HomeMy WebLinkAbout94-00634
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DAtE S. BARBER
Plain~iff
27
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
v.
CHARLES A. WENTZEL, CIVIL ACTION - LAW
Defendant NO. 94-634 CIVIL TERM
IN REI PRETRIAL CONFERENCE
At a pretrial conference held Wednesday, August 23rd,
1995, before the Honorable Harold E. Sheely, President Judge,
present for the Plaintiff was Robert J. MUlderig, Esquire, and
prelent for the Defendant was Ann Margaret Grab, Esquire.
I think there is a good chance that liability will be
admitted in this case, and if it is this case should take no
longer than one day to try. If liability is not admitted, no
longer than two days to try. Both counsel are available the
week of the 18th except Mr. Mulderig is not available on
Thursday the 21st,
This auto accident happened on August 17th, 1992, in
West Fairview Borough, There is only one traffic light in West
Fairview Borough. The Plaintiff was proceeding east across U.S.
Route 11 and 15 and had the green light when he was struck on
his passenger side by a vehicle operated by the Defendant who
ran a red light, Plaintiff claims injuries to his neck and
lower back.
The medical expenses stated by the Plaintiff will not
be admissible at trial since they have been paid by the firlt
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IN THi: CotlRT OF COMMON PI,EAS OF CUMBERLAND COUNTY, PENNSYINANIA
DALE S. BARBER, Civil Action - Law
Plaintiff
vs, No, 634 Ci vi! 1994
CHARLES A. WENTZEL,
Defendant Jury Trial Demanded
MEMORANDUM FOR P~E-TRIAL CONFERENCE
Submitted bYI
Ann Margaret Grab, Esquire
,
Counsel for I
Defendant, Charles A, Went~el
Date of Pre-Trial Conference I August 23, 1995
I , FACTS I
This suit arises out of a motor vehicle accident which
occurred on August 17, 1992 at the intersection of SR 11/15 and
Market Street in West Fairview Borough. At that time, the
Plaintiff had a green light and the Defendant had a red traff ic
light. The impact between the vehicles occurred at the front end
of the Defendant's vehicle and the front passenger or right side
of the Plaintiff's vehicle.
I I , DAMAGES
See Plaintiff's Pre-Trial Memorandum
III, ISSUES
Barber.
A. Negligence of Defendant Charles Wentzel.
B. Contributory negligence of the Plaintiff Dale
damages.
C. Nature and extent of the Plaintiff's injuries and
IV. ISSUES REGARDING EVIDENTIARY RULINGS.
The Defendant requests the Plaintiff be precluded from Placing
medical bills into evidence, Such preclusion has been upheld for
motor vehicle accidents occurring after July 1, 1990 wherein the
1
Superior Court affirmed Martin v, Soblotney, 502 Pa. 418, 466 A.2d
1022 (1983) and its rec(mt decision in Carlson v. Bub.ll.lUlb,
Pa,S, __, 639 A.2d 458 (1994).
V. WITNEJSSES
A. Charles A. Wentzel
B.
Dr. Steven 'rrianta l'yllou - { ,) \ ,,,. I I }.. '-.\
D R b P W lf ,-"" .<"..,..\ \:/r' ~I
r. 0 ert . 0
. \..1 \ \)l ,-,-
L, l_,-,,,
C.
D. J, W. Herman, West Fairview Borough Police Dept,
E. Dale Barber, as on cross examination
F,
Robert J. Bender _ I" ii. Iltl"" 0.1 (.."., .,;'
Defendant reserves the right to call any witnesses identified by
the Plaintiff in his Pre-Trial Memorandum,
VI. EXHIBITSI
1. Medical records of treating physicians of Plaintiff,
Dale Barber.
A. Dr, Jonathan Tocks
B, pennsyl vani a Office of Vocational
Rehabilitation
C. Capital Recovery Center
D, Mechaniasburg Rehab
13, Holy Spirit Hospital
F, Dr, Bruce Goodman
G. Dr, Rex Herbert
H. Dr, Michael Innes
I. Dr, Gary f,ut termoser
2. Income tax returns of Plaintiff Dale Barber produced
in discovery.
3, Employment records from Furniture Liquidators.
2
t.
'l
VI I . SE'l'TLEMENT NEGOTI1\'l'IONS
To datQ plaintiff has demanded $100,000 and Defendant has
the sum of $25,000.
offered
GRIFFITH, STRICKLER, LERMAN,
SOLYMOS & CALK1NS
BY, Q~4)-) )tf,~tlALf J;; (A
Ann Margaret' Grab, 'Ese;!. '
Supreme Court I,D. 55986
Attorn~y for Defendant
11.0 S. Northern Way
York, pennsylvania 17402-3737
Telephone I (717) 757-7602
lh82
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v.
IN THf: COURT OF COMMON PI,.:AB
ClIMmaU,AND COUNTY, PENNSYLVANIA
CIVil, A(,"l'ION, l,AW
DA~E S. BARS.:R,
Plaintiff
CHMI,ES A. WmNTZEI. ami
KATJiRYN L, WENTZEl"
Detendant.
NO. CIVil, 1994
JURY TRIAL DEMANDED
~MPLAlNT
1, Plalntlff, Dille S. Barber, I. an adult Indlvldulll currently re.ldllll at 1139 Norlh Enola Drive,
Enola, Cumberland County, pennaylvBllIa 170211.
2. Detendant, Kathryn 1,. Wenlr.el,ls an adult Individual currently relldll1lJ at R,D.'3, Boll 1911,
Newport, Perry County, Pennsylvanm 17074.
3. Detendant, Charlea A, Wenhel, i. an adult Indlvldual currently re.ldlnJ at R.D.'3, Boll 1911,
Newport, Perry County, Penn.ylvanlA 17074.
4. On AUllllst 17, 1992 Rt 7:00 PM. the Plaintiff wll.lthe operator ot a 1982 Plymouth Te9
travel1lna EllIt on Market Street In the Boroullh ot West Falrvlew, Cumberland County, Penn.ylvanla,
II. At 7:00 PM on AUllllatl7, 1992, Detendant Charle. A. Wentael Will the operator ot a 1987
Ford ElICort belonilnll to Detendant KAthryn L. Wentzel which wll.ltravel1lna North on State Rollte 11-111
In the Boroush ot West Falrvlew, Cumberland County, PennsylvanIA.
6. At approximately 7:00 PM on Monday, AUIlUJt 17, 1992, Plaintiff Will drlYinllllllid Rutomoblle
EllIt on Market Street throUjlh the lnter.ectloll with Btate Route 11-11!.
7. At the aame time, Defendant WII.I trRvolU1lI North on Btate Route 11,111 and colUded with
the rlsht tront wheel and tender ot Plalntl/T'. automobile,
8. The traffic controlllsht at lhe inter.ectlon ot Market Blreet and Btate Route 11-111 WIll
operatlnll on AUllIIst 17, 1992.
9. At the tlmo ot tho collbllon, tho trRlllc IIllht wll.IllI'een tor the trRlllc on Market Btreet and
red tor the trRlllc on Btate Route 11-11!.
10, D.r.ndMt, Chari.. A. W.nt..I, WIU n'aIlpnt end reckl... In lh. operaUon of hit v.hle"
.. foUowl:
A.
B.
C.
D.
fallurll to operate th. vel:lcl. at a W. lpe.d;
failure to proper~ lUIute a c1.ar dlltance ah.ad while operalinl hll vehlel.;
I
failure to keep alert end I1IlIlnlaJn a proper lookout for other trame;
failure to ItOP at the red IItlht atlhelnteraecllon of Market Slreet end Slate Route
lH~;end
E. fallure to maintain proper controlln th. operaUon of hie v.hlcle,
11, At all tlm.. durln8 th. operaUon or the vehlele on AlJ8Ult 17, 1993, Chari.. A. Wenllel waa
IIIltln8 IU the IIpnt or th. owner of the v.hlcle, Defendant Kathryn L. Wenhel.
13. M a relult of the BCCldent, cauled lolelY by the n',llavnce and carele..ne.. of the
Derendant, Chari.. A, Wentzel, Pla1ntllT haI IU.Wned perlonalll\lurle. which include, but lII'e not limited
to, lublulUlllon of the lumber Ipine, chronic low beck peIn, deep referred Ie, peIn (vertebropnJc), mulUple
cervical vertebrae, contualollll, abrlUion~, and hematomu.
13. At the lime of the BCC\dent, PlalntllT WBI employed IU a truck driver ror A .. A Furnllure,
Harrlebl1l'l, Penn.ylvenlA, earnln8 U.OO per hour.
14. M a relult of the BCCldent, coueed solelY by the ne,upnce and CArIlI",ne.. of the
Defendant, Pla1nlllT has been unable to pursue III\Y JlIlnfuI employment.
10. M a relult or the BCC\dent, PlalntllThaI incurred relllQJlIIble and necelllll'y medical ellpenee.
In ripi'd to lhe personal Il\lurles referred to above,
16, M a relult of the BCCldent caused 10lelY by the Derendant'l neallJence and carel_
operaUon of hit vehicle, PlalntllT hall lualalned or Ill4Y au.laIn the foUowinll d.an1apI:
A, peat lIJld future 1011 or lIfe'l enjoyment;
B. peat lIJld Mure peIn and suJl'erlJll;
C. peat lIJld future mental anxiety, embarrlllllment, lIJld humiliation;
D. peat and future medical e.pensel; and
E. peat future lOll of earnln, capacity.
17. Plalnllll' avert that the daJnaael exceed the appJlcable Umltl of lII'bltration and a Jury t
II demand.d.
WHERF,JI'ORE, Plalntl/Trequell. yow' Honorable COllrt 10 nnd Ih. D.f.ndant lIabla to the Plaint
In 11/I amount In nceo of '26,000.00.
RelpectlUlJ,y llubmllted,
THE LAW OFFICES OF RON TURO
.~/;t1/7f
Date '
'"
.ft J.
32 South dtord Street
Carlille, PA 17013
(717) 246,0688
Attorney for Plalntlll'
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YERlFICATION
I verIlY that the ftlalernenl.ll made In the foreaol", Compllllnt lire true lIlld correcl. I undenlllnd
that flllH .latement. herel/l made lire eubJICl to the penalll.. of 18 Pa. C.B,A, Section 4904 r.Jatinl to
unaworn li1alJ\catlon to authorlll...
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IN THI COURT or COMMON P~EAS or CUMBERLAND COUNTY, PENNSY~VANIA
DAI.I S. BARIIlR I civil Action - lAW
plaintiff I
I
v.. I No. 634 civil au
I
CHARLlS A. WENTZEL and 1
KATHRYN L. WIlNTZIlL I
Defendant I Jury Trial Demanded
P~IlCIPIl FOR ~NTRY OF ~PPEARANCE PURSU~T TQ Pa.R.C.P. 1012
TO 'tHE PROTHONOTARY I
~indly enter the appearance at Robert A. Lerman, Ilquire, ot
Grittith, Strickler, Lerman, solymol , Calkin., aa attorney. tor
the Detendantl, Charle. A. Wentzel and Rathryn L. Wentzol, in the
above-captioned matter and mark the docket accordinqly.
GRIFFITH, STRICR~ER, LERMAN,
SOLYMOS , CALRINS
BYI
()
c..~c:l',}"'ItC) .~tJl..i)'~:v0
ROBERT A. LERMAN, ISQUIRE
Attorney tor Detendant.
Supreme Court I.D. No. 07490
110 South Northern Way
York, PA 17402
Telephone No. (717) 757-7602
Datel
~~qy
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UAI.E B. "ARDEIt,
I'laInlilT
v,
, IN 'I'm: COUR'r m' COMMON III,EAS
CUMllbllU.ANIl COUNTY, I'ENN/ilYI.vANIA
CIVIL AGI'ION . I.AW
NO. CIVil. 100.
JURY TRIAl. UEMANm:J)
ClfAlU,~:S A. WEN'I1.EI, .lId
KATtlltYN L. WENTZEl"
D.f.ndanl.
r.oMPI.AIN1'
1. PlaInllff, UnI. B. Ilatber, I. an .dulllndlvlduaJ currentl,y reeldlnll.t6311 North Eno/.a Drlv.,
Enoll, Cumberlond County, l'unn.ylvaIl1ll170~6.
~. Uuf.ndollt, Klllhryn I.. W.nta.l, I. OIIadull individual curr.ntly rllldlnlllll R.D. 13, BOI 196,
N.wporl, P.rry County, P.nll8ylvanla 17074.
II. Uef.ndant, Charle. A. W.ntael, I. an adull individual curr.nll,y rllldinll al R.O.IlIII, 801196,
Nawporl, Perry County, Penn.ylvanla 1707..
.. On AullUtl 17, 199~ al 7:00 PM. Ih. Plaintiff wu Ih. operalor of. 198~ Piymoulh TC3
lrav.lllnll Eul on Markel/illreetln lhe Borouah of Weel FlIirvlew, Cumberland Counly, Penlll)'lv'lIl1.
6. AI 7:00 PM on AullUtl 17, 199~, Defelldanl Charlee A. Welll..1 wu Ihe oper'lor ora 1087
Ford Eecorl belonalna to Oefendanl Kalhryn L. Wenhel which wu lraveWns North on Stale Houle 11-16
In the Boroush of Weel .'alrvlew, Cumberland Collllly, PenlllylvanlA,
6. At.pprollmalely 7:00 PM 011 Monday, AIIIIII.tI7, 100~, P1aIn1l1T wu drivlllll lAId ,ulomobile
Eul Oll Markel Streetthrollllh the Interaeclion with Btnte Route 11-16,
7. Atth. 88Ille lime, Oefendanl wae lr.velllnll North on Stale Raul. 11-16 and co\lld.d with
the rl8ht fronl wheel and fender of PlaInllff', automobile.
8. The lraffic control118hl .1 lhe Inlereecllon of Markel Stred and Stale /tI)ule 11-16 Will
operelillll on AIIIIII.tI7, 1902.
O. AI the lime of the coil~lon, Ihe traffic 118hl wee lP'een for Ihe traffic on Market 81rlll ond
red for the traffic on Btehl ROllte 11-16.
