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Home My WebLink About06-7153F:\WP Directories\AGR\Minoes Comp\Pham, Dustin.wpd David H Rosenberg, Esquire I.D. No. 20569 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Attorneys for Petitioners Fax: (717) 233-3029 E-mail: Rosen berg(&hhrlaw.corn IN THE MATTER OF DUSTIN : IN THE COURT OF COMMON PLEAS PHAM, a minor by and : CIVIL COURT DIVISION through his natural parents and : CUMBERLAND COUNTY, PENNSYLVANIA guardians, DANG PHAM and NHIEN NGUYEN . NO. C)L. MINOR'S COMPROMISE PETITION FOR LEAVE TO COMPROMISE MINOR'S ACTIONS Pursuant to Pennsylvania Rule of Civil Procedure No. 2039, Dang Pham and Nhien Nguyen, the natural parents and legal guardians of minor, Dustin Pham, by their attorneys, HANDLER, HENNING & ROSENBERG, LLP, by David H Rosenberg, Esq., petition this Honorable Court to enter an Order permitting settlement and compromise of this action, and in support thereof, avers: Dustin Pham was born on September 22, 1998 and is therefore, eight years old and a minor. He currently resides at 8 Pennsway Road, Mechanicsburg, Cumberland County, Pennsylvania 17050. 2. Petitioners, Dang Pham and Nhien Nguyen, adult individuals, are said minor's natural father, mother, and legal guardians and they reside with their child at, 8 Pennsway Road, Mechanicsburg, Cumberland County, Pennsylvania 17050. 3. At all times material hereto, the minor, Dustin Pham, was a back seat passenger in a 1998 Jeep Grand Cherokee being operated by his father, Dang Pham, and owned by Swatara Auto Sales, Inc., and bearing Pennsylvania registration number J48620J (hereinafter "minor's vehicle"). 4. At all times material hereto, Defendant, Daricus Releford, was the operator of a 1993 Ford Aerostar, owned by Sharon Relefrod, (hereinafter, Defendant's vehicle) and bearing Pennsylvania registration number RITZ2. 5. On or about May 6, 2006, at about 5:27 p.m., Plaintiff, Dang Pham, was lawfully traveling westbound on SR 11, Carlisle Pike, in Hampden Township, Cumberland County, Pennsylvania. 6. At approximately the same time and place, Defendant, Daricus Releford, was traveling eastbound on SR 11, Carlisle Pike, in Hampden Township, Cumberland County, Pennsylvania. 7. At approximately the same time and place, Defendant, Daricus Releford, lost control of his vehicle and crossed the road directly into the path of Plaintiff's vehicle, striking the Plaintiffs left rear wheel assembly and causing the Plaintiff's vehicle to roll over. 8. As a direct and proximate result of the negligence of Daricus Releford, the minor, Dustin Pham, was ejected from Plaintiffs vehicle and suffered a fractured skull and cephalohematomas. 9. Dustin Pham was transported by helicopter from the scene of the collision to the Hershey Medical Center where he was admitted for treatment and released. 10. The minor has recovered well. He was released from treatment with Hershey -2- Medical Center on May 31, 2006. The outpatient note from the May 31, 2006 appointment indicates the minor is active and there are no residual deficits. Attached hereto, made a part hereof and marked "Exhibit A", is a copy of the outpatient note, dated May 31, 2006. 11. At the time of this collision, the minor, Dustin Pham, was insured under an automobile insurance policy issued to Dang Pham by Geico Insurance Company. To date, all of said minor's collision-related medical bills have been paid by Geico. 12. At the time of the collision, Daricus Releford's vehicle was insured under a policy of motor vehicle insurance issued by USAA Insurance Company. 13. After protracted negotiations, USAA Insurance Company has offered to settle the minor's claim against Respondent, Daricus Releford, for the liability policy limits of $25,000.00. Attached hereto, made a part hereof and marked as "Exhibit 6," is a copy of the proposed release from USAA Insurance Company. 14. In addition to the settlement offer from USAA, Counsel for petitioners is pursuing an Underinsured Motorist claim through Petitioners' insurance carrier, Geico and the insurance carrier for the occupied vehicle, Gemini Insurance Company. 15. Petitioners, Dang Pham and Nhien Nguyen, believe said settlement is in the best interests of their minor son, Dustin Pham, and they propose to accept said settlement offer of $25,000.00 which represents the liability limits. 16. David H Rosenberg, Esq., of HANDLER, HENNING & ROSENBERG, LLP, has been the attorney for the minor in this action and requests reasonable counsel fees of $6,596.30 for services rendered plus costs and expenses of $346.30 pursuant to a -3- Contingent Fee Agreement signed by Petitioner. The 25% fee represents a reduction from the 33-1/3% fee agreement signed by the Petitioner on behalf of his minor son. Thus, the total amount requested for attorney's fees and costs is $6,596.30. Attached hereto, made a part hereof, and marked "Exhibit C," is the Contingent Fee Agreement. Also attached hereto, made a part hereof, and marked "Exhibit D," is a true copy of the billing summary. 17. Petitioner further requests this Honorable Court to order a payment of the balance, $1,946.19 will be placed into a restricted account in the name of the minor, Dustin Pham, marked not to be withdrawn until the age of 18, and $16,500 to be placed in a structured settlement, bearing the name of the minor, Dustin Pham, that will be payable in one guaranteed lump sum on September 22, 2016 on the minor's 18th birthday, totaling at least $24,100.00. WHEREFORE, Petitioner requests this Honorable Court to: a. Approve the above-stated Compromise; b. Authorize the payment of fees above-stated from funds due the minor; C. Direct payment of the net funds due, in accordance with the above- stated Compromise. Respectfully submitted, HANDLER, HENNING & ROSENBERG, LLP DATE: 19'/3 /oc BY: David H R enberg, Esquire I.D. No. 569 1300 inglestown Road Harrisburg, PA 17110 (717) 238-2000 Attorney for Petitioners -4- Wilton & Hershey Medical Center College of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: PHAM, DUY DUSTIN PSUHMC MRN: 7004070 Patient Sex: Male Date of Birth: 2/9/1998 Patient Location: PESU, , Visit Number: 7119783 Visit Type: Clinic O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Engbrecht, Brett W May 31, 2006 Name: PHAM, DUY DUSTIN HMC Number: 7004070 DOB: 02/09/1998 Date of Service: 05/31/2006 Yoke Y. Tan, M.D. 153 South 32nd Street Camp Hill, PA 17011 Dear Dr. Tan: OUTPATIENT LETTER 6/1/2006 8:22:53 AM I had the pleasure of seeing Duy in foliowup. He is an 8-year-old who was in a motor vehicle collision and sustained a closed head injury with left temporal bone fracture approximately 3 weeks ago. He was seen by Neurosurgery today for foliowup evaluation and was discharged from their clinic. His dizziness has improved over time, although occasionally he still feels that when he shuts his eyes, the world spins around him. His balance has been improving. He still complains of some pain in his antecubital region where he had an