA 17~1] ~CF~! S}< MANAGEMEN? i~S#, 23Z110925 EMPLOYER, \;NA -)? HB¢; HERD CHIROPRACTIC CLINI~; c:AM~ HILL pz '7~!~-~s. ;TA(]N()SIS r -' :,.: ~ERVIC()BRACHIAL SYNDROME - ~ T 3 iNJUPi! mc; WRTS !NJUR! LAST BILL, ~,5,,.~z/;~OOe P~ '~;~I~6KPE ID~ 12!~O~, CPT D~S(.RIPTI(.)N P(l)S TOS ~ AMOIINT ~4/eHtze00 9~2i2 ~4/o6/2000 9~Z12 ~/06/2~e~ 9712~ ~/]~/2000 9703~ (4~/!6/2000 q8943 sS/!%/200e 9753e O~/]H1200~ 9894~ ~3/18/200~ 97e45 ~3/1R/ZOOe 97530 ~3/Z]/2000 98941 e3/Z1/Z00¢ 97035 e3/21/200~ 9753e ~S/Ze/Z000 98941 ~R/Z4/20~e 97e35 el/27/200e 989~! ~3/27/2ooe 97o~5 ~3/27/2ooe 9753o 04/12/2ooe 98941 e4/!2/200e 97e35 o4/14/2ooo 98941 o4/14/20oe 97035 O~FICE VISIT-LIMITED !~ 2 ', iLTRA S(i)UND -)PFItIE VISIT-LIMITED 7 '! 2 MANUAL MASSAt?, CMT, SPINAL, THREE TO FOUR REGIONS 1i 2 ELECT. STIMULATION-UNATT ~ l ~ ~LTRASOUND 1 ! CMT~ SPINAL~ THREE TO POUP 9}~(~I(.)Ns ;LTRASOUND KINETIC ACTIVITY 9EHABILITATIO 1! CMT SPINAL, ONE TO TWO 9E(~I()NS 1i 2 ULTRASOUND 11 KINETIC ACTIVITY RBHABILITATIO ~'i CMT, SPINAL, THREE TO FC)U~ REGIONS 11 IILTRASOUND KINETIC ACTIVITY REHABILITATIO 11 ..... SPINAL, THREE TO FOUR R}~GION8 11 2 ULTRASOt N[ '! KINETIC ACTIVITY RBHABILITATIO 1 C. MT, SPINAL~ THREE TO P()NR REGIONS il 2 I~LTRASOUND ] 1 KINETIC ACTIVITY REHABILITATIO ! 2MT, SPINAL, THREE TO F(3IlR REGIONS 11 2 ULTRASOUND 11 KINETIC ACTIVITY REHABILITATIO 1i CMT, SPINAL, THREE TO FOUR RIp.IONS 11 2 _ILT~ASOUND 11 CONTINUED 15,0~ 2~,0~ 15.O0 40.~0 3~,00 15.00 3~.~ 15,o~ 4~,00 30.0~ SUBTOTAL: 2,236.00 ,Page. INS CHARGES ONLY ITEMIZE[) STATEMENT (?LAIM: [)ATE, 05/15/2000 INSURE[)= STEPHANIE BRADLEY PATIENT: SARA L. WORMAN 1304Q7 s22 SPRINGHOUSE ROAD (DAMP BILL PA 17~11 sS#161-~2-~713 POL#C4LRWOR192 DATE/INJ ~ ]0/12/1999 C4RP# MA(-!RI SK MANAGEMENT P () BOX 9227 BOSTON MA 02209-9935 IRS#: 232110925 ~MPLOYER: VNA ()? HBG HERD (?BIROPRACTI(: CLINIC 2704 !MARKET STREET (]AMP ]HILl, D~ 1701]-453! 717/7q7-168! ~8x:717/7~1-164~ D I A(~N(_)S I S: 723. :3 CERVICOBRACHIAL SYNDROME ,29.1 (_.ERVICAL MYAL~IA : 24,2 LUMBA(-~'( ) ~Sq.~ INJURY TO wRIST FO:: PEP- iNJURY DATE OF LAST BILL: 05/11/2~ PR# 121006KPK ID# 121~b [lATE CPT DESCRIPTION * POS TOS # AMOUNT 0411412000 q7530 KINETIC ACTIVITY REHABILITATIO 11 '~ 30.0~ 0412612000 98940 (2MT SPINAL, ()NE TO TWO REGIONS il 2 1 35,0u ~4/26/200~ q7014 ELECT. STIMULATION-~NATT. 1i ] 05/0:3/2000 98940 (]MT SPINAL, C)NE TO TWO REGIONS 11 2 ] 35,0~ O5/~:~/2000 97014 ELECT. STIMULATION-UNATT. 11 1 20.0~I 05/10/2000 98940 CMT SPINAL, ONE TO TWO RE[~ILNS 05/10/2000 970:35 ULTRASOUND ti 1 15.0(~ 05/10/2000 975:30 KINETIC ACTI ITY REBABILITATIO 1i 1 TOTAL: S 2,456.0~ BALANCE ~5/15/2000= S 2.456.O~ ALL CHItRGES / PAYMENTS ITEMIZED STATZM CLAIM: INSURED: STEPHA~IE BRADLEY PATIENT: SA~.A L. WORMAN 130497 522 SPRINGHOUSE ROAD CAMP HILL PA 17011 SS#161-32-3713 POL#GL9909192 DATE/INJ: 10/12/1999 ~RP~ TO: MACRISK MANAGEMENT P O BOX 9227 BOSTON MA 02209-9935 DATE: 01/ IRS#: 