10. I>efundanl, Chnrlee A. Wenlael, WIIU nelllllle'll and rcckluN In the operation of hi. v.hlol
II followa.
A, failure 10 operalelhe vuhlcle .t . we lpeed.
D. failure 10 properly ...ure . clear dlallnc. ah.ad whll. operatln, hie v.blell,
C. fa1,Iure to ke.p B1ert and malnteln . prop.r lookout for olher lral1lc;
D, IliUurelo Ilop at Ihe red Uiht at the interMClIon of Mllk.t 81rllt an4 Slate Houl.
IHII,and
E. faUur. to mahllaln prop.r control In Ih. op.ratlon of hiI v.hlcl.,
11. At allllmee dllrlulllhe operation of Ihe vehicle on AUllU8t 17, 1002, Chari" A, W.ntl.1 WII
IlCtlnll .. the llJlent of the owner of the vehicle, I>efendant KAlhryn I.. W.nte.I,
12, Aa . rClult of tho accident, caueed eole\)' by the 1I.....nc. and carele..n'lI of lh.
Defendant, Char lei A, Wenhel, Plaintiff haa IUllalned perlonal huur!el which Include, bul are not IImlled
to, lubluxallon of the lumbar eplne, chronic low back pain, deep referr.d Ie, pain (verlebrorenlc), multlpl.
c.rvical vert.brae, contullon., abraalonl, and hemalomll.
13. At lhe time of lhe accident, Plaintiff WIllS employed u a truck driver for A " A Furnltur.,
lJarrllbur" Pennlylvania, earnin,'7.1I0 per hour.
14. Aa a rnult of the IlCcldenl, cauued .ole\)' by th. nellti,ene. Md car.leun'lI of the
Defendant, PlalntUT haa been uneble to pUrlue BIIY pInl\Jl .mploYlllent.
111. Aa II rOlult of tho IlCcldent, Plaintiff Iwlncurred reuollllblund neceuary m.dlcal,.pollee.
In reprd to the personaJlnjurloe referred to above.
16. Aa a rOlult of lhe accldenl cauued .ole\)' by the Defendant'. ne....nce and car.l...
operation of hi. vehicle, PblllltllT haa .ultalned or may .u.taJnlhe followln, daJnareli
A, plllt and l\lture 1011I of IIfe'l e"'oymenl;
H. po.t and l'uture pain and lulTerinl>
C. pIIt and l'uture mental Bllxlely, ombarrBIIlllent, and hwnlllallonj
1>. plllt IUld rulure medical e.pen.... and
E. Ilnel future 1011 of earnlnll cllpllClly,
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X. THI COURT or COMMON PLI~8 or CUNIIRLAND COUNTY, 'INM8YLVANXA
DALI I. nRI.., I Civil AoUon-La"
Plaintiff I
I
v. I No. 634 civil 1..4
I
CHARLII A. .INT.IL and I
aATHRY. L. .'NTIIL, I
D.fendan . I .JIII'Y TI'1.1 D..and.4
8TI'ULATIO. or cOUNIIL
Counsel for respective parties hereby agree to dismiss Kathryn
L. Wentzel from this lawsuit with prejudice. The caption may now
be revised to delete her name.
Defendant. CharleR A. Wentzel
remains a party to the lawsuit,
. MULDERIG, SQ.
Law 0 fice. of Ron Turo
32 South Bedford street
Oarlisle, PA 17013
(717) 245-9688
1.0. No.
HAEL B. SCHEI , ESQ.
Griffith, stri.ckler, Lerman
solymos , Calkin.
110 s. Northern Way
York PA 17402
(717) 757-7602
1.0. No. 63868
dko/1AEH
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
DALE B. BARBER, I civil Aotion - Law
Plaintiff I
I
VB. I No. 634 civil 1994
I
CHARLES A. WENTZEL, I
Defendant I Jury Trial Demanded
NO'J'ICE TO PLEAD
TOI Dale s. Barber
0/0 Robert J. MUlderig, Esquire
32 South Bedford street
Carlisle, PA 17013
You are hereby notified to file a written response to the
enclosed New Matter within twenty (20) days from service hereof or
a jUdgment may be entered against you.
GRIFFITH, STRICKLER, LERMAN,
SOLYMOS & CALKINS
"
Ill'
lWlrJ~ ~
~E T A. LERMA , ESQUIRE
supreme Court I,D. No. 07490
110 South Northern Way
York, Pennsylvania 17402
Telephone No. r (717) 757-7602
Attorney for Defendant
I'
, .
XN THE COURT or COMMON PLflAS or CUMBflRLAND COUNTY, PENNSYLVANIA
DALE S.' BARBER, I civil Aotion - Law
plaintif f I
I
ve. I No, 634 civil 1994
I
CHARLflS A. WflNTnL, I
Defendant I Jury Trial Demanded
DI..MDAHT CHAILI. A. .IMTIIL'8
IIIJIA WITH NI' ~TT.I 10 'LAINTI..'8 COMPLAINT
AND NOW, oomes the Defendant, Ch~rles A. Wentzel, by and
through his attorneys, Robert A. Lerman, Esquire and Griffith,
striokler, Lerman, solymos , Calkins, and responds to the
Plaintiff's Complaint as followsl
1.
Denied.
After reasonable investigation, answering
Defendant is without knowledge or information sufficient to form
a belief as to the trut~ or veracity of the allegations contained
in paragraph 1 of Plaintiff's Complaint and the same are denied and
striot proof thereof is demanded.
2.
Admitted,
contemporaneous with the filing of this
Answer, counsel for the respllctive parties stipulated to the
dismissal with prejudice of Ms. Wentzel from this lawsuit.
3. Admitted.
4. Admitted in part and denied in part. It is admitted that
the Plaintiff was travelling East on Market street in the Borough
of West Fairview at said date and time.
After reasonable
investigation, answering Defendant is without knowledge or
1
information eufficient to form a belief a. to the truth or veracity
of the remaining allegations contained in paragraph 4 of
Plail'ltitf'. complaint and the lam. an denied and etriot proof
thereot is demanded.
5. Admitted.
6. Admitted.
7. Admitted in part and denied in part. It i. admitted that
the Defendant's vehicle struck the plaintiff'. vehicle. After
reasonable investigation, answering Defendant is without knowledge
or information sufficillnt to form a belief as to the truth or
veraoity of the remaining allegations contained in paragraph 7 of
Plaintiff's Complaint and the same are denied and strict proof
thereof is demanded.
8. Admitted.
9, Admitted.
10. Denied. It is denied that Defendant Charles Wentzel was
negligent and reckless in the operation of his vehicle and that his
negligence and reoklessneos consisted of the following:
a. Failure to operate the vehicle at a safe speed,
b, Failure to properly assure a clear distanoe ahead
while operating his vehicle,
c, Failure to keep alert and maintain a proper lookout
for other traffic,
d. Failure to stop at the red light at the interseotion
of Market street and state Route 11-15, and
2
e, Failure to maintain proper control in th~ operation
ot his vehicle.
11. Denied. Atter reasonable investigation, answerinq
Defendant is without knowledge or intormation sutfioient to torm
a beliet a~ to the truth or veracity ot the allegatione oontained
in paragraph 11 ot Plaintiff's complaint and the same are denied
and striot proof thereot is demanded.
12. Denied. Atter reasonable investigation, anawerinq
Defendant is without knowledge or information suffioient to form
a belief as to the truth or veracity of the allegations oontained
in paragraph 12 of Plaintiff's Complaint and the same are denied
and strict proof thereof is demanded.
13. Denied. After r~asonable investigation, answering
Defendant is without knowledge or information sufficient to torm
a belief as to the truth or veracity ot the allegations oontained
in paragraph 13 of Plaintiff's Complaint and the same are denied
and strict proof thereof is demanded.
14. Denied. After reasonable investigation, answering
Defendant is without knowledge or information sufficient to form
a belief as to the truth or veracity of tho allegations oontained
in paragraph 14 of Plaintiff's Complaint and the same are denied
and strict proof thereof is demanded.
15. Denied. After reasonable investigation, answering
Defendant is without knowledge or information sufficient to form
a belief as to th~ truth or veracity of the allegations contained
in paragraph 15 of Plaintiff's Complaint and the 8ame are denied
3
and striot proof thereof is demanded.
16. Denied.
After reasonable inv8ltiqation, answering
Defendant is without knowledge or information suffioient to form
a beliaf a. to the truth or veraoity ot the alleqations oontained
in paraqraph 16 ot plaintitf's Complaint and the same are denied
and striot proof thereof is demanded.
17. Denied. paragraph 17 states a legal oonolusion to whioh
Defendant need not respond.
To the extent that', Defendant must
reepond, Defendant denies all factual alleqations contained
therein.
WHEREFORE, Defendants rlllspectfully requelilt this Honorable
Court to enter jUdgment in their favor and aqainst the Plaintiff
together with costs of this lawsuit.
BY WAY or rURTHER DErENSEI
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NI. MATTia
18. paragraphs 1 through 17 of Defendant's ~nBwer are
incorporated herein as though fully set forth at length.
19. Plaintif.f's recovery, it any, shOUld be barred or
diminished by plaintiff's contributory and/or comparative
negligenoe.
20. plaintiff's problems pre-existed the motor vehicle
accident with Defendant,
21. Plaintiff's injuries, if any, are caused by third parties
over whom the Defendant had no control.
4
},
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
DALE S. BARBER, civil Action - Law
Plaint! ff
VII. No. 634 Civil 1994
CHARLES A. WENTZEL,
Defendant Jury Trial Demanded
CERTIFICATE OF SERVICE
AND NOW, this 5th day of April, 1994, I, Michael B. Scheib,
Esquire, a member of the firm of GRIFFITH, STRICI<LER, LERMAN,
SOLYMOS , CALKINS, Esquirfils, hereby certify that I have, this date,
served a oopy of Answer and New Matter of Defendant to Plaintiff's
complaint, by United States Mail / addressed to the party or
attorney of record as follows:
Robert J. MUlderig, Esquire
32 South Bedford Street
carlisle, PA 17013
GRIF'FITH, STRICI<LER, LERMAN,
SOLYM 'CALI< N
BYI
MICIAEL ESQUIRE
Supreme Court I,D. No. 63868
110 South Northern Way
York, Pennsylvania 17402
Telephone NO,I (717) 757-7602
Attorneys for Defendant
vda/1ACE Jl
..
IN THE corJRT OF COMMON PLEAS OF CUMBERI~ND COUNTY, PENNSYLVANIA
DALE S. BARBER, Civil Action ~ Law
plaintiff
v.. No. 634 Civil 1994
CHAALIlS A. WENTZEL/
Defendant Jury Trial Demanded
CERTIFJCATE OF SERVICE
AND NOW, this 11th day of April, 1994, I, Micha~l B. SOheib,
Esquire, a member of the firm of GRIFFITH, STRICI<LER/ LERMAN,
SOLYMOS , CALI<INB, Esquires, hereby certify that 1 have, this date,
.erved Defendant's Interrogatories and Request tor Production of
Dooument. to Plaintiff, by United States Mail, addre..ed to the
party or attorney of record a. followsr
Robert J. MUlderig, Esquire
32 South Bedford street
Carliele, PA 17013
BYe
GRIFFITH/ STRICI<LER, LERMAN,
riOS , CAL~~
HI AEL B. SCHEIB, ESQUI E
Supreme Court 1.0. No. 63868
110 South Northern Way
York, Pennsylvania 17402
Telephone No.1 (717) 757-7602
Attorneys for Defendant
"
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VERIFICATION
I verlt)' lhat the llalentenll mllde In the fore8111na AMwer 10 New MaUer ar. true and CClrrect. I
W1d.r.tand lhal Wee llalemenll herein made are lubjecllo the penallllll of 18 pa. C.S,^, Secllon ~
r.lallna to WIIworn l'aIeUlcallon to aulhQrlllel.
..,/... /5"- "l'-/
Date
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1. Pl.... .t.t. your full n.m., .9. .nd pre..nt .ddr....
Dale Stanley Barber, 533 N. 8nola Drive, 8nola, PA 17025
Aq e I 39 (Da too f 13 i r t h I J u 1 y 3, 1954 )
(.) Hav. YQU .v.r u..d or b.en known by .ny other n...?
If .0/ pl.... .t.t. e.ch oth.r n.m..
No.
(b) How 10n9 h.ve you liv.d .t your pr...nt .ddr...?
39 years, 10 months
a. What i. your pre.ent occup.tion?
Unemployed.
(.) Li.t the nama and addr... of your pre..nt .~ployer/
it .ny.
N/A
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(1) D..oribe the .p.oifio nature bf your ..plo~.nt,
duti.. and re.ponsibiliti...
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e. Giv. the n.m.. and .ddr..... of .11 ho.pit.l. wh.r. you
h.v. been .ither .. an in-pati.nt or an out-patient during the t.n
(10) ye.n prior to the accident cOlllplained of and, a. to e.ch
hospit.l, Cilivll
(a) Dates of admi..ion and di.charq.,
Harr.i.6burg Hospital (out paUent), South pront st., Harrisburg, PA
06t.eopathic Hospital (olH patient), 4300 l,ondonderry Rd., Harri6burg, PA
(b) Nature of the ailment or illne.. for which you were
ho.pitalill8d,
Torn cartilage to left knee (out patient t.reatment)
9. ot your own knowledge, what injuries did you receive in
the aooident involved in this oa.e?
Damage to cartilege in four vertebrae of lower back, damage to cartilege
in one vertebrae of the neck, and aggravated left knee.
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10. Of your own knowllldge, 1 ilt any perJllanent .c__r.,
dilfiqureDlent8, dieablliti.. Clr di8cClDlfClrt. qrowing out of the
within acoi4.nt.
Discomforts aB to injuri~B atated in question 9.
11. Of your own know1edqe, pl.... .et forth the .xact nature
of aU oth.r pr..ent phyaical cODlp1aintl which you alleCle are
attributable to the injuries which you received in the accident
involved in thi. case.