IV, although this is improving also. His mother has noted only some memory changes as the only problem. On examination today, Duy is healthy appearing and in no distress and weighs 24.3 kg. His head is normocephalic and atraumatic and he is alert and oriented x3. His chest is clear to auscultation bilaterally and his heart is regular rate and rhythm. His abdomen is soft, nontender, and nondistended. His right antecubital region has no evidence of thrombophlebitis and no erythema. The area is nontender. There are no palpable abnormalities. Assessment and Plan: Duy is now 3 weeks out from left temporal fracture doing well. From the general trauma standpoint, we do not need to see him back, though would be glad to see him if further problems or concerns arise. He does need to have a hearing test approximately 2 to 3 months from the time of injury since he had a temporal bone Date Printed: 611512006 Time Printed: 5:54 AM i PENNSTATE OWN 10 Milton S. Hershey Medical Center College of Medicine Patient Name: PRAM, DUY DUSTIN PSUHMC MRN: 7004070 1 O u t p a t i e In t L e t t e r D o c u m e n t Final Document Electronically Signed by: Engbrecht, Brett W 6/1/2006 8:22:53 AM fracture. If his dizziness persists he should return for evaluation by neurosurgery. Please let us know if there is anything further we can do for Duy. 203990 CC: Yoke Y Tan, MD 153 South 32nd Street Camp Hill, PA 17011-0000 Sincerely, Brett W Engbrecht, MD Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Andreas Meier, Kerry Fagelman, Brett Engbrecht Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP CS Hershey 717-531-8342 Hbg(York 717-920-5200 BWE /CO DD: 05/31/06 DT: 06/01/06 07:29 Date Printed: 611511006 Time Printed: 5:54 AM . 11/29/2006 11:49 FAX 216 241 9733 NAT'L SETTLEMENT CONSULT RELEASE AND SETTLEMENT AGREEMENT 1. RELEASE AND SETTLEMENT IM 002/004 A. THE UNDERSIGNED, Dustin Pham, a minor, by and through Dang B. Pbarn, parent and natural guardian of Dustin Pham ("CLAIMANTS") on this day of 2006, for and in consideration of the sum of Eight Thousand Five Hundred Dollars and No Cents ($8,500.00) representing upfront cash, paid to us by United Services Automobile Asso iction (USAA) ('INSURER') and the sum of Sixteen Thousand Five Hundred Dollars and No Cents ($1 0.00 fund the periodic payments as provided for in Section 104, Subsection (a) (2) of Intern ue Code of 1986, as amended, specified in Section 11, paragraph F of this AG T, whic, RER contracts and agrees to pay or cause to be paid to the persons or entities in Section a aph G, the receipt and legal sufficiency of all of which are expressly aclmowle', ed, do ereby fore RELEASE CQUIT AND DISCHARGE Sharon M. Releford and Daricus B. ("RESPOND S"), IN ER and their servants, agents, officers, attorneys, claim adjusters, ssors, heirs, assigns ' and all claims, actions, causes of action, damages, liens of every haracter, and/or oth igations of every kind and character, including all expenses incurred or to be in d, on account or arising out of or in any way related to any and all injuries or d ges to me, as result o_f all occurrences involving CLAIlKANTS and RESPONDENTS on, the 6" day o 06, at or near the City of Mechanicsburg in the Commonwealth of._ .. nnsyly B. THIS RELEASE ID TO AND/OR DAMAGES, NO' RESULT FRIP Y RESULTED FRO IT C. As ad( executors or demands and ca s of action future be made by person, limited to, all hospi edical OR MA COVER ALL CLAIMS FOR INJURIES tV P ARTIES AT THE TIME THIS E RESULTED, MAY HEREAFTER VIED TO HAVE BEEN CAUSED BY OR tion for desc ' d payments, CLAIMANTS, for themselves, their heirs, and asst ' , grees to and does indemnify and hold harmless d all o released by this AGREEMENT from any and all claims, y e or character which have been made, or which may in the fi r oration claiming by, through or under them, including, but not or er expenses or liens which are or could be asserted. D. This release only releases the named parties in the release and does not apply to any other party not named in the release nor including, but not bmited to, any medical malpractice claims. Also, this release does not apply to any Under Insurance and/or First Party medical benefits cl H. PERIODIC PAYMENTS A. Notwithstanding any other provision of this AGREEMENT, INSURER is and will remain contractually responsible for all periodic payments under this AGREEMENT. B. RESPONDENTS and INSURER agree that CLAIMANTS (to whom, or upon whose behalf, the periodic payments contracted for in the AGREEMENT are to be made) made claim against 11/29/2006 11:49 FAX 216 241 9733 NAT'L SETTLEMENT CONSULT Q003/004 RESPONDENTS for damages arising from or involving physical injuries or physical sickness. Those claianns, among others, are being released and settled by this AGREEMENT. C. The Parties further agree that all periodic payments specified in Section II, paragraph F. of this AGREEMENT are being funded by the purchase of a "Qualified Funding Asset," as defined in Section 130(d) of the Internal Revenue Code of 1986, from USAA Life Insurance Company, which will provide for payment of the periodic payments, INSURER will be the sole owner of the "Qualified Funding Asset." INSURER guarantees that the periodic payments will be made as specified in the PERIODIC PAYMENT SCHEDULE. CLAIMANTS acknowledge that USAA Life Insurance Company is an affiliate of INSURER and that, because of this affiliation, an indeterminate profit might eventually inure to the benefit of the INSURER. D. CLAIMANTS agree: (1) that INSURER is not req ' ide specific assets to secure the periodic payments; (2) that the periodic payments be aceel d, deferred, increased or decreased by CLAIMANTS; and (3) that the periodic pay t(9) shall d cannot be, subjected in any manner to sale, transfer, assignment, pledge, m age, brance, ' n, collate or any similar transaction. Any attempted sale, transfer, assigr== le ,'mortgage, en brance, , collateral, or similar transaction is void. E. CLAIMANTS sball have no legal, equitable, ve or contingent interest in the "Qualified Funding Asset" and their rights against INSURER, the com from whom the "Qualified Funding Asset" is purchased, or against the "Qualifi. w? g Asset" wiI , solel se of a general creditor. F. PERIODIC PAYMENT SCHED ,?. $24,100.00 guaranteed 1 payab `' n Septe 2, 2016 G. ODIC P (S) WILL B E YABLE TO: Dustin Pharr ?I H. Any perio ayments to made after the death of CLAIMANT, Dustin Pham, under this SETTLEMENT Will ade to a Estate of Dustin Pham, as designated at the time of settlement (or ' in time to t `after by the guardian of said CLAIMANT with Court Approval) by s CLAI , upon att the age of majority, and delivered to INSURER. If no person or entity designated b d C T, or if the person or entity designated is not living at the time of said CL T'S dea yxnent will be made to the Estate of said CLAIMANT. I. All sums set f Low- ere ction Mute damages on account of personal physical injuries or physical sickness, within the zn?eani 104 (a)(2) of the Internal