23~ EMPLOYER:i HERD CHI} 2704 CAMP ~{IL] 717/7~7-~ DIAGNOSIS: 723.3 CERVICOBRACHIA3~ sYNDROME 729.1 CERVICAL MYALGIA 724.2 LUMBAGO 959.3 INJURY TO WRIST FC: PER-INJURY DATE OF LAST BILL: 07/13/2000 PR# 121006KPK ID~ 12] DATE CPT D~S~RIPTION ----- 05/17/2000 98941 CMT, SPINAL, THREE TO FOUR R~GD 05/17/2000 9~035 ULTRASOUND 05/30/2000 98940 05/30/2000 97035 06/06/2000 98941 06/06/2000 97530 06/07/2000 97035 06/15/2000 98940 06/15/2000 97035 06/15/2000 97530 06/23/2000 98940 06/23/2000 97035 07/06/2000 98940 07/06/2000 97035 05/25/2000 05/25/2000 CMT SPINAL, ONE TO TWO REGI(]~S ULTRASOUND CMT, SPINAL, THREE TO FOUR HEGI KINETIC ACTIVITY REHABILITATI0 ULTRASOUND CMT SPINAL, ONE TO TWO REGIONS ULTRASOUND KINETIC ACTIVITY REHABILITATIO CMT SPINAL, ONE TO TWO REGIONS ULTRASOUND CMT SPINAL, ONE TO TWO REGIONS ULTRJ%SOUND pAYMENT IN ADJUST IA RECORDS FEE N T 7/2ool ~10925 VNA OF HBG )PRACTIC CLINIC ET STREET [PA 17011-4531 581 Fax:717/731-1648 NS 11 2 i 40.00 11 I 15.00 11 2 I 35.00 11 1 15.00 INS 11 2 i 40,00 1i i 30.00 11 I 15.00 11 2 i 35.00 ~1 1 15.00 11 1 30.00 11 2 1 35.00 11 1 15.00 11 2 1 35,00 11 1 15.00 -19.00 19.00 TOTAL: $ 450,00 ~NCE 01/17/2001: $ 2,626.00 ~0 ]D~d 0INIqD(/~qH 8~gIIELLIL IE :~0 I00E/LI/I0 MEDICARE MEDICAID CHAMPUS CHAMPVA- (Medicare#) I (Medicaid #) [] Soonso~'sSSN), SARA L. 5 PAT[ENT'SADDRESS NO Street) .~F R.i.N(~ HC)I. JSE ,:.;-,o c' '," :~ RD IqI::.ALTH ,'~.%.~tJb,~ F'F'O BOX ,.,0.~ -,.F, :1: '¥ 'T ~qBLIRGI"I SEX :l 7 0 t 1 7 :['7)' STATE b OTHER INSURED'S DATE OF BIRTH DD ; RITE AID It's not just a store. It's a solut~on~''~ Store ~04818 4957 CARLISLE PK MECHANICSBURG, 17055 (717) 975-0199 Register #1 Transaction ~1261 Cashier #48186369 1/20/00 12:31PM RITE RE~ARD~SAI~INB$ Customer ID: .-' 1 SCANNED PHARMACY 20.00 RX# 7140g 1 SCANNED PHARMACY 20.00 RX# 71410 ' 2 Items Subtotal 40.00 Tax .00 Total 40.00 *PAID BY VISA* 40.D0 VISA card * ~XXXXXXXXXXXX0271 Exp 10/31/02 App ~ AUTO Ref ~ 009179 Card ~resen~ TenOered 40.00 Cash Change .00 Visit our online pharmacy at drugstore.com 1-800-RITEAID for customer service HF_~LTHCARE RECOVERIES P.O. Box 37440 Louisville, Kentucky 40233-7440 FEDERAL TAX ID: 61-1141758 TELEPHONE NUMBER: (877) 765-9373 PAGE 1 OF 2 CONSOLIDATED STATEMENT OF BENEFITS PATIENT'S NAME: HEALTH PLAN: DATE OF INJURY: SERVICE PERIOD: FILE NUMBER: SARA WORMAN HealthAmerica/HealthAssurance 10112/99 1115199-8130101 CV-204282471020 Subject tochange. Instructions: · WH~, the patient's name, SARA WORMAN, and file number, CV-204282471020, on the check. Provider of Service Diagnosis Code Claim Number Date of Service Procedure Code{a) Billed Amt. Paid Amt. COWLEY MED ASC LAB V72.83 OTH SPCF PREOP 23282024 7/14/00 85021 Automated hemogr $10.00 $4.32 7/14100 80051 Electrolyte pane I $37.00 $3.66 DAILEY MD~STEPHEN W 813.41 Fx of mdlu~/ul I 20521565 11/5/99 29075 Application of f $160.00 $53.83 1115/99 73100 X-ray exam of wr $60.00 