Aggravation of prior injury to left knee cartilege.
12. If you have been hospitalized by reasons of the aocident
her.in .ued upon, list the names and addresses of all .uch
h08pitall, clinics, or other Dledical institution. in Which you were
a patient a. a r8lult of this accidsnt, giving the dat81 of
confinement and the .um. of money paid by you or on your behalf,
or owing to each for .ervices to you.
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N/A - Never hospitalized, all therapy/treatment done on out patient
statuB.
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13. Pl.... ..t forth the full n.ma and addr... of ..oh .nd
.v.ry dootor or oth.r m.dic.l par.on who haa .tt.nd.d or .xamin.d
you .a . r..ult of the within accid.nt, .nd the auma of mon.y paid
or owin9 to ..ch tor ..rvic.. to you.
eal Li.t tha dat., month, and y.ar of .ach axamin.tion or
att.nd.noe by .aoh auch dootor or medical person.
See attached.
,f
14. on what date did you lut work prior to the acoident
which i. the .ubject of thi. litigation?
August 14, 1992
15. If you have returned to work, either on a fUll-time or
part-time basie, when did you return and atate whether the return
has been to full-time or pa~t-time employment.
Plaintiff has been unable to return to work due to lnjuries received
in accident.
14
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U. Sp.oUioaUy, what amount ot time have you lost; from your
r'9ular plao. of .mploym.nt a. a r..ult of this aooid.nt, fro. the
date ot .aid aooid.nt up to and inoludinCJ the pres.nt?
119 week II
17. EXaotly how muoh inoom., it any, do you olalmto have
lOlt to date a. a relult of the within aooid.nt?
$26,700.00
(a) It you have lost time trom work, pl.... ..tate the
number of days and qive the exaot date, month and year of eaoh day
lo.t.
(1) the amount of said 1088' and
(2) the method of oalculatinq said 10as,
(3) the facta upon which you rely to ba.. your
oaloulations.
89 weeko. of employment were lost, from the date of accident,
August 17, 1992 until present. Plaintiff made $7.50 per hour
and worked a 40 hour week,which multlplled by 99 weeks total
$26,700.00, wlthout pay raLf~s, time Off, vacations, etc.
'"'"
,.....
(a) The name and la.t-known addre../
(b) A detailed de.oription ot the relevant flct.
known /
(c) Whether written or otherwi.e recQrded .t.tement
ha. been taken, and, it .0, the name end
addre.. of the per.on taking the .tatament
and the per.on in pre.ent cu.tody of the
,
.tatement /
(d) If you will do 80 without a Motion to Produoe,
attach a copy of each .tatement to your
Answers to these Interrogatorie..
Steve Mickloff, 446 3rd St., Weat Palrviuw, PA 17UZ~ - wltnuB8 to accident.
Brian DaVidson, 510 Water St" New Cumburland, PA - wItness to accident.
Officer J. W. Herman, W. Fairviuw Pollce Chi..! - Inv..utlgator of actident.
::12. stat.. the nil me I addu.., ocoupation and field of
apeeial hation, if any, or o/ulh pOrion whom you exp.ot to oall a.
IIn expert witne.. lit trill), nnd atat.e ft. t.o eaoh the .ubjeat IIllltter
on whioh the expert i. expected to te.tity.
Decision as to what "Xlil.ttn will t"nllry ,It ttllll hllfl not been made by
counsel as of yet, but t.hln IntPIIIl'/lllory 'lll"ntl.on will be updated when
the decision ia madE!.
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3~. Set torth the qualiticationl ot all thole per.onl lilted
in the An.wer to the preoeding Interrogatory and in doinq .0, a.
to each expert, lilt I
fomal educaticm, the lohool. attended,
including year. of attendanoe and degree. or certitication.
received, experienoe in particular Ueld., inoluding name. and
addre.ses of employers with inolusive yeau of employment and
pOlitions held, teaohing positions or other aftiliation., and a
list of all publioations authored by said person., inoluding the
title of the work, the name of the periodical or book in which it
was printed, and the date of its printinq. (In lieu of anlwering
this Interrogatory, please attaoh a oopy of eaoh expert'.
currioulum Vitae or resume.)
NIA.
34. (a) Set forth the faots to whioh eaoh expert you have
listed is expeoted to testify,
(b) Set forth the opinions to whioh each suoh expert
is expected to testify.
Experts will testify to the extent of Plaintiff's injuries due to
the accident in August, 1992, including but not limited tOI
diagnosis, treatment, future prognoBis.
18
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(f) state whether there are any provilion., .uoh ..
medioal pay olau.es, fir.t party benetit., uninsured motorist'.
oov.rage, underinsured motorist's coverage, or other insurance
payment provi.ions, whioh will provide b.netit. to a party injured
by your vehiole and .et forth any oonditions, exolu.ion. or other
relevant term. oonaerninq .uch additional benetits, includin9 the
amount(.) ot ooveraqe,
(9) The number ot vehiole. covered, it applicable.
(h) Your legal domicile at the time in.uranoe wa.
applied tOrt
(i) Your legal domioile at the samB time eaoh pOlicy at
in.uranoe (or any endorsement thereto) was issued,
(j) Did you eleot tull tort option or 11mi ted tort
option?
(f) See attached insurance policy.
(g) one
(h) Plaintiff did not apply for insurance
Ii) see answer 261h)
(j) Bee anBwer 26(h)
27. Ha. the insuranoe oompany or oompanies involved railld
any iI.ue a. to your coverage tor damaqes arilinq trom the
atoresaid aocident? It so, please set torth in detail the basi.
tor suoh i..ue, reservation ot right or denial ot ooveraqe.
Yes, General Accident Insurance Company terminated coverage after
$5,000.00 limit.
20
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42. All dooument. prepared by Plaintiff, or by any in.urer.,
repr..entative., agent. or anyone aQtinq on behalf of plaintiff,
.xcept hi./her attorney., durinq an inv..tiqation of any a.pect ot
the incident in qu..tion. Such documenh .hall include any
docum.nt. made or prepared up throuqh the pre.ent time, with the
excludon ot the mental impre..ion., conclu.ion., or opinion.
re.p.otinq the value or merit ot . claim or deten.e, or r..pectinq
.trat.qy or tactice.
(NOTEI A. reterred to herein, "documents" include. written,
print.d, typed, recorded, or qraphic matter, however produced or
reproduced, inoludinq oorrespondenoe, teleqrams, other written
oommunioations, data processinq storaqe units, tapes, contract.,
aqreements, notes, memoranda, analyses, projections, indices, work
paper., atudies, reports, surveys, diaries, calendars, filma,
photographs, diagrams, drawinqs, minutes of meetinqa or any other
writinq (includinq copies of the foreqoinq, reqardless ot whether
the parties to whom this request is addressed is now in the
posl.ssion, cUltody or contrcl ot the ori9inal) now in the
poa..saion, custody or control of Plaintiff, his/her tormer or
prel8nt oounsel, aqents, employees, officers, insurera, or any
other perlon aotinq on Plaintitf's behalf.)
None at this time. Police report previously forwarded to,counsel.
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46. If you Ir. maintaininq a olaim for impairm.nt of ..rninv
cap.oity, pl.... prc~uo. oopi.. of your r.der.l inoom. t.x r.turn.
for p..t .ix (6) y..r..
please see attached.
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46. ~l.a.. pr04uo. your w-a (WaV. a~d tax .t.t...nt.) for
the paat aix (6) yeara.
Please see attached.
47. ~roduo. copi.. of all trial exhibit.,
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None at. this time.
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DIA N08111r
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'AY"INT '8 DUI UPON ft CllPt OF 1HI. STATfHF.Nt,
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TO YOUR INSURANCE CAR IER
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HOl Y SPIRIT HOSPITAL
501 tmnw 21ST SrnEET
CAM" HILL. P^ 17011.2288
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EMPLOYER I
ADDRESS.
CHURCHI
NAHEI
ADDRESS I
NAME I
ADDRESS t
C~tt'IIL~: p[~aIS';'LVAN'I~" '1701~
~. EMERllENCY. '-ORH
P~TILNT INFORMATION
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8~RBER ,DALE
&33 NORTH ENOLA OR
07/03/19~4 AGEl
~N~ FURNITURE
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IIU-38-2111
111-132-4&51
OEOI 041021
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CHRISTIAN HISSIONARY ~LLIANCE
Ptl "1 111-232-&'''0
EHERGENCY CONTACT INFORMATION
DANNER ,BEVERLY REL TO PT, V WORK PH 1#' 111-732-4&61
&33 NORTH ENOLA OR IENOLA /PA/l7025 PH ". 1 17-132-4&&8
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PH 1#'
CASE INFORMATION
181057 SPURRIER DAVID MO REG SOURCE, EO PAflENT TYPEI E
IBI051 SPURRIER DAVID MO HOSP SERV, ECU FINANCIAL ClSI T
151412 TOCKS ~ONATHAN MO VISIT CLINIC COOEI Eeu ROUT
ICO-9 DX.
ADHIT llR I
ATTNO DRI
REf'ER DR I
ADH IT OX I
COMPLAINT. HVA
AHB BRT IN BYI
LOWER BACK
BRT IN BYI GIRLfRIEND
ACCIDENT INFORMATION
OATE/TIHEI 08/11/92 19'15 ACC IND. A JOB RELATED. N
DESchlPTIONI HVA DRIVER WAS WEARING SEATBElT
NAHE.
ADDRESS I
EHPLonR I
ADDRESS I
DALE BARBER
533 NORTH ENOlA OR
ANA FURNITURE
PLAN I NSURANCE CO
SUBSCRIBER
II Hili AUTO INSURANCE I/O
DANNER . BEVERl Y
12
13
14
HEDICARE SECONDARY QUESTIONS I
HEDICARE SIGNATURE ON rlLEI
COMMENTS I
tOAlE
LOCATION.
GUARANTOR INFORMATION
PT REl TO GUARI 5
IENOI. A /PA/I 7025
CONTACT NAME.
1//
55"1 181-38-2121
PH 1#1 711-132-45&8
PH ,. 711-232-&640
INSURANCE INFORMATION
COB POll CY , GROUP ,
REl PC VFY MA CONTRACT NUMBER
RPA562341B3
V Y
INIT IAlSI
PRECERT II
PRECERT 21
PTII'
~(),'I':,U;:JIC.".':E _'_
?r~"~l ;~' OR -"~I-'It"'I'" 1-/cl1":i"('- RC"'-'S-
_.'\,11.. " '~r.I"\'1l .....'" I.) (')dll.:'" ..~~~.f\ t. ,
.-
I lI.reby AUlllonz=: D~. __ .l~2_ and wnomne/' bellhe moy dullnolll U
hli/hor' O.uISlIllll!' 10' reooe.. all pro Ourel llld.. IUch.: Ireolmen! as II DeceUlry.
J: H!!R.e.B.'t: ^UTHOR1Z.E: P.~ YME'Nr directl)- ",' Holy' Spirit HospilAL oC Ihe- 1I0lpllol Inluronce benefTls'
ol.b.J:Wise paYlble: 10" roe but DOC IO! exceed. Ihe bllance: dll.. 01 th.. provld~r'1 re,ulor clllrles for
1111.. period. ot. bOlpiLl.llu!io/r- L ulldemaod. l: am; fllla.nclall~ re$pOllslble: 10, Ihe bOlpllaL ror,
,ebll.lpS'J nOl: cove~cI:. b~' Ibis: lulllorluliQlT_ , '
r. RER.E!tY ^UTHOflIJ'" PAYMENT' dlrec!ly- 10: Ihe- above- DlII1ed: physle!u!: ror medlCQL beneITls
olbefWise= payable: 10; l:1e but OOt 10: uceerl: Ihe balLOce due- of the: provldet'. re,ular chules (or
Ihls' p.erlCld; of.. bOlpil:.lizotiol!_ 1- u.nde:m.nd I am: flnancially re$llonslblc- 10 Ihe- physician for
chorres: nOI covered b)- Utis: 11ILhoriz:lIjOD~
I HERE3 Y AUTHORIZE.
hospluU. ann: .s.i s.
SI,QQIUrll:
Relotion: 10 PolieO[:
RELE'..I,SE OF INFORMATION 10
clolm _
, .~e:-'r-.-
~ --
insurance cornpnnier (or Ih.. completion ,of
Wltne.ss:
~-
8:/7- 9)_
Date:
.. .. .. 'r -.. .. .'
... -~ST,\.TEMrnr TO PERMrr PA YMEi'I"r Or MEDICARE. BENEFITS
TO PROVIDERS~ PUYSICIANS AND PATIE.i''\'T'
DATE: _
MED[CARE NUMBER:.
'.
.
SI ON" TUItE.:'
1 requeSl payment or Authorized. Medic:.r.. benerlu 10 me or 00 mv behDIr for anv servlees
furnished. me- by or in' Holy Spirit >>0$91131. Including physicion services, I authorize iny bolder
of D1edlcCll and O!ber inCormltion about Ole, 10 release to Medic:.re- and its arents ally fn(onnQllon
needed 10 dctermlne these beoellu (or related services,
HOSPITAL BENE..9TSfPA.RT A1F~F. DATE:
MEDICAl. BENEFITSfPART Bltn, DATE:
.. . '.. . ... ,. '.
RELEASE AGAINST MEDICAL ADVICE
This Is 10 cer;l{v thBl r.
Hospil:.J: am Ic:~lnr the bOSDIt:1 aloinst lne
ond the ~ominlstrallon. I hlYe been iniormed
end lhe 110S0ltol (rom :11 res90nlibilil:/,
, 0 patienl "I Holy Spin:
~dvlce oi Dr, ,
oi Ihe rilk involveD ond bereo:, release the doc:::
~ I."....t",..
.. 9"" .. ...
--------------...--...
Time:
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~ :::0: :';t:
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'vimel!:
;..,:.
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. ,
., ~n.Y IlPIRIT t<<l5P1TAL ~
~T~NT CJ' RAOIlUlGY AM) DIAG~..C IHAGING
CAMP HILL1 PENNSYLVANIA 17011
(7 7) 71.3-2"00
. .