Revenue Code of 1986, as amended. r. Discharge of Obligation: The obligation of the RESPONDENTS and the INSURER to make each Periodic Payment shall be discharged upon the mailing of a valid check in the amount of such payment to the designated address of each Payee named in Section II of this Release, or by deposit by electronic funds transfer in the amount of such payment to an account designated by each Payee identified in Section E. TH. GENERAL PROVISIONS 2 11/20/2006 11:49 FAX 216 241 9733 NAT'L SETTLEMENT CONSULT IZO04/004 A_ It is expressly understood and agreed that this settlement is a compromise of a disputed claim, that the payments provided for may not be construed as an admission of liability by RESPONDENTS or INSURBR, and that RESPONDENTS and INSURER expressly deny any liability to CLAIMANTS. B. CLAIMANTS covenant that no representations or promises other than those expressed in this SETTLEMENT AGREEMENT have been made to them in regard to this settlement, that they have carefully read and fully understand this SETTLEMENT AGREEMENT, and that they understand that upon execution of this SETTLEMENT AGREEMENT, all rights, claims or demands CLARY ANTS may have against RESPONDENTS and INSURER, except the contract to make periodic payments included in this SETTLEMENT AGREEMENT, are completely extinguished. C. SETTLEMENT AGREEMENT is to be c+ Commonwealth of Pennsylvania. Any person who, facilitating a fraud against an insurer, submits a deceptive statement is guilty of insu ce fraud. rq I EXECUTED BY ALL PARTIES as of the date first st CLAIMANT: Dustin Pham, a minor Dang B. Pham, as parent and of Dustin Pham, a minor WITNESS: INSURER: Und Services A ile Association ('U'SAA) Name feted under the laws of the and or knowing that he/she is a claim containing a false or Title EXECUTED at this day of . .2006. CONTINGENT FEE AGREEMENT I, Dang B. Pham, natural father and legal guardian of Dustin Pham, do hereby retain HANDLER, HENNING & ROSENBERG, LLP., of Harrisburg, Pennsylvania, as my attorneys in this matter to represent me and to process, negotiate, arbitrate a settlement or to institute in my name, any legal proceedings or actions that, in their judgment are necessary, against Daricus Releford or against anyone else as a result of injuries and damages I sustained in an incident that occurred on 5/6/2006. 1 agree not to settle, negotiate or adjust the above claim or any proceedings based thereon without the written consent of my said attorneys. In consideration of the services so to be rendered by Handler, Henning & Rosenberg, LLP, I hereby covenant, promise and agree to pay them for their professional services rendered, THIRTY-THREE AND ONE-THIRD PERCENT (33 1/3%) of whatever sum is recovered as a result of settlement without lawsuit; or FORTY PERCENT (40%) of whatever sum is recovered after lawsuit is filed or in the event of arbitration or mediation. I will reimburse Handler, Henning & Rosenberg, LLP. for any necessary expenses advanced on my behalf in pursuing my claim. Examples of typical expenses include Court filing fees, investigation, auto mileage, photocopies, court reporters, medical records, expert witness fees, etc. If no money is obtained, client will not owe a legal fee or expenses. I also agree to take possession of my medical files at the conclusion of this case. My failure to take possession of these files within 60 days after the conclusion of the case will authorize my lawyers to destroy said files. I agree that HANDLER, HENNING & ROSENBERG, LLP. may associate additional lawyers to assist with this case and I agree to the sharing of fees between lawyers. I understand the terms herein apply to other lawyers associated on this case. l understand that the association of other lawyers does not increase the amount of the attorney fees at the conclusion of the case. Counsel reserves the right to withdraw if they desire to do so, for any reason(s) they deem proper. I acknowledge that I have read, approved and understood the above Contingent Fee Agreement and I acknowledge having received a copy of the same. The terms set forth herein are accepted. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 30th day of May, 2006. (SEAL) y `'Da , natural father and legal guardian of Dustin Pham andler, Qnning& os¢nberg,up ATTORNEYS AT LAW 1300 Linglestown Road, Harrisburg, PA 17110 Dustin Pham 8 Pennsway Road Mechanicsburg, PA 17050 INVOICE PAYMENT DUE UPON RECEIPT EXPENSES Client No: 211418 Matter: 00000 Attorney: DHR MV Pre-Bill No: 20897 Bill Date: December 13, 2006 06/26/2006 Vendor Sourcecorp Healthserve, Inc.; General Case Expense 131.51 CASE 06/26/2006 $131.51 08/14/2006 Vendor HERSHEY MEDICAL CENTER; General Case Expense 15.00 CASE 08114/2006 , $15.00 10/12/2006 Vendor Sourcecorp Healthserve, Inc.; General Case Expense 26.31 CASE 10112/2006 $26.31 11/27/2006 Vendor CUMBERLAND COUNTY ORPHAN'S COURT; General Case 15.00 CASE 11/2712006 $15.00 12/13/2006 Vendor PROTH OF CUMBERLAND CO, General Case Expense 55.50 CASE 12/13/2006 $55.50 12/13/2006 Vendor CUMBERLAND COUNTY ORPHAN'S COURT, General Case -15.00 CASE 12/13/2006 -$15.00 12/31/2006 Document Reproduction 0.80 COPY 12/31/2006 $0.80 12/31/2006 Document Reproduction 97.80 ISI 12/31!2005 $97.80 12/31/2006 Postage Costs 1.95 POS 12/31/2006 $1.95 12/31/2006 Postage Costs 17.25 POST 12/31/2006 $17.25 12/31/2006 Long Distance Telephone Charges 0.18 TELE 12/3112006 $0.18 TOTAL EXPENSES $346.30 Total due this invoice $346.30 TOTAL BALANCE DUE $346.30 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. '-Ni-f i guyen 4 Date: / 10s O 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 nor 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. -- D. J13?Fiafi Pham Date: ; d5rla? .v Lr? ? d n t T7 t J 1 \J _..y?f 0 Z-15 DEC 19 2006 rU David H Rosenberg, Esquire I.D. No. 20569 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Attorneys for Petitioner Fax: (717) 233-3029 E-mail: Rosenberq(&-hhrlaw.com IN THE MATTER OF DUSTIN : IN THE COURT OF COMMON PLEAS PRAM, a minor by and : CIVIL COURT DIVISION through his natural parents and : CUMBERLAND COUNTY, PENNSYLVANIA guardians, DANG PHAM and NHIEN NGUYEN n I . NO. OL --• J/S3 1. [ c..?. l.. 1 : MINOR'S COMPROMISE ORDER AND NOW, this Z V day of , 2006, upon consideration of the foregoing Petition, IT IS HEREBY ORDERED that the disbursement of funds, as well as counsel fees and expenses, are approved as set forth in said Petition and shall be disbursed in accordance with the terms and conditions of the settlement agreement as follows: A. Direct payment of $6,596.30 to David H Rosenberg, Esq., representing reasonable attorney's fees of $6,250.00 and $346.30 for reimbursement of costs; B. Direct payment of the balance of $1,903.70, placed into a restricted account in the name of the minor, Dustin Pham, marked not to be withdrawn until the age of 18; C. Direct payment of $16,500 to be placed in a structured settlement, bearing the name of the minor, Dustin Pham, that will be payable