I $27.19 11/5/99 I A4590 SPECIAL CASTING $13.00 $10.40 I 813.41 Fx of radlu~/ul 20756625 11/19/99 I 73100 X-ray exam of wr $60.00 $27.19 I 354.0 Carpal tunnel e¥ 1012214484 4/12/00 I 99212 Ofrme/outpafien $40.00 $14.03 354.0 Carpal tunnel s¥ 1013111580 4118/00 29648 Wrist endoscop}fl $1028.00 $288.54 727.03 TRIGGER FINGER 1017119997 5/19/00 99212 OfficeJoutpafien $40.00 $29.03 5/19/00 20600 Drain/inject sma $83.00 $28.17 5/19/00 J0702 BETAMETHASONE AC $8.08 $4.96 727.03 TRIGGER FINGER 23190654 6/16/00 I 99213 Office/outpatien $50.00 $26.48 I 727.03 TRIGGER FINGER 1024107673 8/1/00 I 26055 Tendon sheatfl in $828.00 $189.54 726.32 Enthe~opathy el 1025518081 8/18/00 20605 Dmin/~nject i nt $84.00 $28.15 8/18/00 J0702 BETAMETHASONE AC $16.16 $10.26 354.0 Caq~al tunnel ay 1029201456 9/26/00 29848 Wdst endoscopy/ $1028.00 $288.54 DINCHER DC,GERALD M 723.3 Cervlcebrachlal 1023406370 8/2/00 98940 CMT, spinal~ 1-2 $35.00 $17.00 DOMINQUEZ PT,JOSE 727.03 TRIGGER FINGER 1029013148 10/2/00 97799 Physical medicin $80.00 $32.00 1014/00 97799 Physical medicin $80.00 $32 10/6/00 97799 Physical medicin $80.00 $32.00 354.0 Carpal tunnel u¥ 1030720441 10/16/00 97799 Physicat medicin $80.00 $32.00 354.0 Carpal tunnel s¥ 1030720442 10/18100 97799 Physical medicin $80.00 $32.00 354.0 Carpal tunnel ay 1030720443 10/20/00 97799 Physical medicin $80.00 $32.00 HEALTHCARE RECOVERIES P.O. Box 37440 Louisville, Kentucky 40233-7440 FEDERAL ']-AX ID: 61-1141758 TELEPHONE NUMBER: (877) 765-9373 PAGE 2 OF 2 CONSOLIDATED STATEMENT OF BENEFITS PATIENT'S NAME: HEALTH PLAN: DATE OF INJURY: SERV1CE PERIOD: FILE NUMBER: SARA WORIVIAN HealthAmerica/HealthAssu rance 10/12/99 1115/99-8/30/01 CV-204282471020 Subject to change. instructions: · Make checks payable to: Healthcare Recoveries. · W~i[e the ~afient's name, SARA WORMAN, and file number, CV-204282471020, on the check. Provider of Service Diagnosis Cede ~ Claim Number Date of Service ! Billed Amt. Paid Amt. I 10/23/00 10/'25/00 10127100 10/30/00 11/1/00 11/3/00 GRANDVIEW SURGERY & IProcedure Code{s) 354.0 Car ~al tunnel s¥ 97799 Ph, sicai medicin 4/18/00 354.0 Car 3al tunnel sy 97799 Ph' sicaI medicin 354.0 Car 3al tunnel e¥ 97799 Ph' ,sic, at medicin 354.0 Car 3al tunnel ey 97799 Ph' ,sical medicin 354.0 Car 3al tunnel sy 97799 Ph' ~ical medicin 354.0 Car 3al tunnel s¥ 97002 Ph ~ical therapy 354.0 Caf ~al tunnel e¥ 29848 Wrist endoscopy/ 727.03 TRIGGER FINGER 1030720~ $80.00 1030720445 $32.00 $80.00, $32.00 1031322581~ 354.0 Carpal tunnel s¥ $80.00 $32.00 1031322582 $60.00, $32.00 10320119091 $80.00J $32.00 1032011910I $75.001 $8.76 22013413~ $3221.57 $2255.10 22729170 GRANDVIEW SURGERY C 8/1/00 26055 Tendon sheath in $1876.68 $373.60 24303439 29848 Wrist endoscopy/ 727.03 TRIGGER FINGER 97799 Physical medicin 9126/00 JOYNER SPORTS-BLUE 9/19/00 JOYNER SPORTSMEDICl J 727.03 TRIGGER FINGER $2740.87 1027801622 $205.00 1028311401 $80.00 $80m00 