.
PATIENT, BARBER, DALE
m. 12""7'
sac 8lC, 181-38-2121
CAD OR., 5MRIER, DAVID
PT TYPE. E
ADH OAT! 08/17/1'''2 0?r48PH
LOCATllJI ECI}
--.----- -------OICTATIljfDATE'. 08/1611'''2
TRANSCRIPTION OAT~ 08/16/1"2 IOr02AH
I
ARRIVAL OAT!,
HOSP SERVICE I ECI}
I"
EKANINATllJI. LUM6AR SPINE (bV)r
CCJf1F.NTS, Thltrt, arlt s t ~ 11Imllar tyre vertebrlll bQdll!!~ vi th rUdimentary r Ibe
.t TI2, Thlt supltrlor most lumbar typlt vertltbral body vl'I be 'abel,d TI2
for this It~am.
Thltrlt Is mt ld narrovlng or the L5-51 I ntl!!rvertf1br. I disc SPOCIt. The
rllm,'nlng disc sp.cn appear normal. Thpre Is mlnlmlll hYPltrt.rophtc: bony
spurrIng anterIorly and posterIorly at LA ilnd LS, The posterior ell/menta
are Int.ct, Thlt 51 Joints appltar normal.
CONCI.lJSllJI, HI IrJ narrovlng at l.S-SI I' prlllent, Ploast lltlt dlacunlon
abovlt,
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DAn: OF !KAN. 08/1711"2
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HOLY SPIAIT HOSPITAL
CAMP HILL, PA
EMERGENCY DEPARTMENT
PHYSICIAN ORnER FORM
PATIINI CLASSIfiCATION
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september 17, 1992
REI BARBr.R, Dalo 8.
~33 N. Enola Drivo
Enola, "^ 17025
AGEl J8
8S" 181-38-2121
I,
STUDYl HRI of \",ho lumbnl" flpille.
REFERRING PIIYSICIMII Jonnthnn Tocko, H. D.
CLINICAL III STORY I I,ow bnck pain, r icJht foot t)umbneslf.
HRI PULSE SEQUENCES' 1, Tl, T2 nnqittnl
2, Tl, HPaR axiol
fooal area of
endplate of T12
[,umbnr vertebrae ore of normal .i9nll
Jntt'lIsity, he19ht and n1Jqnment. There 1. .
inonaoe" signal intensity within the inferior
oonsiotent with a hemangioma.
COMMENTS I
Th. L!I-Sl diso hillS decreased signal intensity consistent with
d.qeneration and dehydration. There is a diffuse annular bu1ge but
no evidence of focal hernliltion. The 81 roots are well d.lineated
without displacement. '1'he 1,5 roots are norDlal. Faoet joint
hypertrophy is noted.
At L4-!I tho diso is daqenr.rative with a more prominent diffuse
annular bulge indenting the thecal 000. There is no evidence of
focal herniation in the I,~ roots and neural foramina are normal.
Mild facet joint overgrowth is noted.
At L3-4 the disc is degenerntive nnd dehydrated with a mild diffuse
annular bulge slightly illdelltlng the thecnl sao. There is no
evidence of fooal disc h{>rnlntion. Tho remaining lumbar disos show
moderately qood hydration with the exception of early dehrdration
of the LI-2 diso. There is no evidence of spinal stenol.. Th_
conus and ellluda equina are normal.
CONCLUSION I
herniation.
Degenerative bulging L3-4, L4-!I IlInd L!I-Sl
discs. tlo evidence of discrete fooal d18d
\, J II
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F~d Idontl 2J 2489J25
rot Idontl BARBD1\
TheroplBtl ERIC r MCCUEN P T
PhYBlclonl JON^TIIAN B. 'fOCI<S,M.D.
DlagnoBlsl 847
arMHIfl & STRAINS - PARTS Of' BACI<
PI
"
MCCUEN .. ASSOCII\1'E!l 1"1'
20~ GRANOVlf.W AVENUE
CAMP HILL fA 17011
737 737 9818
DALE S BARBER
5J3 N ENOl,A, DRIVf.
ENOLA, 1'1\ 17025
>
S'I'I\'i'F.MF.N'I' OF flcCOI.lN'I'
fill I\ctlvlty 1~rouqh 10-IJ-1992
_._-------------------------------'------~-----------"--~--------~------------
Date Type DeRcr! pt I on Amount
--~--------------------------------------------------------------------------
9/01/92 97010 1I0T/COLD PI\CKS/ICE MlIBBI\GE 16.00
97124 MlIBSI\GE 20.00
97128 1'111 MED W/U,s. 20,00
97720 EX1'Rf:MI'I'Y '1'F.S'I'ING 30.00
93020 LUMBflR flOLl, 14.00
9/02/92 97010 1I0T/COW PM~KS/ICE MlIBSflGE 16.00
97124 MflSSflGE 20.00
97128 1'111 MED WIll,S, 20.00
9/03/92 97010 1I0T/COLD .'I\CI<S/ICE MflSSI\GE 16.00
97124 MASSI\GE 20.00
97128 1'111 MED W/U,S. 20.00
9/04/92 97010 1I0T/COLD ~I\CI<S/ICE MI\SS^GE 16.00
97124 Ml\sSAGE 20.00
97128 1'111 MED W/U,S, 20.00
9/08/92 !HOI0 1I01'/COLD PI\CI<S/lCE MflSSI\GE 16.00
97124 MASSI\GE 20.00
97128 1'111 MEll W/U.S, 20.00
9/10/92 97010 1I0T/COLD .'I\CI<S/lCE MflSill\GE 16.00 '
97124 MASSI\GE: 20.00
97128 I'llv' MEll W{U,G. 20.00
9/23/92 97014 EI,ECTRICI\, S'l'IMlJLI\TIOH 20.00
97124 MI\SSI\GF. 20.00
97128 PilI MF.ll W/U,s, 20.00
97720 EXTREM1'I'Y TESTUlG 30.00
9/25/92 97014 EI,ECTRICI\I, S'l'IMlJJ.1\1'ION 20,,00
97124 MASSAGF. 20.00
97128 1'111 MED W/U,S, ao.OO
9/28/92 97010 1I0T/COLll .'I\CI<S/ J,cf; MMlSI\GE U.OO
97124 MASSI\GF. 20.00
97128 PilI MF.fJ Will,S, 20.00
"
, '
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P.
D~LI 8 BARBER
statement continufld From prevloul PI
-~--------~---~"--*---------------------------------~-------------------'~----
______________"_______________~__________________________~______________w____
Dlta
Type
Description
Amount.
"30/92
97014
97124
97128
97010
97124
97128
97014
97124
97128
9.,014
97124
97128
B,.lftnce Forward
ELECTRICM, IlTIMUL,ATlON
MT\SSAGF.
PII'1I HED W/U,S,
1I0T/COLD PACl</l/ICE MASSTlGE
MT\SBAGE
1'11'11 HED W/U.B,
F.LECTRICAL B1'lMUL.ATION
MASSAGE
PII'1I HED W(u.s,
El,EC'rRlCTI , flTIMUL,ATION
MASSAGE
PII'1l HEll W/U,S,
586.00
20.00
20.00
20.00
16.00
20.00
20.00
20.00
20.00
20.00
20.00
20.00
20.00
10(02/92
10/07/92
10/09/92
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September 1, 1992
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Jonathan B. Tacks, H.D,
4470 Valley Road
Enol., PA 17025
REI Dale Barber
DXI ~ow Back atr"in SIP HVA
Dea/: Dr. Tocksl
Hr. nale Barber is a 3D-year-old male who w~s initially evaluated
at our camp Hill ottice on Septemb~r 1, 1992, with complaints of
pain in the lumbar aren radiating into the left buttock and
posterior thigh. He stated his pain initiated following a moto/:
vehicle accident all August 17, 1992, At that time, he was taken to
Holy Spirit tlospital and x-rays were taken, tie wall given pain
pUla and was discharged from the hospital. tie waa followed-Up in
you/: office. tie stated he initially saw you approximately one week
following the motor vehicle accident and at that time medication.
w.r. /:e-ordered and he was put on bed rest, tie was seen in your
office again on August 31, 1992, and at that time physical therapy
was ordered. He stated th~t tho pain started in the center of the
back .nd is now lipreading down the left lower extremity. He .tate.
pain i. intermittent and staying at the same level. Bending over,
liftinq hie legs and prolonged sitting aqgravatllB his pain whUe
laying on his stomach, walking and archinq his back eases hia pain.
He .tated that the pain does not wake him during the night and he
feels good when first rising In the morning. His paln t.hen
increases as the day progresses, and the evening is the worst time
of the day.
Object! ve findings show Hr, Bar.ber ambulated with an extremelY
9uarded gait. His sitting attitude was protected and he .at on his
left buttock. Lumba/: ROM W/l!!l extremely limited and was as follow.1
flexion limited in 90\ of the range and painful I extension limited
in 1e' of the range and painfull right rotation and left rotation
limited in 7lU of the range and painful I right side bendinq was
limited in 90' of the range and painfull lert side bendinq was
limited in ?!l' of the range and painful. straight leg raile on the
left was limited to 60 degre'llIl and produced leg and blck pain. Leg
lengths Were equal in llupl,ne llnd lon'll sitting. His sitting posture
showed him to have a good lordosis; however, he had a left lateral
shift, This left lateral shift lllso was shown in his standing
posture. His ROM of both lower extremitles was within normal
lim! ts. He had decreased strllngth in both lower extremi Ue.
s.condary to pain. On palpation, ha was tender in the para lumbar
musculature bilaterally with an associated IIp8llm. He w.. also
tender over the spinous procll!Ises of Ll-!l.
McCt"Jr1 &. A"'lrk:lflr." "l'f1'lrA' Yhet'8fJV. ".c
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september 16, 1992
Jonathan B. Toc~., M.D,
4470 Valley Road
Enola, PA 17025
Rt:l Dale Barber
DXl Low Back strain SIP MVA
Dear Dr. TOC~SI
Hr. Dale Barber is a 38-year-old ~ale who was initially evaluated
at our camp Hill office on septe~bflr 1, 1992, with complaint. of
pain in the lumbar ar~a rAdiating to the lett buttock and posterior
thigh. He stated his pain initiated following a motor vehicle
accident on August 17, 1992.
He initially was started on a treat~ent pr09ram consisting of cold
pack in prone, to llowed by ultrasound, mAsBllqe and therapeut ic
exeroise. He was started on extension exercises, He received two
treatments of this, and on his third treatment on september
3, 1992, he stated that h& continues to have significant pain. At
that time we added in shifting exercises, which centralized his
pain, followed by prone on elbows, We discontinued the prone
pre.s-up.. At Dale'S treatment on september ~, 1992, he stated
that. he felt improved tollowing his treatment! however, it only
last.ed approximately two hours and then his pain returned. He
Itated that the extension exercises were aggravating his pain. At
his treatment on september 4, 1992, we discontinued extension
exerehes and kept him on lateral shifting exerches. At that time
his lumbar ROM continued to be decreased! however, it had improved
from his initial evaluation. Lumbar ROM at that time was all
follows: flexion llmi ted in 80' of the range and painful!
ext.ensioh limited in 50\ at the range and painful! right rotation
limit.ed 50' and painful; left rotation limited in 25' of the range
and painful/ right side bending limitEld in 75' of the range and
painful/ left side bending limited in 50\ ot the nnqe and painful,
Dale'S next treatment was on September B, 1992, and he stated that
he felt better and that he had rested over the weekend, He stated
that the pain was intermittent and was coming less freqUently. At
that time, we started him on flexion exercises! as the extension
exercises continued to IIggravate him, His las\: treatment was on
September 10, 1992, and Ilt that time he complllined of some numbnesl
at the outer border of the right toot. At that time, we held off
on any exercises and he stated he was qoin9 to call your off ice
regarding the foot numbness, He returned a call to our department
on Sept.ember 11, 1992, and stated that his physical therapy had
been discontinued at your request, ,
McC..." /l. ""..,...IIt.... """,'e'" Th...."", PC
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Jonathan B. Tack', M.D.
4470 V.ll.y Road
Inol., FA 17025
REI Dalo Barb'r
OXI Low Back Qtrain S/
O.ar Dr. Tock.1
Mr. 0.1. Barb.r r.turn.d to our phy.ical therapy d.partm.nt at our
Camp Hill offic. on September 23, 1992. Hi. phy.ical tharafY had
be.n di.continu.d on September 11, 1992, due to numbn..s nth.
right foot. H. .tat.d he had an MRI on Sept.mber 17, 1992, and the
r..ult. w.re negativ.. H. had a follow-up visit in your offic. on
Sept.mber 18, 1992, and at that time physical th.rapy was
r.-ord.r.d. prolonged sitting and bending over aggravate hi. pain
whU. laying flat and his pllin medication uus hil pain. He iI
rating hi. pain a 4 on a scal. of 0-10 in tha lumbar area.
Obj.ctiv. finding' .how Mr. Barbar continu.s to ambulate with I
guard.d glit patt.rn. Lumbar ROM was as follow.1 fl.xion limit'd
in gO' of the range and painful, .xt.nsion limited in 75' of the
rang' .nd painfui, right rotation limited in 75' of the rang. and
painful/ left rotation limited in 50' of the rang. and painful/
right .id. b.nding limit.d in 90' of the range and painful/ left
.id. b.nding limit.d in 15' of the range and painful, straight l.g
r.iI. w.. limited to 50. bilat.rally and produced back pain. ROM
w.. within normal limit. in both lower extr.miti.s. H. had
d.cr....d .tr.ngth throughout both lower .xtr.miti.a ..cond.ry to
pain. H. w.s v.ry t.nd.r in the paralumbar musculature .nd ov.r
the .pinou. proc..... of L3, L4 and L5.
Initial tr.atm.nt consisted of moilt h.at with int.rferrential
.t1\11ulat1on, follow.d by ultrasound and m8lug" I did not
In.truct Mr. Barb.r in any ex.rci.es at this ti~e, but pl.n to .dd
ex,rei... wh.n hi. pain decr.a.... We did revi.w proper po.tur..