in one guaranteed lump sum on September 22, 2016 on the minor's 18'h birthday. D. Proof of deposit is to be filed with the Court. BY THE COURT: J. / F1 7i ..3 I F:\WP Directories\AMMMinor's comp\Pham, Dustin-UIM.wpd David H Rosenberg, Esquire I.D. No. 20569 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Attorneys for Petitioners Fax: (717) 233-3029 E-mail: RosenberaO-hhrlaw.com IN THE MATTER OF DUY DUSTIN IN THE COURT OF COMMON PLEAS PRAM, a minor by and : CIVIL COURT DIVISION through his natural parents and : CUMBERLAND COUNTY, PENNSYLVANIA guardians, DANG PHAM and NHIEN NGUYEN NO. 06-7153 : MINOR'S COMPROMISE PETITION FOR LEAVE TO COMPROMISE MINOR'S ACTIONS Pursuant to Pennsylvania Rule of Civil Procedure No. 2039, Dang Pham and Nhien Nguyen, the natural parents and legal guardians of minor, Duy Dustin Pham, by their attorneys, HANDLER, HENNING & ROSENBERG, LLP, by David H Rosenberg, Esq., petition this Honorable Court to enter an Order permitting settlement and compromise of this action, and in support thereof, avers: 1. Duy Dustin Pham was born on February 9, 1998, and is therefore, nine years old and a minor. He currently resides at 8 Penns Way Road, Mechanicsburg, Cumberland County, Pennsylvania 17050. 2. Petitioners, Dang Pham and Nhien Nguyen, adult individuals, are said 1 minor's natural father, mother, and legal guardians and they reside with their child at, 8 Penns Way Road, Mechanicsburg, Cumberland County, Pennsylvania 17050. 3. At all times material hereto, the minor, Duy Dustin Pham, was a back seat passenger in a 1998 Jeep Grand Cherokee being operated by his father, Dang Pham, and owned by Swatara Auto Sales, Inc., and bearing Pennsylvania registration number J48620J (hereinafter "minor's vehicle") 4. At all times material hereto, Defendant, Daricus Releford, was the operator of a 1993 Ford Aerostar, owned by Sharon Relefrod, (hereinafter, Defendant's vehicle) and bearing Pennsylvania registration number RITZ2. 5. On or about May 6, 2006, at about 5:27 p.m., Plaintiff, Dang Pham, was lawfully traveling westbound on SR 11, Carlisle Pike, in Hampden Township, Cumberland County, Pennsylvania. 6. At approximately the same time and place, Defendant, Daricus Releford, was traveling eastbound on SR 11, Carlisle Pike, in Hampden Township, Cumberland County, Pennsylvania. 7. At approximately the same time and place, Defendant, Daricus Releford, lost control of his vehicle and crossed the road directly into the path of Plaintiff's vehicle, striking the Plaintiff's left rear wheel assembly and causing the Plaintiffs vehicle to roll over. 8. As a direct and proximate result of the negligence of Daricus Releford, the minor, Duy Dustin Pham, was ejected from Plaintiffs vehicle and suffered a fractured skull and cephalohematomas. 9. Duy Dustin Pham was transported by helicopter from the scene of the 2 collision to the Hershey Medical Center where he was admitted for treatment and released. 10. The minor has recovered well. He was released from treatment with Hershey Medical Center on July 12,2006. The outpatient note from the July 12,2006, appointment indicates the minor's ears and hearing are normal. Attached hereto, made a part hereof and marked "Exhibit A", is a copy of the outpatient note, dated July 12,2006. 11. Minor was tested by Hershey Medical Center for sleep apnea on September 1, 2007, but there were no significant findings of sleep apnea, and minor was not rescheduled for a follow up appointment. Attached hereto, made a part hereof, and marked "Exhibit B", is a copy of the doctor's report, dated September 1, 2007. 12. At the time of this collision, the minor, Duy Dustin Pham, was insured under an automobile insurance policy issued to Dang Pham by Geico Insurance Company. To date, all of said minor's collision-related medical bills have been paid by Geico, exhausting the five thousand ($5,000) dollars in coverage and by Petitioners Health Insurance Carrier, Prime Source Health Network. 13. At the time of the collision, Daricus Releford's vehicle was insured under a policy of motor vehicle insurance issued by USAA Insurance Company. 14. USAA Insurance Company settled all liability claims arising from the aforementioned collision forthe liability policy limit of $25,000.00. Settlementwas approved by this Honorable Court on December 26, 2006. Attached hereto, made a part hereof, and marked "Exhibit C", is a copy of the order of Court dated December 26, 2006. 15. Petitioners, Dang Pham and Nhien Nguyen, by and through their counsel, 3 David H Rosenberg, Esq., pursued additional settlement monies via underinsured motorist benefits available through Petitioner's automobile policy. 16. After protracted negotiations, StarNet Insurance Company, offered to settle the Underinsured Motorist claims for the policy limits of $100,000.00. 17. Petitioners, Dang Pham and Nhien Nguyen, believe said settlement is in the best interests of their minor son, Duy Dustin Pham, and they propose to accept said settlement offer of $100,000.00 which represents the policy limits. 18. David H Rosenberg, Esq., of HANDLER, HENNING & ROSENBERG, LLP, has been the attorney for the minor in this action and requests reasonable counsel fees of $25,000.00 for services rendered plus costs and expenses of $64.15 pursuant to a Contingent Fee Agreement signed by Petitioner. The 25% fee represents a reduction from the 33-1/3% fee agreement signed by the Petitioner on behalf of his minor son. Thus, the total amount requested for attorney's fees and costs is $25,064.15. Attached hereto, made a part hereof, and marked "Exhibit D", is the Contingent Fee Agreement. Also attached hereto, made a part hereof, and marked "Exhibit E", is a true copy of the billing summary. 19. Petitioner further requests this Honorable Court to order a payment of the balance, $74,935.85 to be placed into a restricted account in the name of the minor, Duy Dustin Pham, marked not to be withdrawn until the age of 18, on February 9, 2016, totaling at least $74,935.85. 