9/21/00 [ 97799 Physical medicin 9/22/00 j 97799 Physical medicin 9/25/00 I 97799 Physical medicin $80.00 QUIRK MD~BRIANC 11/19/99 729.5 PAIN IN LIMB 1127724319 8/30/01 I 99213 Office/outpatien $56.00 TEUFEL ORTHOTIC-PRO 814.0 Fx carpal bone(s L3908 WHFO,WRIST EXT.C 354.0 Carpal tunnel sy 95900 Motor nerve test 20628868 ' $45.00 21255180 $240.00 VIOl. AGO MD, ED S 1/17/00 $1534.88 $42.00 $32.00 $32.00 $32.00 $28.48 $36.00 $127.97 1117/00 95904 Sensory nerve te $240.00 $110.21 1/17/00 95861 Muscle test, two $300.00 $107.70 WEST SHORE ANESTHES 354.0 Carpal tunnel sy 01810 Anesthesia, Iowe 4118/00 22047305 $390.00 $192.00i 727.03 TRIGGER FINGER 22859442 8/1/0D 01810 Anesthesia~ Iowe $325.00 $160.00 23222237 9/26/00 354.0 Carpal tunnel sy $390.00 $14,805.36 ~ Amount Received $0.00 $6,665.99 J Balance Due $6~66S.99 01810 Anesthesia. Iowe Total Billed Char~ies Total Paid Cha~es $192.00 60C CAMPANELLI DRIVE, BRAINTREE, MA. 02184 ~a~ ^ddt,: P.O. SOX r~2?,~~iDENT REPORT Claim # GL9909192 Giant Location: Your Name: Address: Telephone: Date of Accident: I(~.- l ~-- ¢¢4~ Time: Where did Accident happen: Camp Hill, PA ~ ~'~1~) I~1- I~:~q Date'of Birth:_ t0~ iO~ ~Soc. Sec What Happened (please describe): injuries: Name of Store Employee Reported To: },qx(~,1 Date: 10-_..~- 479 Signature: SARA L. WORMAN, Plaintiff V. GIANT FOOD STORES, INC., IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION-LAW No. 2001-5511 a/Ida GIANT T FOOD STORES,: LLC : Defendant : JURY TRIAL DEMANDED CERTIFICATE OF SERVICE On this ~'J[- ~ay of September, 2003, I hereby certify that Plaintiff's Arbitration Exhibits was served upon the following by U.S. mail: George B. Failer, Jr., Esquire MARTSON, DEARDORFF WILLIAMS & OTTO Ten East High Street Carlisle, PA 17013 Michael J. Pykosh, Esquire P.O. Box 368 3805 Market Street Camp Hill, PA 17011 Dale F. Shughart, Jr., Esquire 35 F. High Street Suite 203 Carlisle, PA 17013 James M. Robinson, Esquire 28 South Pitt Street Carlisle, P,A 17013 HANDLER HENNING & ROSENBERG W. ~/~tt~Esq)~ re 1300 Linglesto~/yh Ro~cl Harrisburg, PA' 171/1'0 (717)238-2000 / ATTORNEY FOR PLAINTIFF IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA OATH 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 ~ scharge the duties of our office with fidelity,c'.~e~~ '~_ ~--- '~'~,::~ (X'~~-:~~ ~ / ~V'~ ~'~ c~ :: c~ AWARD ~cZ W~'~he undersigned arbitrators, having been duly appointed and sworn (or affirmed), make t~foll~ing award: ~ote: If da~nages for delay are awarded, they fhall be separately stated0 I' Arbitrator, dissents. (insertname~je..: : Date of Hearing: Date of Award: * ! Chai~rrnan / NOTICE OF ENTRY OF AWARD Now, the /.~ day of ~/~ ,204.~ , at ~ :~9~: , ~) .M., the above award was entered upon the docket and notice thereof given by mail to the pm'tics or their attorneys. Artibitrators'compensafion to be I:;/ /~,7~ Paid upon appeal: Prothonotary $290.00 By: -