I pl.n to ... Mr. Barber three time. a w..k for four w..~. for the
above tr.atm.nt. Goal. are to decrease pain and return him to hi.
pr.viou. functional abilitie..
Thank you for r.f.rring this patient to our ..rvic.. If you have
any qu..tion. or furth.r recomm.ndation. conc.rning hi. ear., f..l
fr.. to contact our office,
Sincerely,
Haure.n Donahu" P.T.
HDI..k
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HEALTH INSURANCE CLAIM FORM
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OUT'ATJIHT 'NYI10AL T".~'Y
laok Ivaluatio. 'o~~
"
HI..e.
Dale lubu
Dlttoe
10/11/"
Age.
II
.1
I
Dla9noa1ae
I'hydchne
Occupation.
ohronlo llllllbar atrain
D~. Good.ln
A , A Furniture
site of pdnl
In lIotor vehlole looident,
pltlent hit on ri9ht aid,
Oentral loW baok to down l.ft Ie,
flow Oocurred I
81 Date of onaot. '/17/'2
Sur,erye
X-rays I
CAT Scanl
Len kn..
Holy spirit
MRII
On blak
MIA
Hylllogrllm I
HI'"
oth.rl NIA
I'aat Medlcal HistorYI Hon-.l9nifiaant, l.ft knee hlatory. al9nlfiolnt for
loopea/torn olrtlle,e
Rate palne
o
1
II
,~ ~Cb~
("!'" 4 II .
'-.!'~
..J.nte.naJ.~ con.tent.,
~d of 4ay neltber
(circle one)
~.
No
(oircle one)
.
10
since Ona.t Pain Hasl
11 pain conatant? y..
Worae atl be,lnnln,
H/A? No Where? N/'"
Moat Comfortable positionl Lyln9 on beak
L.a.t Comfortable positionl Ben41 Ilt to Itand
What , the pain? lit, trlnlfl~1
Whit . th. pain? vloodln, .oht heat
Do.. paln AWlken You It Night? Y.a
Do.a Plin , with Cough? YII Snoo..? re.
00 you have problems with Bowel? No
Lower Extremity 'aln? Left low.r. IlItre.ity
M.dicltionsl "aproayn, vloodln
Any support.? Luabar ou.hlon
I'reviou. RlCT Mocuen
I'raviou. Back Problema? Hon.
l'atient'l GOl181 "'a in fre.," "R.turn to work"
01 Po.ture I rorward hll", flit blok
AIlH1. Trunk I Q.!all.t.lli (em or degrees) oualH:v
FD 0 - 20'
D8 0 - 10' "11 with paln
Lr R o - 111' AU aO'lIIl.nh are verr .10w
') .ak t:VlIlultlun
,,1Ige 3
Innominate (lon9 11t). Mot t.lt.4
""""
~
/
other I
,aln '11th prone prop
Tnatm~ntl
.ron. roll' .oi.t be.t to lumbo..or.l .r.a roll' 10 .lnute. rIb ult~a.ound low I
.inut.. 1.' '110.1 to billUr.l lumbo"oll'l1 I'arllpln.1.
~. Rehab Potential I Go04
comment. ,atlent pre.ente with lumboleoral paln wlth left lower
.xtremlty involv.m.nt
fiG I
ov.r 10 ....ion.
1. ,.in l.vel 1 - . out or 10
I. Inor.... .p..4 or love..nt
3. Inor.... lumb.r ran9. or lotion to 10' wlthln nor.al 11.1t.
.. D.or.... t.nO.rne.' bllaterll lumbo.lorll .rel
IJ.li I
A.etor. funotion.l loblllty
PI
contlnue x 10 94 wlth loiet he.t, ultra.ound, .TX to lu.UJo.aoral arel. D.ret
.1.. .eoon4.ry no Ip... p.lpat.4.
&~UiJlJJJ(?I.
Chrl. GroBBnlckel, P.T.
Idh
o alllC\a..
Dat.
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.~_Ol _NO UU"Y VIII"ICAYlON r-.
0"" POLICYHn' 11"11
NT I PIll NlJMIl1ll
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A.t- A Hloli-/tlrV
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G';,olo.. I 'PI/- 170~S
-l SOCIAl. UCURITY NO '81 - .~~ - ::l/.;l
L
G"lII.m.n'
Th. .bove n.m.d D.,.on hll .rol,.d 10' b.n",II... ,uull o"n,u"" su"'In.d In an '.ccld.nl on Ih. d.l. IndIC.I.d, W.
und.r,'.nd II'". Dtrlon II your .mploy" 0' rormer .mploy" To ''''Sf u.,n determining b.n.lilllh.. m.y b. du.lnl. D.,.on. P,....
provld. ul wllh Ih. .n,w," to Ih. following qullllon.
Th.nk yOu lor yOU' COOp.llllon,
. . - ..----+. .. -CLAIM OEPr."
t, OCcupltlon: :1Q.U(LD~L\l.e~ '. . " ,', ---. -----.-..-H--'-...rr-----:---
I, Olt.1 01 Emplovm.nt: From: _~__ l(t t .1.9..91._ .__ Tn,ougn: ...JAAA.~_.l~
:I, Wig. or Slllry I' 0' -t 6^
Dlt. 0' Accld.nt: Pllr Hour '" S __~_.\.l.._._._____ Pllr Week 0 S
Per Monlh U S___.__..___...._____
No, 0' Hours Worklld: JL..._Ptr Dav YD Pllr W..k
No, 0' OaV' Worked: In Per Wllk
4, Do.. the Employ' . work MondlV through Frld.y? a v.. /'il No II not, F.~p'lln ~
..l...__.__... _~______.____._~
., 0.1.. Ab..nt due 10 Iccldlnl: FI~~~ Oav ~~t-.~t=' I j I- tq',~f..' 0.111 Aelurn.d 11 d.5h ~
('1 II not conllcullvl, dllu Ibsenl? ____.._____.___.____.___
(bIOI" 01 Inllclpl"d rllurn? _______._...___.._ . ..,..".--- ....,---... -...------.,---
., DIIII Ibsent 'or Olhlr reasons: First OOV Oul __._____. _ "...... .,_'" Oil. A.turnld
(.) Plllse Expllln .________.._. ..____... - ,,_ '" - , " .- ---------.
.,. HIS .mplov.e 'lied clSlm 10' blll",'ils under any Worker', Cnmnlln,.IIf)n or ~imllar Law u. ,,,,ull o""i. Accld.nt?
a VIS ~ No
I, Hu Implovee received, IS he receiving or is hllll,Il,lIed 10 'Ilceive ben.fils under anV Worker'. Comp.nsatlon or
slmlllr llw IS I result 01 thiS accident?
o V'I K No CJ Undetermin.d
., Nlm. 01 Work.r'l Comp.nsatlon Clrrl.r __ . _._____ _ . .n.._ _ _ PolicV No,__..___ _____
10, II .mployl. .ntllled to blln.fIIs under I wag. or salary contlnulllon plan? rJ Ves ;.r No
It, II .mploV" .ntltl.d 10b.n.Ii's under .ny heallh andlO' accldenllns'lranc. progra",? a VIS K No
" '0, lhl nlm. 0' the In sur" _ _.._.__ _...., .m. __.h.b.' _.________ _'_b
What welklv dlllblhlV Incom. banlllilS, " any, a'll p,ovld~d? ___ _. . .._________._._._____.___
12, "vou Irl.." .mployed, pllla,seanaCh,YOU la,. relurn (s. lor allea::,tw~I,Y',a's pr~g ~ date 0' lh. Icold.n'
011:n~:~iPt5~~~::0~:~'~~-.s:p~~'t~.. vourCla~:::rd~o~/) {/) e _.---.- _
j-i TIlI.:{)~d~ "hon,: ~~'S'.:/.Q
1..1101
(-.., ~
... ~Iechanicsbllrs Rehab ~'ystem
-_.._-~.~-~--_._~_... ~ .--. ---..-..... .._.._~..._. .-- _______.P.-~-
7'h' f/'/Ilonolllb,~ /h/"'/IIo/l(r (',,,/,,
Tht rollowln,IUlhorlrlllollS Ind releasrs are 011 behalr or ...---!?Illilt s. suber -
(tbt "Pltltnt H), I pallenl II R"loIIII Work PerrormAnc' And nlnd Ctnler (tbe "Rthlb"),
conctrnlnll
I. CONSENT TO TREATMENT AND REI,EASE OF INFoRMATION
I btrtby Iln Ib, dul)' IUlhorbed penonllel or tbe R,hlb ptnnlsllon 10 rtlult
relnlnl tnlonnlUon relardlnl Iht ph)'llcAI And menIal condlllon or Iht Patlenl, wbtn
rellltd to the patient', WeJraret to An)' pmon or InstltuUon, \llIh the rollowlnl'peclflc
e)jcepllollSl
.,-..--.-----.
1 Illume III rL~k ror an)' condit Ion IhAI 11I1)' Irl\l' I. Ibe relull or IIllnl In)' Rehab
equipment \I'hlch Is Ihe propt'I1)' or Ihe Rl'hAb, Ihl' Ull' or \\ hleh b nl'Ulsary to, or dulrable
In Iccllmplbhlnl the pre.urlbrd IherAI')'.
1 luthorl7-' thl' IlIerAplll1 and all Rehob penonnt'1 In chlrae or the PaUenl In the
Rehab: (I) 10 adnllnlll.r to Ihr 1'0111'111 III)' I realllll'nll; (1) 10 prrronn upon Ihe 'aUenl
operaUolI5 or proudur'l; all allllAY be dl'tlJled lIerullry or advL~able by Rebab personnel
In Ihe dlaanoll't rar. and treallllenl or thr l'Allelll.
Tht Patient arkllowledl'l IhAI the 1I05pllal 10nl.IlmtJ fundlons II a luchlna
InstlluUon. The 'aU,nl aaret.~ Ihll, unlm the rallent noUntS Ihe Rehab to Iht contrary
In "rIUnl, h,'sh, IllA)' pArtlclpol. as A leochlng lubJ'cl In varloul educaUon prOlrams at
Ihe Rtllab.
AulhorluUon must br slglled b)' Ibr rall'lIl, or, In rAIl' or. minor or when raUenl
",; ph)'lIcally or menlall)' Incolllpelrnl, by IlIe nearell rrlalh'e.
~ ~)~/5-~ 11/Q/Q,
(5lan_tur, Dr ,.II,nl,1',,.on I\.'pol\dhl.) . . (1)11')
([! -;L~~
(lhl.llol\,hlp 10 1'.11.111) (WllnHl)
U. RELEASE OF INFOIlMA'1'ION
I hereby lulhorlr.r tht Rfhnh 10 tl'lfAlf allY Rnd all InroMn.llon concemlnl my
oUlp.Utnl Itutmenl or .1!L9J92 Ihro\lRh to
n..plnnlnlt "01') (tn4bllt "'1')
y ~.....G. ~~
l~pKlrl .lInrn,), bOlpll.I, phl,ldnn, Dr romp.n~ 1IIIll'.
CR,lIllon.\blp 10 r.II,nl)
(1)'1')
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, (WIIIIW)
(5l<<nIIUrt or ...II,nl/l"rlon ""pol\,lhl.)
. .
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. .
STATIC STRENGTH TESTING
INFORMED CONSENT
Slade Stmgth Testing Is a method of delermining )'our slJensth 10 help
understand how your Injury has affecled )'our ability 10 work. You wlll be
placed in spedfle posldons 10 lesl Ille sl1englll of differenl p8115 of your
bod)'. In each position you will be asked 10 push or pull againsl a handle
which does nol move, You will hold each position ror .5 5l\conda, There
will be 30 seconds of rest between each exertion, Yow evaluator will be
looking for indications thaI )'oU have given your besl effort without causlns
any paUl Incruse, Each lesl will be repeated (rom 2 . Slimes 10 determine
)'our beal err art. .
nlere lSe certain risks Involved with Static Strength Tesling IncludlnS .
lemporary pain Increase. an aggravation 10 your exlslUli Injwy or a new
injury. In order 10 make lestlng as safe as possible )'ou should pull on the
handle vel)' slowly until )'OU have reached )'our best effort, b...t )'01.1 should
nOl pull hard enough 10 experience any pain Increase. You should nol jerk
or pull suddenly and If you do experience any pain Increase, you should
SlOP pulllna immediately and report IL '
Slatlc Strength Testing is conducted only on a ,'olunUlr)' basis. You wlll
nol be asked 10 perform any lest which )'ou do not wanl 10 perform or do
nol feel you are able 10 perform,
TIle Static Strength Telling process contalnSlests 10 delennlne It you are
cooperating 10 delennlne )'our besl work ability, Any Indication thaI you
are nol giving your besl effort will be reporled along with the results of
this evaluation,
Based on the above Informalion, r agree 10 cooperale fully and 10
participale in Ille Slatlc Strenglh Tesling process 10 help delennine my
actual safe working ability.
'Date'
Patienl
Dale
Witness
,.-..
~
I
FUNCTJO~AL CAPACITY EVALUATION
INFOH~IED CONSENT
You Ale r.olnr. 10 br ,I\'rn . "f..4ntlJ.t'J1J.LC.trJ.ti.n~:tllu.lS.lm" which Is . mles
or luts or ",U1r.th, nrxibllil)', e ndu!l1lce, rain, Ullflo\,.fCUlAl fi.nmt malerial
hl1ld/int aN/i!)', cOO,dinlti(l/l, lullc ro~rurina, rtpelJlf\'e mOnme/lll, l1ld any
othu .uts whi' h \.-111 hell' dwrminc )'c>ur ufe mL,imum Iblli!)' '0 \/,'.,,)(, All
I.~e .uts An \'IJ/Il11tAJ}' l1ld )'OU ml)' ICru,c 11l)' lUll! )'OU rrel )'OU Ale no. uplble
or rtf{orrnln~ II AJ/IUlJ will br thor(l\.'i.~ll)' nrltlne If '0 )'OU before )'OU are
uhd.o pCI r"ml thrm,
)"ou are nol e),reeled.o urrriwce l1l)' incruse In )'OW eWJenl 'evel or pain or
difC(lmfort. You should ."empllo !lOp neh IUI brrore )'OU experience any
Incrun In )'01'1 cunenl Irvel orraln or dheomfort, You lIJe upecled.o
cooptrlle full)' with l1le e\'llulti(ln wd flOp 1Jl)' lull-efore 11l)' Sncrease In )'our
cunenl 'e\-eJ or paln or discomfort.