4 WHEREFORE, Petitioner requests this Honorable Court to: a. Approve the above-stated Compromise; b. Authorize the payment of fees above-stated from funds due the minor; C. Direct payment of the net funds due, in accordance with the above- stated Compromise. Respectfully submitted, HANDLER, HENNING & ROSENBERG, LLP DATE: BY:? David H , Esquire 1. D. No. 569 1300 L' glestown Road Harris urg, PA 17110 (717) 238-2000 Attorney for Petitioners 5 PENNSTATE IVfil#on I Ekimhey Medical Center College of Median Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: PHAM, DUY DUSTIN PSUHMC MRN: 7004070 Patient Sex: Male Date of Birth: 2/9/1998 Patient Location: ENTI, , Visit Number: 7233308 Visit Type: Clinic O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Hrabovsky, Sharilee M 7/13/2006 6:16:29 AM OUTPATIENT LETTER July 12, 2006 Name: PHAM, DUY DUSTIN HMC Number: 7004070 DOB: 02/09/1998 Date of Service: 07/12/2006 Peter W. Dillon, M.D. PO Box 850 University Hospital Hershey, PA 17033 Dear Dr. Dillon: I saw Dustin for evaluation of his hearing and left temporal bone fracture. He was in an automobile accident where he was ejected from the auto May 5, 2006. He is being followed by Peds Neurology and Neurosurgery. He presents today feeling well. Mom reports no dizziness, headaches. She states he is walking and running fine. He is hearing, speaking and eating well. He has no nausea or vomiting. On examination today, the right and left ear canals and tympanic membranes are normal. Nose: Mucous membranes normal. His pharynx, oral cavity are normal. He has no palpable cervical lymphadenopathy. An audiogram done today shows normal hearing sensitivity with excellent work recognition bilaterally. Tympanograms are normal on the right and left. My impression is that his ears are normal. Hearing normal. The plan is to discharge from our care. Will reevaluate in future if needed. Date Printed: 101311006 KNNSTATE 1wIilton Sr 1krshey Mec ' Center College of Medi d ne Patient Name: PHAM, DUY DUSTIN PSUHMC MRN: 7004070 O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Hrabovsky, Sharilee M 7/13/2006 6:16:29 AM Thank you for involving me in his care. 267986 CC: Peter W Dillon, MD Penn State Milton S. Hershey Medical Center PO Box 850 Hershey, PA 17033 Sincerely, Sharilee M Hrabovsky, RN, MSN, CRNP Nurse Practitioner-Otolaryngology-Head & NeckSurgery UPC Suite 200, Hershey Medical Center 500 University Drive, Hershey, PA 17033 (717) 531-6822 SMH /CO DD: 07/12/06 DT: 07/13/06 03:44 Date Printed: 101312006 Time Printed: 12:22 PM PENNSTATE amm 'tlton S. Hmhe UP y Aledical Center Go?&W of Medicine Patient Name: PHAM, DUY DUSTIN Patient Sex: Male Patient Location: SLEP, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 7004070 Date of Birth: 2/9/1998 Visit Number: 08791882 I_ S I e e p - S t u d y Final Name: PRAM, DUY DUSTIN Patient Number: 7004070 DOB: 02109/1998 Date of Service: 09/01/2007 IDENTIFYING DATA, REFERRING SOURCE. AND SYMPTOMS: Duy Pham was referred to the Sleep Research and Treatment Center for diagnostic study by Dr. Yoke Tan for possible sleep apnea . SLEEP LABORATORY EVALUATION: This patient was evaluated in the Sleep Research and Treatment Center on the night of September 1, 2007 for one 10 hour nocturnal diagnostic polysomnogram. The patient was monitored continuously with polysomnography recordings of EEG, EOG, EMG, respiration (thermocouples and thoracic strain "gauge), EKG, finger oximetry, and audio and visual recordings. Evaluation of the polysomnography revealed no obstructive apneas and no obstructive hypopneas. There were 2 central apneas. The apnea/hypopnea index was 0.22. The mean apnea/hypopnea duration was 9.3 seconds. The longest central apnea duration was 10.9 seconds. No snoring was reported by the overnight staff. Patient's resting Sa02 was 98 %, while minimum oxygen saturation during nonREM sleep was 95 % and during REM sleep was 94 %. Sa02 was below 90% for 1.3 % of the recording. Also, there were no breathing related arousals and 2 arousals of unknown origin. There were no periodic limb movement arousals. The periodic limb movement index was 0. Date Printed: 111212007 PENNSTATE 4F Milton & Hershey hU icai meter College of Me ' e Patient Name: PHAM, DUY DUSTIN PSUHMC MRN: 7004070 I S I e e p - S t u d y Final In terms of sleep efficiency, the sleep latency was 15 minutes and REM latency was 177 minutes. Total sleep time was approximately 9 hours and 4.5 minutes (sleep efficiency of 90.1 %). Also, we counted 25 short awakenings (duration of > 40 seconds < 10 minutes) and no long awakenings (duration > 10 minutes). The patient spent 2.5 % of sleep in stage 1, 34.9 % in stage 2, 41.6 % in slow wave and 21 % in REM. IMPRESSION: These results do not indicate evidence of significant sleep apnea. Patient will be contacted to schedule follow-up appointment in the Sleep Clinic for complete evaluation and interpretive of results. Date Printed: 111212007 Time Printed: 11:58 AM DEC 19 2006 A*? David H Rosenberg, Esquire I.D. No. 20569 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Attorneys for Petitioner Fax: (717) 233-3029 E-mail: Rosen ber-g0hhrlaw.com IN THE MATTER OF DUSTIN : IN THE COURT OF COMMON PLEAS PRAM, a minor by and : CIVIL COURT DIVISION through his natural parents and : CUMBERLAND COUNTY, PENNSYLVANIA guardians, DANG PHAM and NHIEN NGUYEN _ NO. OG MINOR'S COMPROMISE ORDER AND NOW, this -21A day of 2006, upon consideration of the foregoing Petition, IT IS HEREBY ORDERED that the disbursement of funds, as well as counsel fees and expenses, are approved as set forth in said Petition and shall be disbursed in accordance with the terms and conditions of the settlement agreement as follows: A. Direct payment of $6,596.30 to David H Rosenberg, Esq., representing reasonable attorney's fees of $6,250.00 and $346.30 for reimbursement of costs; B. Direct payment of the balance of $1,903.70, placed into a restricted account in the name of the minor, Dustin Pham, marked not to be withdrawn until the age of 18; C. Direct payment of $16,500 to be placed in a structured settlement, bearing the name of the minor, Dustin Pham, that will be payable in one guaranteed lump sum on September 22, 2016 on the minor's 18th birthday. D. Proof of deposit is to be filed with the Court. . TRUE COPY ROM RECORD 'in Testimony whrrnnf, t?nto set my 1* 4 ao? f sa I J Pe. It V ti 1, •• "Y' BY THE COURT: CONTINGENT FEE AGREEMENT I, Dang B. Pham, natural father and legal guardian of Dustin Pham, do hereby retain HANDLER, HENNING & ROSENBERG, LLP., of Harrisburg, Pennsylvania, as my attorneys in this matter to represent me and to process, negotiate, arbitrate a settlement or to institute in my name, any legal proceedings or actions that, in their judgment are necessary, against Daricus Releford or against anyone else as a result of injuries and damages I sustained in an incident that occurred on 5/6/2006. I agree not to settle, negotiate or adjust the above claim or any proceedings based thereon without the written consent of my said attorneys. In consideration of the services so to be rendered by Handler, Henning & Rosenberg, LLP, I hereby covenant, promise and agree to pay them for their professional services rendered, THIRTY-THREE AND ONE-THIRD PERCENT (331/3%) of whatever sum is recovered as a result of settlement without lawsuit; or FORTY PERCENT (40%) of whatever sum is recovered after lawsuit is filed or in the event of arbitration or mediation. I will reimburse Handler, Henning & Rosenberg, LLP. for any necessary expenses advanced on my behalf in pursuing my claim. Examples of typical expenses include Court filing fees, investigation, auto mileage, photocopies, court reporters, medical records, expert witness fees, etc. If no money is obtained, client will not owe a legal fee or expenses. I also agree to take possession of my medical files at the conclusion of this case. My failure to take possession of these files within 60 days after the conclusion of the case will authorize my lawyers to destroy said files. I agree that HANDLER, HENNING & ROSENBERG, LLP. may associate additional lawyers to assist with this case and I agree to the sharing of fees between lawyers. I understand the terms herein apply to other lawyers associated on this case. l understand that the association of other lawyers does not increase the amount of the attorney fees at the conclusion of the case. Counsel reserves the right to withdraw if they desire to do so, for any reason(s) they deem proper. I acknowledge that I have read, approved and understood the above Contingent Fee Agreement and I acknowledge having received a copy of the same. The terms set forth herein are accepted. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 30th day of May, 2006. (SEAL) y Da , natural father and legal guardian of Dustin Pham andlar, annin9b osanbar9AP ATTORNEYS AT LAW 1300 Linglestown Road, Harrisburg, PA 17110 Dustin Pham 8 Pennsway Road Mechanicsburg, PA 17050 INVOICE PAYMENT DUE UPON RECEIPT Balance forward as of invoice dated March 1, 2007 EXPENSES Client No: 211418 Matter: 00000 Attorney: DHR MV Pre-Bill No: 24232 Bill Date: December 20, 2007 $0.00 09/18/2007 Vendor CUMBERLAND COUNTY ORPHAN'S COURT, General Case 15.00 yD9/1812 Ar'• 77+x°` n A 09!18/2007 Vendor CUMBERLAND COUNTY ORPHANS COURT General Case 15.00 r CASE~ - s f l ,. ti r ..i ? y- ! <l ? : '= ?15:00 fl9/18f-0 ?? a Y??4?° P? r " " 12/31/2007 " .. : Document Reproduction 0.20 COPY' 12 3 2007 '":4* ` ?Y $0:20: r ; + r, a ':4 at <'t r }(' sl , ,., 1 5 00 /2007 12/3 Fax Charges . FAX 12t3f2OQ7 s" $5:00 s r 12/31/2007 Document Reproduction 33.40 : ISl A9 21 X12407' $33:40 `M? , mk 12/311200 7 u. Postage Costs 9.52 ' ' ; $9.52. }2/312(307 ? :_; POS ..,.:; Y' _.., T 12/31/2007 ... Postage Costs 14.81 POST', r ' ,$14.81. s 12/31%2007 r= 12/31L/2007 , k Long Distance Telephone Charges 1.22 TELI 12/313f37 ` $122 "." TOTAL EXPENSES $64.15 Total due this invoice $64.15 TOTAL BALANCE DUE $64.15 David H Rosenberg, Esquire I.D. No. 20569 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Attorneys for Petitioner Fax: (717) 233-3029 E-mail: Rosenberq(&-hhrlaw.com IN THE MATTER OF DUSTIN : IN THE COURT OF COMMON PLEAS PHAM, a minor by and : CIVIL COURT DIVISION through his natural parents and : CUMBERLAND COUNTY, PENNSYLVANIA guardians, DANG PHAM and NHIEN NGUYEN NO. 06-7153 : MINOR'S COMPROMISE ORDER AND NOW, this day of , 2008, upon consideration of the foregoing Petition, IT IS HEREBY ORDERED that the disbursement of funds, as well as counsel fees and expenses, are approved as set forth in said Petition and shall be disbursed in accordance with the terms and conditions of the settlement agreement as follows: A. Direct payment of $25,064.15 to David H Rosenberg, Esq., representing reasonable attorney's fees of $25,000.00 and $64.15 for reimbursement of costs; B. Direct payment of the balance of $74,935.85, placed into a restricted account in the name of the minor, Dustin Pham, marked not to be withdrawn until the age of 18, on February 9, 2016; C. Proof of deposit is to be filed with the Court. BY THE COURT: J. r 7 _ .ra... "''" rT"1 t? , ? ,??? ?? ter.;.,.., ?? ° :?y - ..?' ?» ^ tA JAN 15 2008 rat' David H Rosenberg, Esquire I.D. No. 20569 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Attorneys for Petitioner Fax: (717) 233-3029 E-mail: Rosen berg(&-hhrlaw.com IN THE MATTER OF DUY DUSTIN : IN THE COURT OF COMMON PLEAS PHAM, a minor by and : CIVIL COURT DIVISION through his natural parents and : CUMBERLAND COUNTY, PENNSYLVANIA guardians, DANG PHAM and NHIEN NGUYEN NO. 06-7153 MINOR'S COMPROMISE ORDER AND NOW, this /7' day of 2008, upon consideration of the foregoing Petition, IT IS HEREBY ORDERED that the disbursement of funds, as well as counsel fees and expenses, are approved as set forth in said Petition and shall be disbursed in accordance with the terms and conditions of the settlement agreement as follows: A. Direct payment of $25,064.15 to David H Rosenberg, Esq., representing reasonable attorney's fees of $25,000.00 and $64.15 for reimbursement of costs; B. Direct payment of the balance of $74,935.85, placed into a restricted account in the name of the minor, Duy Dustin Pham, marked not to be withdrawn until the age of 18, on February 9, 2016; C. Proof of deposit is to be filed with the Court. BY THE COURT: J. Ar-IOD 6O- 81-/ L S °d L ! fN, q j 0Z F:\WP Directories\AMC\Motions & Petitions\Withdrawal $\Pham, Dustin.wpd David H Rosenberg, Esquire I.D. No. 20569 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Attorneys for Petitioners Fax: (717) 233-3029 E-mail: Rosen berga hhrlaw.com IN THE MATTER OF DUY DUSTIN : IN THE COURT OF COMMON PLEAS PHAM, a minor by and : CIVIL COURT DIVISION through his natural parents and : CUMBERLAND COUNTY, PENNSYLVANIA guardians, DANG PHAM and NHIEN NGUYEN NO. 06-7153 : MINOR'S COMPROMISE PETITION FOR LEAVE TO WITHDRAW MINOR'S FUNDS FROM ATTORNEY'S TRUST ACCOUNT Pursuant to Pennsylvania Rule of Civil Procedure No. 2039(2), David H Rosenberg, the Counsel of Record for Petitioners, Duy Dustin Pham and his natural parents and guardians Dang Pham and Nhien Nguyen, by and through their attorneys, Handler, Henning & Rosenberg, LLP, petitions this Honorable Court to enter an Order, permitting withdrawal of funds from said minor's restricted account and, in support thereof, avers as follows: 1. Duy Dustin Pham was born on February 9, 1998, and is therefore, ten years -1- old and a minor. He currently resides at 8 Pennsway Road, Mechanicsburg, Cumberland County, Pennsylvania 17050. 2. Petitioners, Dang Pham and Nhien Nguyen, adult individuals, are said minor's natural father, mother, and legal guardians and they reside with their child at, 8 Pennsway Road, Mechanicsburg, Cumberland County, Pennsylvania 17050. 3. On or about May 6, 2006, the minor, Duy Dustin Pham, was injured in a motor vehicle collision, caused by the Defendant, Daricus Releford. 4. As a result of the injuries said minor sustained, the Petitioner entered into a settlement agreement via underinsured motorist benefits available through Petitioners' automobile policy, StarNet Insurance Company, for the policy limits of $100,000.00. 5. On January 17, 2008, this Honorable Court approved the proposed settlement and directed that the net settlement proceeds of $74,935.85, be placed into a restricted account, bearing the name of the minor, Duy Dustin Pham, and marked "Not to be withdrawn until the minor reaches the age of 18 or without the Order of a Court of competent jurisdiction." Attached hereto, made a part hereof, and marked "Exhibit A," is a copy of the January 17, 2008, Order. 