TIme Ale mum [Merrnl rill~.P\'!lh . f;me ti(lnal Carldt), [VI'ultion because
)'OU will be a,ked to Herl efron, hl1ldlr weir.Mst IJJd rcr10rm .ctMtiu with
inuuslna deireu or difflcu'l)' which c(luld UUSt an Increase In )'001 cunent
'evel or plln or dlm\mfort, or l1l'8&TI\'htion to )'our e);hlin, Injury. There la
.Iso I posslt.Ilil)'l1lal )'OU could urrrienee . new Injury. bul this ,isk Is small and
)'OU will be able '0 conbol 11l)' IrSI b)' f1orrln& II )'OU feel 1Jl)'lncruse In paln or
discomfort. You wllllbo be .ble 10 !lop le!llna II )'OU ful l1l)' discomfort In
In)' ol1lu pl11 01')'001 body, The e\'tJutlor will take e\"t')' pru,ullon 10 insure
l1lat )'OU ue prolecled from l1l)' porrnlia")' hUl1dous .Irutllon. and )'OU will
nnu be forced '0 (lerform 1Jl)' le&l wMet. )'ClU do not .....rst.lo rcrform.
The functionll Clr.d!)' Eva.lu2Iion rJC'ceH c('nr'lns le~1! 10 drlermlne If)'ou ue
cClClrer1linc 10 delumine )'OUl t.es! .... orJ; ablli!)', An)' indiclliCln thaI )'OU are not
Giving )'0U1 bell ef{or1 will be rerorted alont with the ,e~uh.s or this e\'./ulllon.
Bued on the aoo\'e informlrion, r '[,ree 10 [(lOreUle full)' l1ld 10 rl11ldpllC in
the Functiont.l C'rlell)' E\'aluation 10 hell' delmrunr my lerud nle working
I blli!)'.
O.le Patien!'. SiVlIlWe
Oale __ E\"/ullor', Sir.nllWe
".",
~Iychllk, Geek h (., We I ~ I!r, rc
rlltrlck Deckle, ~Aq,
,.-.,
nec I!mher 2, 1992
PIIRo '1.
Roc Dnle 811rber
performed In Ill'ptemher 1992, Thill revelllell no evidence of n dlllc
hernlotlon ond Willi not Rug~l'Rllve of II trill""ntlc Influencll, although,
thl'1re were aome chllngea compnllhll' with dl'~IHlp.rntlve ehlingeR,
11111 IlIacomforl In the low hllck IlIId Il'ft knee pl'rRIRted dellpltll the
eonaervntlve tTentmellt, fllR pre.1 rllumnl Ie work nctlvlLy conllhted
of delivering rurllllllrll nllll III' Itnd 1101 rl'lllrrwd 10 work Rlnce thll
IIC e ilhm t ,
^ review of hlR pllllt medlclIl hllllnry WIIR nOllconl,Tlhulory regarding
hili low hllek RymptornR, hOWl'ver, hl' did hllve nine Ruq~lcIII procedurell
on the left knee performed hy Ill', Rex lIerhert prior to the traumatic
InrJuence, Becaulle of Or, IIl.'rheTI'1l lntlmllle relatlonahlp with
thiA man'R left knee prohll'mR, I RUf',gellted Ihlll: Ihia part icular
lIerles of complalntll bl! follnwed throURh Ill', lIerhert's office,
ilia low hack compllllnta wero relativE' to a algnHlcant Ilmount of
dlscomforl In the low hllck 111 though there It WIIR of varylnA Intensity,
lie denied ony Ilugmentn! Ion of Ihe poln RuhRequenl 1:0 Increolles In
. Intro-IIbdomlnlll preRllure manlfollted hy coughing, IIneezlng or
strlllnlnp, ot IIlool, lie wlla Cllpllhle of wlllklng through a IIhopplng
center 1If! well lIa wlltchlrl/\ lp!l'vlllloll for /lel/ernl hourR, hOl~evert
he required the opportunity for pOlllllorllll chnllp,ell wilh both
IIC t I v It I ell ,
PhYl-llclII eXllmlnlllloll revf!rl'fl,1 he wnHetl wllh n hl'Alllllll glllt
pnlletn, III! waa cllpllble of wnlldnA Oil hlA to'?" /lilli/or helllA IT)
an Independent fASi)lon, Tllere wns II lOAII of lloTmnl lordoAls.
1""""\
Myehnk, (JeeHn ,. Welker, PC
Plltrlck Oeckle, ERq.
,....,
I>ecemher 2, 1992
PIIRe 3
~el "ule ""rber
Thetll WBR I nc nnud pllr liver t ehnll mllRcle R'''IRm with tenderneR8
tQ plllplltlon over the pORt~rlDr RplnDuR proceRReR.
Flexion wnR precluded to rive degreeR with ninety degree8 normsl.
Exten!llun WIlR dc/nil to ten dllgrlll!R with Ihlrty degreeB normlll. lie
hlld II mArkedly preclu!llon In Inlernl Cloxlon /lnd laternl rotation.
The AchllleR' uCll!MeR wer~ Ilhpenl blllllernll)' /lnd he hod only
trllce pIII"IIII' r"C1oxI/R hlllllrrlllly, The Rf>nRory SYRtem Willi
Intnc I,
StrlllRht leR ral!llng WAR neAllllvl! In the Hitting pORlllon,
!lupine pOllltlon, IItrnlght Ir", r.11!llng Willi relltrlct.d on Ule
nt rorty-rlve degreeR, There WIIR no grent toe weakness.
In the
right
Examination or the lert knee revenled no evidence of an effusion t~
be pre8ent. He hnd generllllzed lenderneRR to pnlpntlon. Th.re wne
n full degree or fl.xlon Ilnd oxtenRlon with comparnble crepltntlon.
Thl! cruclnte nnd collnterlll 11",lIment!l were Intnct. There WSR no
. Rpeclrlc joint line tenderneR!l,
tly ImpuRlIlon rl!Cerud to II Iumbnr !ltrnln which would h/lve been
directly nnd csuRnlly relnled to the trnllmlltlc oplRode or AugURt 17,
1992. I RURP,llSted some olltplltlent modnlltleR or therapy to conRlet
or hydrocollntor pllcks, ultrn!lollnd, myorn!lclnl r!!lellee, Intermittent
pelvic trllctlon pnd aqu/lthernpy for Rtretch /lnd RtrenRth!!nlng.
I,
t"""I
Hychsk, Geckle , Welker, PC
Istrlck Geckle, EBq,
,.,..
December 2, 1992
PBg. '.
Rei Dale BBrbl!r
Theile IIr rnnp,ementll were made nnd he did under",o the Il[orement loned
progrnm. lie wall reevaluated on Novemb"r '" 1992 Bnd hnd sbRulutely
no Improvement relnllve to hln low bllck problemll dellplle having
the progr~m over n period 'If 1'-'11 dnYR.
Ills ellamlnlltlon IIp,lIln revenled telldoTn'HllI to palpation over the
pOliter lor lIplnoulI procflnllvlI, ^ mnrked dl'CrVlllle In the dep,rp.e of
flelllon, l'lltenlllon, lntp.rnl rotnllon /lnd later/ll flexion.
Nellrolop,lclllly, he rrlllnlnl'd Intl1ct 11I111 I ,lid fnel thnl perhnpll there
W/lII Borne 101111 pnrnvertebral 1Il1lllcll' Rpl1f1m prnllllnt.
I nnked him to underp,o n fllll('llol1111 cnpnclty <!vflluotlon of the
Illmbnr Ilplne lit which polllt crrtnlnly vnl hllty /lnd nymptom
mnp,nlflcatlon could be chl'cked nil well an performed n very detBIled
a computerized evaluntlon or hill low back nrea.
The functional capacity evnlllflllon wall never performed because he
did not keep hill orlp,lnnl Appointment. lie hAd been contacted on
severol occoslonll ond npp/lrently Informed the work hordenlng
.
Ilecretorlal starr thnt he WAil I',olny, to check wi th hill nttorney pr lor
to undergoing the nforementll,ned eVlllunllon, lie hOIl not been seen '
by me Rlnce thnt time 110 thlll I nm 11lll1ble to comment further
relat Ive to hill cond It lon,
I trullt thlll Inrormatlon III or valuo to you, however, If there are
nny further qll~Rtlonll, \I1r.nlle do tInt hell I tntll to contact Mil nnd I
I1I1RUre you of my cooperation.
Very
f'.^.C,5.
,
,
BG/jh
Enc l,oRure
'-.
~
MIUIf.R, I)M,.;
OCTonER 13. 1992
WnI'I Involved In /In AI,to lll~clllf1Jlt ot:I'IIrrlllg 011 the IlLh or ^"Rllot
1992 In Weftt ralrvlew
WII" the dr iver of A olowlll'" vehldn 1101111'. I.hroll",h II p,relln IIp,ht
IIl1d "'liB "truck Oil the rlRhl. 11I10Rrll,.,ror olrl"
WIIS wenrl..", seot bell" IIl1d did 1101 0110111111 II 1000 or COllOc\OIHIIIOIIII
Willi lIot throwlI hom lhl? COllr Inl!o o( the cllh
the cor Willi 11IoperAhle lit Ihe ocellI! or Ih(' IIccldelll
Willi Been lit lIoly llplrll \loApllAI /11111 wnA l'vnIIIlIled, II-rllyod 11111.1
l!lImnlnpd
phYRlclnn
lhernpy
IInd Willi p,lvell
.
Willi Been In rollow-up by hlo rrnnlly
medicAtion 110 weJ.l 110 modnllllp.o or
liT! tlRI Willi orch.red
cOllllnllell 10 hllv(' ,1I0co",rorl In Ihe low hllck nnd lert kllee
he worko deliver 111'" furnlll/re and hilA nol worked "IIIce the
IIccldent
review of hlo pool medlclIl hlAlory 10 lIollcolllrlbulory regllrdlrlR
his bllck AlLhough he hAft hlld nine Burp,leAl procedureB Oil the left
kT!ee hy Dr. Rell \lerbert
dl"cuoRhmln rep,ard" to rollowlllp,wlth IJr, \I('rbert or I>r. Green
but wall hl"tructed Ilot lo O('e both phYRlclIIII'" at the Rllme time
Informed pllt lent I,hlll he ohould hllvP r('cordA relenfled to
I>r, Goodman rep,lIrdlnp, hi" kll('l! pr lor 10 II11Y treatment
denieR Aryy Aup,mentAtloll
C"IIAhle or wnlk Inp, lhroll,.,h
A televllllon "how with thl!
IIeeded
elCllmlnllt lOll rllveAI" he wlllkA with A heAIl/lIlt !lnll pllllerll
(,III1Ahle llf walk Inp, 1lI1 hlR 1.0(>R lI11d/or 1ll'(>11'I
10"" or lordoolR
IT!creooed "11110"' with I'oolrr lOT oplnollo procroA I.enderneoll
(1elllon ~o, eMtenlllon 10"
",Ilrkedly precluded lllternl f1eMlon and
^chllll'R nre IIhltl'lll hllnlrrnlly, trllel!
Rl!nOory Ilyolem Inlncl
II ohllppln/1, c(,lll.er AO wel 1 no wAlchlng
IIppor lunll y r 01' pllA It IlInn 1 ChAnR& 1111
InlerAI rotlltloll
plllellne rel'll'MIlIl
,...,'\
~
BARDER, "AI.E
OCTOBF.R JJt 1992 (~"nllnlllld
IIlflll~hl III~ rllllllnp. III rll'Rnllvll In Ihll 1I11l1nR ponlllon
no ",reAL loe wellknllllll
In Ihe lIuplne pOlllllon, Iilf/ll",hl I..", rnllllnR III felltrlcLed (In lhe
r Ip,hl AL I,~o
eXAmlnAllon of Ihe lefl knee--no effulllon
lendernellll 10 plllpAllon
rl,lll flexion Alld exl,enlllon
cllOlpnrnble crepllnL Ion
crl/clnle And collnlllrnl IIp,nlllllnlll nre IlIlncl
Joint IIIIeR nre nonll1ndpr
100I'r e 11111 onl IUOIhn r III r n In
refer 10 Ur, Wllllnm'lI for pOlllllble mR n,hllllllllon
!"r~J().J~r_/)y_drR~_()JJ!I~()Ll)nr;k.s.Ll,ltL ra!!,I!.I!!I~L!l!yt!LaBc I a 1 release ,
)JI.l ~ _r .~g..!.!-'~!..J>.eJ'?)E_ tr..~ c lion
"llU_~_lJ).er..!lPL.x.l!L~!1!..1!.~,rY.L.ch /lnd ,,,s l r .llllgl hlllllr,IILJ)U
I'Tn
IIhould receive mod/lllllllll dllrlll'" period or wnlllll'" (or APPolnlment~l
.
November I" 1992
hall hnd nbRolulely no Impfovemenl relnllve to his low bnck
dellplle hnvltlp, the I!rop,rnm over n period of 10 dAYR
exnmll1nllon rllvenlll reclprocnl heel-loll p,nlt pntlern
no nnlnlp,ln
I')e nl1d heel
In lhe er!?ct
leAA "1'"nm
pORterlor IIplnoulI prOCellll!?1I
mnrkedly dlmlnlllhed rlexlnn,
lnternl flexion
there hnll been no nlternllnn In the deep lllndon re(lexes, sensory
or molor chnnAell
nell!!dllle fl:F. tl) the lumbnr nren (or vnl hilly nnd "'011)1,011I
mnp,nH I cnllon
r('IUTn n[Ler lefll ()
WAlkll wt'11
pOlllllon, 10llA
or l"r,loIIIA
lire lender 10 pnll'nllon
eXlt'nlllnn, Internl rotntl!)"
and
""'""
II \~~
~" (~opll(ll
"", rtY"C')Vr,'IY
~f.' ,', '<J
('C'llll'I'
.., ~p' ~
I"',
, .,. I, I ,I, . II \ I, ,I ~ I. I' ~ f, I 'I "I t"
:1'"'' "",din iii Illd
('1111,,111I1,"/\ tlllll
(/11l1:111\1"~1
M,.:tIlI~I\l, rWM,UM' 'ON
"I\'f' p.N'r. 1)11' II 11111'"1'''
Ill\TP.. .'Illy 23, 1993
Tim (1111'.1,1'111'. W,'A !II','"I"",I ill II """"" v../oI,'I" IIl'ldrl,,"1 11..'7-'12 wh,,"
h" W.11I hi,t nil Ihl' ,"IRR"II\J1'" "I,J" hy n I'nJ I h,,1 WfJllt I.h"nIl9h II "1'"
light. Wh,," {",II<1I1I: W;I" hit nil Ihl' I"IA"""\I"" Rhl", h,. ,dll'pI',I 11111:
or hili IIhnlllu.r hill'lI"R'1, hit hili I'IIIhl "h"ul,'",. 0" Ih" Il<1"I: 1111,1
hll'l h f!!11 ,I nil Ih" ill"I,',' "f hill rI"",., hill 1<1,"" 111",111011' Ihn ,1!Hlh
c,'III'II09 IlIjlll'I"" III ,,11 "f I h""" I hI"'" ,II ff"""III' M'''I1R, 1II',I1111A
1'0111'. Illjllry I:h,. rill' 11'111 ,I,.v,' '''1,,',1 I"w h,1I'1( I'"ill, I"H kTl"" (",1",
ilnrllp-rt. IIhnlll,',." l',lITl. /I" I.h",."r""" w",,1 In /In.ly /ll'ldt IIoRp\l"I
F.mprgnllcy flnom, h"d x-,.ay" rI"",, 11t II , 111'lI'h",."",1 nil ,.,.,IlI', VI,'o,lllI,
Will'm 1l(1(lllcl1llollfl, nllll 'hupI'"f"", /llfl ,,"I" ,III' IInl IrnpI'ov" nV"I'
th" II"X' 1111'"'' 11,'YA Mill I" LlI!l' It \'''I1''",lIly I """"Ilfll'" III H.,' I"w
h,lCk 111''',' MIll 01111'1' ., "",'11 "" h,. w,.,,1 1 nil", 'I'",.f<R wh" ",,"I' i 1111"" I h,'
Rnmn tha"Ill'Y ""I. ,,"":0""""11,11',1 phy" I ",,1 'h"I'''I,'y, fI<1 0"1,, t TI,' 11 Y w,.",
t.h,'01l9h (lhyn Ie... I 1I1"1'IlI'Y ,,1 ~I""'U""" whl"', A",."tr,,1 III h~dl' 'lIIl
"Jl9ht'y wll:h ll"I'III~.,I',loII or h""I, II II t','AOIIII,I, o1Ild /HI flx,.t'r>I"f'
pl'OQrnm, IInw"vl"', A I,ll'" h,. ,1\,1 1101 hllV" nllllliri"11111 h,.Ip, h...
"V,.,III:llo1l1y w""t: 10 1'1,,, I'i'h'lh ho,,1' I I., I "fl MI olllr;IH,,"I: II lid" I' "",
Onorlm,'H' rOl' .'11 \"IIAI I'wo 10 1 hI'"'' "'0111 )11' wit II PhYAII',,1 Ih""Il\'Y ,',111
01' h<1,. mod,llll: I"R i IIC 111,1 I "" ""(1'" I, II" ""I'Y wh i "II n""w."l 10 h" r I.h..
mOAt',. S I ",,,, I hfJ 1.'" i II flr"'A I "1,,,1 hI' w",ll 1.0 Ill', I"""R, 11
chl..oprllpl:n,1' whn RI\IIli.rl"'lf,lly h" I (11,,1 H,,, p"U",,1 with Ih"
t:.h"rIlPY, fI... would <l,,1 "1",,lflf,,"ll Imp"lIv"m"nl' flOtll,.,L1m"A 7'\11
ImI'I'ov<1mo"l. wllh Ih""IlI'Y ""I 1111,'1' 1.1", p.,i" wflll',l \I"llrlllnlly
ITlcr"nl'lf1rl. 11<1 hll" h""" A""\"\' Ill'. III""A Rill"" 12-'12 ,'ppl'n~lmi'lt:r'Iy
I,wo 1'.0 Ih,...." I:Im"R n w<1"I(, II,' r""I" hlA "M'9fl of moUolI IIl1d [1111"
h,'lva bt>n..ril,I,ml f,'om I.hlA wit II All \I '''IA I'i,I".
TIm prltl"", com"I"III" or "" Mill "rr I,'fl Ai,I",1 1I"..k ,,,,111 U,"1
<',111""" If'fI ,1)'m II"IJI 111\1 ,II ""o,,,fll'" ''''"0,,11,,", III" fll"I"'R h" will
oft,," hI' I1hl" In ..."ll'v" IhlA hy '"'11,1111" hll, h"",1 10 Ih" 1'1\lhl, "I'
'lh""91.1I11 hi" l'oAIII..". II" In 1I11"'lI'" whlll "1'111\10 IhlA 1'.11" oil, II
,lotHI fIIIt'rm I, ,.., I: wh,," hi" I "w 1",,,11 1"11 II I A 1''''1'1'11 fll"l h" will h,1 v,.
mo "" I: l'Ollld "A w II h h I A I I' fI n \,1",1 .",,>11 I'ill II hilI It I'MI or"lIl'
1",I"I'"",',,"I'y. III ",lrlllloll. h" "0'''1'1;11"" "f " IIlffll"" low ",1,,1<
p,,11I !lom"I:I"'''A "11<11111 I.", 11110 Ih" l"w",' I'~II"'mlll,,,, I'llllnl,,,, "
111I911."g R""R.1II"" or hi" I'IQhl: roo... 1~lIh dlll'op.,,,..l:lc Ih"",II'Y
I.hll I'Ighl:. fnlll ,IIA,.nmro,1. IItIlI t IWIIIIII' hilA ""Rnlv",I 1.111 hI' A':I I I
g" I. " 'ow "M'k 11.1111 wll:h ..",1111110" '0 III" hlll.lorkA 1\1'''',111. III
",lrll t.1 011, h" n I A" h",1 1" fIlm"" 11111 II willi OI"'Ml I 01111 I Rw,.11 HI9 or
I:hp. (10111:111'1..,. klll'<1 nl'",' 1."", 1'0,""" "'llI '1""'1, Thl! plll.I'ml hi'l,1 11
11onl,I,Ollflll
^,'i1II1I,',lwUItIl'rt f; "M'IIAIIII ^"I1~;Y'\I"'o\
""'"
1"'0
rill/A . 2, nil I' hI' I', Ilil I"
1-23-93
m,':lor t..H kn",. inlllry il' work Invlllvl"" ilJ.'I'I'n~I'n.1I"'ly R"W'II
1'1111'\1",'1"1'11'10"'" "r Ih",1I' '"'IIIl'nA"npl" wllh 'I nillH'r'ft "YR': ",'m<lv,.,l
",,,1,, ,"..,11111 ,"mllft"'IIR r"'llnV"'1. In I'IIl'l h" Il,,,l"rwnn' ",'h"hllll.,I,lolI
111111 bllRIlll111V \In', h",'k IIlll'k 11l1ill r,..!". ()v"r"ll Ul"roJ'l1rt",I.""I1I1,1
1I"llIrn or 11\1 nr hlR ",lin hilV" IInl "h""'I',,1 rd.'Jnirl'~'1fllly Rill""
p,'ohllhlv '1-'l2 ;",,1 h" ,Ipld,'/' ""y IIPW w"ill""'AA, IIlHllhll"AA, 1,llIgIIII'"
1','111 challg"R, n" ",'ohl,om ,'hiln~I'!A, '1,' ,",II""""A 1111 hlA pl1l11R ",."
1 IIcrellR",1 hV mnvpm"nl 1111,1 1"'1,,' I WI, II I n 1"",1, 1.'" i II III'PIO" I n II" I"'A'
wh"lI Ahu"I I nl' wll \ ,~h h,' "ilI1 "I An h... I" hy "1"",,.1 III~' h I A 1","11.1 "". I r
I,h,~ low h.'llk pillll IR R"V''t'" h" will II" IIO\~1l III II ""fllllolllh"I' hlA
llhlrnpr""lnr P"'" him III .."", "1111 ""I.,x hh, mll'~I""R ,'"11 I.h" h,''''1
I'll 1 II will 1 '"p"nV" IIt'"IO;" jr'illl y,
!'.~~J....IJ.l.f.!}nl"l.l. ,J!Jn'oxy
^"ergl,p.AI noli" kIlIlWII; III1"pll"lIzil'I","", IpO '''''0'' "'lIr~,"ry x ri
0" 7 with 11,'lhl'ORI'o,d,' "YR' fill "'1""Y, "'",,,vlll "11,1 "",,11,'" mpIIIR"lOR
""mov,,1 hy 'I", II",'h,.o I' I Nlth 1.,,,1 1lI11''1''''Y III I 'In 7 l'lllll W,'fI
('omplp.t",o)y ""v""",1 hy 1'111'1; Wnd<t ,1,.1",'1' rnl' ^ ;",,1 ^ FlInd'"I'"
whl...h IIIvnlv,..1 lh'lvlll" illl,1 nlovlllU rll,.,"IIII'''1 (~,,,,,,,,"t.l'llt ion:
11'!Cl'flIlR,,,1 AlII"" Ih" ",','101,,"1; ^"I"" 1"01 ,1r','r,o,'A'HI wllh pl'nh"hly
.~ 'i pOlln,1 w"l"hl' I'HH~ 'olill A,n",. II", In)III'VI n,.I.~I'ion~hlpR:
A"P.1l';II."rI r,.o", hlA wlr,. ;llIrI 1111"'" ,"""It'''1I I'nl' rnlll' V"nI'R wllh
""1 jol' proh 1 "IIlR I "'Jill I Y "I """ II" II !HI 110' 1',1\" 'lIIppn I' I, n l"l~n h" ,Iw'n
no' IIllvp. MI III"'"'''' ,Ill" I" lh.. III,1hlllty 10 Imr-l, , lip "ilR ol'lgJII"lly
r11,."cl;fld hy I,It" "0111" '0 """ " 111",11",,1 "Vii Ill,'"1011 "II ,1-Fl-<l:l r,,1'
whi"h he m",I" ,111 ,'t'poin'IIl,,"1 wll'h Ill', Hlly,I,.., illlll WMl ,'v,111l1l'",II~lth
Iln TMF" nl', Ally,l"" th,," lIlov",1 .111,1 ""V"I' 1."",pl(!I'r>,1 iln,l/nr R"'.I, 1'1
II." repo,.I'. lip. I,; '''"' ""lIlln" I" 'l'h" <',11dl"I 1I,"'ov,'l'y C'p.nl,',' 1'0
~(!t: that. ""1'0"1, rl"IAII""1 HI""pl orl,," lilt "1'1'111'1:0.,1 1111" "01:1'1')11111,.
f,~1l1n\J I1RI,o"I' 1111,1 r"''''"''lIlly ,1W.lll(1l1ln', rill" 10 1.',,111/ f'I1IIIJIIf'1
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hiI'll. 110 I,,",IA In 1"",1 hill'l, wll'h hYI"'I',',!r'IIRlnll nr Ih,. Imnll",'
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Innl'" Ihnll hill I"", iliA I h",'".'\" "",1 IIlII'."" "III'Vf'1I1 W""I' rlnl with
l,.vr.1 l""lvll1, 1'111/1, M"I MIIII. "" "I III "I " I~II h hi 1.,1'1'1'", J'r'PIII'Vi,l'tlln,
kll""" f!xt.'.rll"lIy ,,,1,,,1:,,,1 wllh hi" h""I" 10\l,>lh"r nll,I "O,.A nlll.
lIol.h ,,.,.1. Ill'" Allplllil""rl.
rlnxlhllll,y nll,l ,,11'r'I.,,11I III IliA '''',:k i,",1 I'xll'I'mll,I,." Ill'" ,'111 11,,",..,1
h"low n" W,.1l "" "" III" "t,,1 I,' .111,1 rl,.xlhlllly ""Atl,," "ltnr.h,',l.
"nil I', 1'"1",1
,~
~
PiIU" .~, O,1I'h"I', ""Ip.
7-22-'}J
1'hn V/1I.."lv/1 1,,,,,1: Willi (",,,11 Iv" ror pilln. IIpon I'lIlpi,IloII I:hf'!l'l! WI1"
IIn p.lIt.r"mp Imulor point' "I""" to 1-1". .101111' 1111" In ..,." ,11'''/1 of 1-1."
11It.1,,"lmll" dOI'''\ nn,I 1'1lIPI"'''l'lnl\llI''. 'I'h" I "W"" thol'I11"I" Mul IlImhnl'
JlII/,/1"plnI11" W"l'p f"It'ly I'\fp,i nt1l1 p"llIrlll. IIoth "N"'" t,"IIF"l WfH'"
,hw r0I111"d In 1,1 """" mold III y, I lIP I,. rt ""It'" I h"n 1:."" I'i \/ht., 'I'h..
pep. Inrll'!"tp,1 1I"Ip. III rI1l1l,I'II1II1I1I/ "1,, ",',I"nI:III'Y Ipv,,1 of worlc,
"" 1''''11",,,1 1:0 Ilfl I h.. 'III" III 11."., ,,1 ;IIIY ",'1 \l1Il:. II" W"il 11 nil t, I"
1,0 "'111111: an,l 1',,/11"11 1,0 .: h" 111'1111I111 ror II r I ""I' 10 klllll'k I" II rt:. flnrly
mpr!hanlc" WI'I'/! '1'111' with ""l'\(' Iml'l'''I'''I' I I'lIlIlctwl"l:lnr, In"I:'''/lrl n(
tlll'nlng wll:h hi" r""I. ^I"" nlonrl II I Ion" n"",1 10 It" ma,ll'! ror pl'opprly
flt.I:I,nIJ ""..I: ntu/ h" ,,111I111,1 1,1' "Il"w",! I" ,'hMlgo """II:.lm," ""
nf\(',..n"1l1'Y.