6. On or about March 18, 2008, Petitioner's counsel deposited Petitioner's settlement proceeds into the attorney's trust account until such time as the proceeds could be deposited into a restricted account in the name of Duy Dustin Pham. 7. Recently, it has come to the attention of Counsel of Record, David H Rosenberg, that certain medical bills, in the amount of $4,240.72, pertaining to the treatment of Duy Dustin Pham are in fact outstanding. Attached hereto, made a part hereof, and marked "Exhibit B," is a copy of the outstanding bills in the amounts of -2- $3,070.88 payable to Hershey Medical Center Hospital, $819.84 payable to Hershey Medical Center Physician, and $350.00 payable to Hampden Township Ambulance Assoc. 8. It is requested that the amount of $4,240.72 be permitted to be withdrawn from the attorney's trust account in order to settle Duy Dustin Pham's outstanding medical bills. The counsel of record further requests reasonable costs and expenses of $59.19 to be withdrawn from the attorney's trust account. Thus, the total amount requested for settlement of medical bills and reasonable costs is $4,299.91. Attached hereto, made a part hereof, and marked "Exhibit U is a true copy of the billing summary. 9. Therefore, the adjusted amount that would then be deposited into the restricted account in Duy Dustin Pham's name is equal in amount to $70,635.94. WHEREFORE, in light of the foregoing, Counsel of Record, David H Rosenberg, respectfully requests that this Honorable Court approve withdrawal of $4,299.91 from the aforementioned attorney's trust account for payment of Duy Dustin Pham's outstanding medical bills and reasonable costs. Respectfully submitted, HANDLER, HENNING & ROSENBERG, LLP Date By David H /lestown berg, Esquire I . D. #321300 Li Road Harrisburg, PA 17110 (717) 238-2000 Attorneys for Plaintiff -3- JAN 15 2008 r" David H Rosenberg, Esquire I.D. No. 20569 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Fax: (717) 233-3029 E-mail: Rosenberg(Mhhrlaw.com Attorneys for Petitioner IN THE MATTER OF DUY DUSTIN : IN THE COURT OF COMMON PLEAS PRAM, a minor by and : CIVIL COURT DIVISION through his natural parents and : CUMBERLAND COUNTY, PENNSYLVANIA guardians, DANG PHAM and NHIEN NGUYEN NO. 06-7163 : MINOR'S COMPROMISE ORDER AND NOW, this _4122Elday of ' 2008, upon consideration of the foregoing Petition, IT IS HEREBY ORDERED that the disbursement of funds, as well as counsel fees and expenses, are approved as set forth in said Petition and shall be disbursed in accordance with the terms and conditions of the settlement agreement as follows: A. Direct payment of $25,064.15 to David H Rosenberg, Esq., representing reasonable attorney's fees of $25,000.00 and $64.15 for reimbursement of costs; B. Direct payment of the balance of $74,935.85, placed into a restricted account in the name of the minor, Duy Dustin Pham, marked not to be withdrawn until the age of 18, on February 9, 2016; C. Proof of deposit is to be filed with the Court. Z r;rr1 I RIEIr r,rE Sol 3 ..: s Cou`nJ1 ;?? CCarlIA, ill. f T 7 ik,_ 4?.' BY THE COURT: J. FED-28-2008 THU 10;51 AM PT FIN SVS MS HE 500 Statement on; Guarantor: PHAM DANG BRIAN 8 PENNS WAY RD MECHANICSBURG, PA 17050-0 FAX;717 531 0222 P,023 MEDICAL CENTER ERSITY DRIVE Y, PA 17033 2/28/08 at 09:59 AM 0 PAGE: 1 Patient: PHAM DUSTIN Visit #: 71142 4 --------------------------------- ----------------------- ------------- Date I Svc Code J Descr'ption Uni.tsl Debit Credits 05106106 711107 AIR AMBULANC TRANSPO 1 10229 00 05/06/06 711108 AIR AMBULANC MILEAGE 17 1683 00 06/12/06 902040 AUTO/WORK CO PAYMEN -1 5000.00- 10/02/06 902005 COMMERCIAL P Y HOSP -1 2720.79- 10/02/06 920173 PRIMESOURCE JUSTMEN -1 2978.00- 03/31/07 980090 HOSPITAL BAD DEBT W/O -1 1213.21- 03/31/07 980091 HOSPITAL BAD DEBT PLA 1 1213 21 - * - Not posted I -Balanc?: 1----1213_21. FEE-28-2008 THU 10:51 AM PT FIN SVS MS HE 500 Statement on: FAX:717 531 0222 P,024 MEDICAL CENTER ERSITY DRIVE Y, PA 17033 2/28/08 at 09:59 AM Guarantor: PRAM DANG BRIAN 8 PENNS WAY RD MECHANICSBURG, PA 17050-00 0 PAGE: 1 Patient: PHAM UY DUSTIN Visit #: 86207T6 j - Date j Svc Code Date Descri --- ption j - --- Unitsj -------- Debit ------- j ----- ---- ------------ j - ----------- ------------- 08/31/07 --- -------- 347001 --------- - MRI BRAIN - - --- 'HANCED 1 1749 00 - 09/27/07 920173 PRIMESOURC DUSTMEN -1 437.25- 12/31/07 980090 HOSPITAL B EBT W/O - 1 1311.75- 12/31/07 980091 HOSPITAL BAD DEBT PLA 1 1311 75 * - - Not posted ------- ------`------ --- --- j - - Balanc ------- 1 ---- 1311.75 1 -------------- FEE-28-2008 THU 10:51 AM PT FIN SVS MS HE 500 Statement on: FAX:717 531 0222 P,025 MEDICAL CENTER ERSITY DRIVE Y, PA 17033 2/28/08 at 09:59 AM Guarantor: PHAM DANG BRIAN 8 PENNS WAY RD MECHANICSBURG, PA 17050-00 0 PAGE: 1 Patient: PHAM UY DUSTIN Visit #: 87918$2 Date -( Svc Code ( Description - 1-Units( -Debit -( Credits 09/01/07 7434 POLYSOMNOG Y, 4+ P 1 921 00 09/01/07 522211 12 LEAD EL OCARDIO 1 124 00 09/27/07 920173 PRIMESOURC JIISTMEN -1 31.00- 11/13/07 902005 COMMERCIAL T HOSP -1 531.83- 11/13/07 920173 PRIMESOURC DUSTMEN -1 230.25- 01/31/08 980090 HOSPITAL B EBT W/O -1 251.92- 01/31/08 980091 HOSPITAL B D PLA DEBT 1 251 92 * - Not posted I BalanCq: --(-----251.92 -- FED-28-2008 THU 10;51 AM PT FIN SVS FAX;717 531 0222 P,026 MS HE 500 Statement on: MEDICAL CENTER ERSITY DRIVE Y, PA 17033 2/28/08 at 09:59 AM PAGE: 1 Guarantor: PHAM DANG BRIAN 8 PENNS WAY RD MECHANICSBURG, PA 17050-00 0 Patient: PHAM U Visit #: 8791918 DUSTIN Date ( Svc Code -I - - Description Units] Debit -Credits 09/02/07 104014 ALKALINE PHO PHATASE 1 15 00 09/02/07 104016 BILIRUBIN TO AL 1 15 00 09/02/07 104042 CREATININE, LOOD 1 15 00 09/02/07 104060 GLUCOSE, BL D 1 14 00 09/02/07 104065 UREA NITROG (BUN), 1 14 00 09/02/07 104102 LIPID PROFIL 1 68 00 09/02/07 104156 SGPT (ALT) 1 16 00 09/02/07 104568 TSH THYROID TIM NORM 1 84 00 09/02/07 104569 T4, FREE 1 63 00 09/02/07 105657 CBC W/PLT/DI F AUTO 1 51 00 09/02/07 106010 URINALYSIS- IC/REFL 1 19 00 09/02/07 109804 VENIPUNCTURE 1 18 00 10/26/07 920173 PRIMESOURCE JUSTMEN -1 98.00- 01/31/08 980090 HOSPITAL BAD DEBT W/O -1 294.00- 01/31/08 980091 HOSPITAL BAD DEBT PLA 1 294 .00 - * - Not posted I-Balanc?_-------294_00 W'+rxro z vW0 x$A AvKxx x O N y A eD N M zr? z A co (D N W Co C W W L'! 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DUOTJ- f PH AM VISIT NUI)i4,BLR: 8620?5¢ DOCTOR(S) ARABINDA KCHOUi3HAfZY MD Q 1V'OF D1AC*,WFLOG LOCATION: OP HOSPITAL CPT Payments/ Pending Patient Date Code Diagnosis Description Charges Adiustments Insurance Balance 08/31/07 70551 784.0 MRI BRAIN UNENHANCED $ 459.00 09/19/07 APPLIED TO DEDUCTIBLE 09/19/07 YOUR INSURANCE ALLOWANCE $ -376.62 09/19/07 BALANCE AFTER INS* $ 82.38 TOTAL: $ 459.00 $ -376.62 $ 0.00 $ 82.38 WNT NAMI:.DUY DUVISIT NUM ER O.., D DIV'OF'$LEEP MEDICINE 0CAkTION CPT Date Code Diagnosis Description 09/01/07 95810 780.57 COMPREHEN POLYSOMNOGRAPHY 09/28/07 APPLIED TO DEDUCTI 09128/07 YOUR INSURANCE ALLOWANCE 09/28/07 BALANCE AFTER INS* TOTAL: Payments/ Pending Charges Adiustments Insurance $ 684.00 $ -487.85 Patient Balance $ 196.15 $ 684.00 $ -487.85 $ 0.00 $ 196.15 PATIENT N?:.D(51 DUSTIN PRAM VI6jT, - NVMBER:,a%4000 DOCTOR($) ANi0P KARIPAQT M6DIV OF SHEEP MFDICIRE; LQCiTTION: OP'HOSPIU CPT Date Code Diagnosis Description * 10/03/07 99205 780.50 OUTPATIENT VISIT NEW * 10/25/07 APPLIED TO DEDUCTI * 10/25/07 YOUR INSURANCE ALLOWANCE * 10/25/07 BALANCE AFTER INS* TOTAL: GRAND TOTAL: Payments/ Pending Patient Charges Adiustments Insurance Balance $ 303.00 $ -118.48 $ 184.52 $ 303.00 $ -118.48 $ 0.00 $ 184.52 $ 1,446.00 $ -982.95 $ 0.00 $ 463.05 * (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHYSTI-02 ........................................................................................................................................................................................ PLEASE COMPLETE IF YOUR ADDRESS OR INSURANCE HAS CHANGED NAME RELATIONSHIP TO PATIENT HOME TELEPHONE WORK TELEPHONE ADDRESS CITY STATE ZIP POLICYHOLDER'S NAME INSURANCE COMPANY NAME GROUP POLICY/PLAN NUMBER POLICYHOLDER'S IDENTIFICATION NUMBER CLAIM MAILING ADDRESS POLICYHOLDER'S DATE OF BIRTH RELATIONSHIP TO PATIENT CITY STATE ZIP POLICYHOLDER'S EMPLOYER NAME INSURANCE COMPANY TELEPHONE (Workers Compensation & Auto Insurance Claims Only) DATES OF COVERAGE Adjuster's Name: Claim #: EFFECTIVE FROM: EFFECTIVE TO: PENNSTATE 1 1 st Statement P 1 f 2 MSHMC PHYSICIANS GROUP EIIILLMIti ES PO BOX 643313, PftWrgh, PA 1 5284-3 31 3 Thank you for allowing Penn State University Physicians Group to provide you with services. Please send your payment for the full amount. If you have any questions concerning how your insurance company processed your claim, please call them. If no insurance is listed on the back of this statement and one is available please P00027 contact our office with your information. DANG BRIAN PHAM 8 PENNS WAY RD MECHANICSBURG PA 17050-1777 11111111it11111 116,11oulthsti,Adis,I I Please note: To keep your account current, our policy is to apply your payment to the oldest outstanding balance. Patient Name DUY DUSTIN PHAM Statement Date 11/06/07 Account Number 7004070 Total Charges $1,446.00 Insurance Payments/Adjustments $ -982.95 Patient payments $ 0.00 Pending with Insurance $ 0.00 FA7ount You Owe $463.051 This new statement has been specially designed with you in mind. Let us know what other improvements we should make. Please e-mail your ideas to: Staternentidea mc-psu edu or write to us at: Penn State Milton S. Hershey Medical Center Statement Ideas, PO Box 854, MC A410 Hershey, PA 17033 To make payments, billing quemoris or insurance changes: Para preguntas acerca de su factura o cambios de seguro contarnos con representartes disponibles para asistir a Ia comunidad hispana. Phone: (717) 531-5069 or (8011) 254-2619 In Persona: Financial counselors are available in the Academic Support Building (on campus just-east of the main hospital and University Physicians Center). Available hours: Monday, Tuesday & Wednesday 8:00 am to 5:30 pm Thursday & Friday 8:00 am to 4:30 pm Written Correspondence: Penn State Milton S. Hershey Medical Center Patient Financial Servicas Department PO Box 854, Mail Code A410 Hershey, PA 17033-0854 Department of Pubk Welfare 1-800-692-7462 .Children's Health Insurance Program (CWIP) 1-800-543-7101 (Uninsured children and adOlsat under age 19) -AduRBasic Program 1-800-543-7101 (Uninsured adults between the ages of 19 and 64) PLEASE GIVE TO PCF2 This statement is for your physician services only. The hospital may frig. separ y for;their services- M445WHYST,-01 ..__ ........................................................._...... .............................................................................................. PENNSTATE Statement Date: 11/013107 NIA PHYSICIANS GROUP 113111.1110 SERVICES PO Box 843313 Pittsburgh, PA 15264-3313 11 -130401 CHECKS SHOUL SE MAOF PAYJ?l.'E ANO SENT TO: MSHMC PHYSICIANS GROUP PO BOX 643313 PITTSBURGH, PA 15264-3313 I???Il?l?l???l?l?ll???l??l?rll?rrll???rll??llr??rll??ll?lr?l?l ?J X, lwl-40, Account No, Expiration Date Signature X 00007004070 UP CVV Cade 0000000000046305110607 ', Check here if your address or insurance informabon has chewQed. ,d ppme indwate chengss on Um back of Una pxw, To For ?.uur acts, you may pay by Visa, preference, provide the account irllDrhlltirl; W*-aiprr ttdftw. MAR. le. 2008 4:03AM HAMPDEN TWP EMS NO.208 P.2/2 871mmu Tommy IP Amumm= 33MICY (k: 0600770 230 SOVM SPORTING 'FILL PAM XRCHii?=C3WJG, PA 17050 (717) 761-3343 TA8 # 23-6050136 D7?'1'B: 03/18/2008 paT33 aM : DUY PHAN SILL TO: DANG PEAK 8 PEONS WAY ROAD MECHANICSBURG, PA 17050 AQCd[W #: 4063914438 CONTR= #: 0600770 DATA OP ssRVICm: 05/06/2006 BATTmv PICMM Up: CARLISLE PIKE MEC$ANICSBDRG, PA 17050 PATZ=T TAS3N TO: LIFE LION - HERSHEY geico DLL" 1121 COST-Q7.'Z • - aumm --089CAtPT= 2006 BLS BASE RATE A0429 350.00 1.0 350.00 DISPOSABLE SUPPLIES 0.00 0.0 0.00 Caom"ut*: THIRD NOTICE - PLEASE SEND PAYMENT OR sOBTO'a1L 350.00 CALL TO SET-UP PAYMENTS. (761-5343) AvcRm THIS INVOICE IS WILL BE SENT FOR COLLECTION IF PAID 0.00 PAYMENT IS NOT RECEIVED IN 30 DAYS. PLEASE PUT INVOICE NUMBER ON CHECK. THANKS Tsaw Tw. TOTAL 350-00 andler, Qnningfi 1 Menberg,LLP ATTORNEYS AT LAW 1300 Linglestown Road, Harrisburg, PA 17110 Dustin Pham 8 Pennsway Road Mechanicsburg, PA 17050 INVOICE Client No: 211418 Matter: 00000 Attorney: DHR MV Pre-Bill No: 24967 Bill Date: March 20, 2008 PAYMENT DUE UPON RECEIPT Balance forward as of invoice dated March 20, 2008 $0.00 EXPENSES 01/14/2008 CHARTONE INC. records from Penn State Hershey Medical Center 44.48 CASFq;4?? `',,'ta;i $4 48 " to 03/31/2008 Document Reproduction 9 00 COPY $9.00 , . 03/31/2008 Document Reproduction 1.00 15f ' ` `` ?r31?2(10 $1.00 03/31/2008 Postage Costs 2.05 j"j $2.,05 k' '' 03/31/2008 Postage Costs 2 57 PAST „I lc?i .0 ,? $2:57 . .. 03/31/2008 Long Distance Telephone Charges 0 09 TELR.1 n" TOTAL EXPENSES $59.19 Total due this invoice $59.19 TOTAL BALANCE DUE $59.19 Trust Remaining Balance $74,935.85 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. Wien Nguyen J b'r Date: /) .J /,)- ?u <-:-> :., `-i 4? t ?? ?- '. ? ? ' .? ;, ?:: r_' ? --<; 'artt e 3 20 0 8 /.a 4 David H Rosenberg, Esquire I.D. No. 20569 HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Road Harrisburg, PA 17110 Telephone: (717) 238-2000 Fax: (717) 233-3029 E-mail: Rosenberg(a). hhrlaw.com Attorneys for Petitioners IN THE MATTER OF DUY DUSTIN : IN THE COURT OF COMMON PLEAS PHAM, a minor by and : CIVIL COURT DIVISION through his natural parents and : CUMBERLAND COUNTY, PENNSYLVANIA guardians, DANG PHAM and NHIEN NGUYEN NO. 06-7153 : MINOR'S COMPROMISE ORDER OF COURT AND NOW, this I `day of NI , 2008, upon consideration of the within Petition, IT IS HEREBY ORDERED that the Petition for Leave to Withdraw Minor's restricted- account funds in the above-captioned matter is approved and $4,299.91 may be withdrawn from the aforementioned attorney's trust account for payment of the outstanding medical bills of the minor, Duy Dustin Pham and reasonable costs. DISTRIBUTION: ?David H Rosenberg, Esq. HANDLER, HENNING & ROSENBERG, LLP 1300 Linglestown Rd. Harrisburg, PA 17110 1.:0IltS ?a1 lcCL BY THE COURT: ---/ (11t- J. 4 'Y/7/o,0 L714 ?.??t(?4I,?,??,??`????3N? Jed s rte, -- r •?{? T Wd L - 8dy goon M7,'; O- jLq r