~,I1.I1.fJ~Mflnt,
1)111" hll" "IIIn\(I"Mll', rI""lhllll y ,1"rl,'II" in hi" l:,t'IlJll, "" w,,1l ""
III hili ,,,..,'k, "holll,l"r, ..n,1 Il1w"'I' ,..,,1 I','mll I,..". II" ha,. ""10" ,.tr"n\/Ih
""vmm"t.I't"" III hi" low,." ""11'"",111",,, IIi.. p,..dlll''' 101 ,'''Vlnm"II'l,',,1
wll,h II rJ""I,,,,,,.fl III Ih" n,""",,1 1,10"",1<'''' "n,1 IlImh",' r'lIrV"R .11"!
,'omm"IIIlIII'III:P ("""\111 1'",,11'1,,11"11" In hlR IIO,,'k .11,,1 ,,,,,,k, Illll,. w""
l'o"Il:lvo (0,. ,II"" ".ul AI )olnl' ,lynrlln,"'I,," how"v",' H,f>V m"y t".
f..I"o pmdl:lvn ,III" 10 Ih" R"Vf"'it'y fir ,1""1"'"01,,,1 "illig" or mol: Ion III
11111 low ....d" I I'lIn" , ",,,1 lowf'" ,."I.,,"mll'I"R, 0"1,, \01 r"'''RI',,1 IV
,,,",,...lonl'''9 ,,1' " 1lf'f""",lI'V 1,'v,,1 "r w",'k, II... h.lll hArl Aom,..
I "AI: ,.lIdl 011 I" .,,.,,,."p,.I,, I" ,1111,\ ,,~, ",,,1 "I,'''',. i n~I p"Rlllr"". 0" If'
Imlll,! h,.n"rll-. ",,,,,, " r.oI11P"I'h""Rlv" 1,,.n~Jl'il", I" "rl,ll'f~n" 110" 'nl 'nwlllll
~ln.,1 A,
,'-".I.9_r:.L!.f.!r..m.. 99.~ ,1 ~
I.) 'mprovfl f1p.lrlhlll"'V I" wlthl" no"mlll 11,,1ItR.
2,) Impl'OVr1 "I,I'''n~,I,h t,n wll hln ""1'10111 Ilml'" t',hl'f)II~,Io,.,,,I',.
,1. I 'mpI'ovl' hnrlv In,.,~hilld ,'" .."..I ""~Inll"'n I "II.
4. ) Provirl" IIppr""r 1.,1", ...,h"'"I, 1 nn I" p"I,. mMh,q..mn,,'.,
~.l Iml'I'ov" flll"'Uo" I" " ",n,'" ,',1111 (",.,. .." al,.,
,1!'-'mL!;,!!.r.~_..9g.IIJ ,~
'ro ,."I:.llrn tn work r"I I II""., ("II dllty ,,'" "Jnh 0' hi, chohlf' I
I'onl:I nllnrt
I""'t
I"".
RARIIF.R, "^LE
OC'l'()IIF.I~ 1:1, 1991 <,ollll,",,,d
"lrlll",ht I.,,,, 1'11111111'\ I" 1J"",II'lvI' III Ih,. "1111111'. 111111111011
no Arent toe wl!lIknOfll1
In the Ruplne pOl1ltloll, 1111'1I1,\hl 10/1, rIlIAI"1\ IA rOAlrlctlld on lhe
I' I~hl III I,~')
aNllmllllllloll oC Ihe lert kllf'l'--no ('CCIIAlolI
tellderlloR, to plllpnlloll
Cull CleNlolI IllItl (,NlelllllolJ
compnrllble croplllllloll
cruclnle Illld colllllernl II~IIIl1l!IIIR lire Intllel
JollIl lineR lire nunlellder
ImpreRR lon, IWllhllr Rlrll I II
reCer to "I', WIllInm'A fol' pOllAlhle ~1J1l l,dmJRRlnrl
I~I.:.xJ_(U!!.t:.JI>'.<!!.Y_cu lJ.!..'.~--'1.l'plld,H . ,. II II I'II'Wlllld, lIIyor Ilfte 1111 .I'~' Ll!.I!.',II' ,_
1." I e ~ml I I !!!.~_JJ!.1 v J~I,X!!.cIJUI!
~qulIl!ler .!!P.Y.......!.!.!LJ or 8 !.r~t.Ch!,IlI,(J.111 re,1I8tl)I!_" J))1LJU.Q
prn
Rhould recelvl! 1II(,dnlllll'n dllI'IIII\ period l,f wnltlng for npPolntment~l
November I" 1992
hllR hlld nbRolutel y no Improvement relllllvl! to hi.. low bnck
deRp Ite hllv I ng the prop, "11I11 over II pel' (od of IU dnyR
eNnmlnntlon revenls reclprocIII heel-Ioe I1,nlt pllttern
110 fIIll II 1/\ I II
toe IInd heel
In tho erect
leRR spnsm
pORler lor ..plIlOllS prOCI'AAeA
ntllrkedly dlmllllAhl'd C"'XIOIl,
Internl rleNlolI
there hnll been 110 nllerlllloll 1,\ ,Ill! dN'p lell<lOII reClI!NeA, nellfllJry
or molor chllllgen
IIchedul,e FeE to the lumbnr nrcn for vnllcllLy nnd "yml,LOIII
mng" U lent 11m
return lifter lenl ()
\J
WI,I kn well
pOA 111011, IOAA
oC lordonlA
nre '''lIder 10 plllpnlloll
I'xll'lln(oll, Intel',11 rotntloll
IInd
~
r-.
IlMlmlt, ll^"l,
OC'I'Ol\r.R I'), 1992
WII~ I"volved III II" IIUto 11<'1'1"1'111 '""'III'I'III/'. 0" 'h,' 11th llf /1111'.11I'1
1992 III Wel'lt F'nlrvlew
Willi thll driver o[ II ~lowllIl~ vl'hlcll' ",olnp, lhrollp,h II /I,"IH'II II/I,hl
and waR ~Cruck 0" the rlp,hl 1"'R~e"p,cr ~I"e
Willi wellrlllg lIellt hellA IIl1d did 1101 ~uRtnln II IORII o[ C1II1RclollBlleRII
Willi 1I0t tI,rowlI [1'0111 lh... confltu'Il of the cnh
tho ellr Willi JIIOpOI'lIbll! lit 1111.' "I'('nl' 01' lho 11('1'111<'",
WII8 Been ot lIoly Spirit IIoApllnl 11",1 Willi eVlllulIled, Il-rnyed olld
unmlned
phYA I c Inn
th'Jl'npy
nlld WIIR ",Iven
\11111 Reell In [oll,ow-IIp hy hlR fllllllly
medlclltloll IIA well ItA lIIorlllllllCR or
nn MRl wnA ordered
contlllullR l', hllvo dlllClllllflll'1 III 'Ill' IIIW hll,'I, 11I111 I,.j I 1'111'"
he workA deliver I lip, furllllul'e nllrl hllll lI11t WOl'klHl RIIICC lhe
IIccldellt
review of hlR pili'll n1e,1\ CII I hlAtory IA noncolllrlhutory rep,nrdlllp,
hlA bnck nllhoup,h he hllR h,," nlllo Rurp,lcnL procedureR Otl the lert
kllee by Ill'. Itell lIerhon
dlRCURAlolI III rl!1I,IIrdA 10 following wllh Ill', 1I(~l'hl!l't or 1)1', (;1'1'1'"
but WIIR InRlructed IIOt lo /we holh phYAlcllIll'A ,lit lhe Allnle lime
IlIfonned pnl: lent lhnt he Ahould hllvl! 1'I'l'ol'dA l'elel1Red to
Dr, Goodmlln rep,nrdlnp, hili k"I''' prior tll IIIlY tl'entlllolll
denieR IIny lIup,mentnllo"
cnpnhle of wlIl,k I"", Ihrollp,h
n loJevlRlotl Ahow with till'
needed
ellllmlnlltlon reve/llR hI! wlllka wllh I' 1ll'II1tllnl /',1111 p"Uerll
cllpnhll! or wnLkinp, 011 hlA IOCR IIl1dlol' heelR
IOAA of lor"oRIA
IncrellRe" fllHl~m with pOliter 101' IIl>1fHHIA proceflA ten"erneAR
rleKlon ')0, eKtensloll 10"
mnrkedly precluded LlIlorlll flelllon 1111"
AchilleA nre nhsent hlllllel'IIlly, II'IICI'
Renflory Ayalem Intncl
II IIhnpplllf', ",,"l "I' IIA wI'11 11/1 Iwtchltlll
nppnl' 1.11" It Y fIll. pOA I '-111II1I1 <,hllll"'!! 1111
I liteI'll I rollltloll
plltel LI.le rcflcKeR
.....
.~
f",
Mrl'hnll"''''''.
Il.hn" SYAIPm
1"" ",.,1""'"
nh,. ",","mnm,,, '''''1'''
rl/NUT IUNAI, (/Al'AIJ 1 TY lEV Al,I/AT 1(/M
r,RSONAr.
NAHlr Dale Q, Sarber
IIII0HTr 8'1" WEIOH'rr 177 lb.
PHVSICIANr Bruoe Goodm4nt H.D,
INSURANCE COr Oener.l Aooldent
DIAGNOSIS. Chronlo lumbar IltraLn
DATI or INJURVr 8/17/92
II.I.IU'QRY or II1JUl\l
trr-:-Sarber r.ports tha tolloHln, history. II. reporh on 8/111911.
he w.. Involved In . motor vehloul.r aooldent, He report. he telt
10Her baok, lett knea and l.tt Ie, pain tolloHln, the aooldent,
He reporh. vehlol. w.nt throu,h a lL,M .nd .truok the rl,ht
p....n,er aide ot hle vehlole, 1111I rl'lportll he Ifllll taken to IIoly
8plrlt "oapltal where h. w.. ,lven .n inJeotlon and medication,
X'ray. were taken ot hi" 10Her baak re,lon. H. report. he Hall
.rel....d later that ev"nln" II. l'fIporta durin, the aooldent, hh
l.tt kn.e .truok the wlndoH orank ot the door. He report. i.
rl,ht .houlder hlt the door uat and hiB h..d hlt the IILndow,
H. ..11 hll tamlly phyll101an the tollowLn, day. Jon.than Took.,
H,D. He wu pre.orLbed rut, Nspro.yn, Voltll'en and YLoodln. Ife
report. h. wa. on bed re"t tor a ooupl. of weeks prLor to
attendln, phydoal therapy, II. reports he 11111 referred to HoCuen
Alloolat.. and r.ports he "did pretty deoent". He reports
reoeLvLn, moL.t h.at, ultrllsound, .1.otrlo.1 .tLmulatlon. He
report. all these tr.4tment. he t.lt were beneflolal and he wa.
t1nally lIorked Into ffxerohe, He reports he attended
Ipproxlmately thr.e to tour week",
DATt: I il/e/92
SSr 18L-38-2UL
BUr HAGEr 38
Ha Itat.. h. oon.ulted Bruoe Goodman, H,D, .nd was .een tor
4'lUaUo. tor two lIeekll, II" report"d "lIIptom8 in "llxLn, Ilnd
lI.nln, but he telt .ood to be mavin, the kn.e and the baok, lilt
repor'" he contlnullS to have ah4rp ~aLn on oooasLon Ln hlls lower
baok brLefly whLoh b.oomes a dull 40he, He report. he liaS unable
to deep last n"ht, lie reports this La .. unusuAl ooourrenoa,
He report. h. experlenced lett foot numbness tor three da,e, ThLII
leemed to b. praoLpLt4ted by rot4tlon of the hip,
He J:'8ceLved 4n HRI .tudy of the lower baok, He reporh that: he
LI told that oartllll,e may be bul.Ln. and the dl.a .l,ht be
preasLn, on a ner...., "e re~ortl he wlehen aomeone "ould take II
cood look at the HRI and tell him exaotly what i. IIron,. He
reports dROe his InJury, he Ie afraid to do enythln, noUn,
inoreued paLn with Lnoreued aotivity. H. reports "th. more I
take at easy, th" b.thr oft I am". "" J:'8portlt "I do not: thLnk
111. R'III."AI Wnt~ ""'''01'"'' C'"IPl
If ".,,, 'n'ntnlnl/nllnM ''''mn' I.In, '(117) nnl ,1~,11 . ("IIlII n111~11
21~ s, ~"",' 51'.., . Wl)'ml,~.hlll~, r^ 1111 11 . (Till ~I~ :1:1.17 '1717) n7~ 1'171 ,.^X
'''ff M ,h, NAIl If,ltrtb,hMlrJrt "'.'/""" 0"",;""
""-'
i/~
,
I
""""'I
I"'"
/JAI.I: IIAJlIIlt1l
:I
VqU ,UVIS aall d" muoh IIbmlt thfl VlIln", lie rllp""!;,, "111m nqt,
Inhr."hd in baok lSur'flry, I ~"llld rllther ,,,t a Joh IIIId autter
~1th thll pain Ilrllt", "" rnvr,..t," ""'''It,,. or pII11I tot,Ill1y
InolllJ"lolt.lltlllS mft", 1111 I'"l'ortll he ,JOOll not. fefll l,hVII 101.11 therllpy
I. the anewer to hla prohlem.
/111 pa.t medlelll hhtory InrHollt,ell "'I In,luatr1al aOQld'lIIt on t,he
Job In 1964, /1ft report" he torfl II o/lrHh.e in the lett kllllll.
1/11 worklld for aJ'prex1mlStely alx monthl! and reporta falUn, at
work beellulIl! of hh knee, /Ill reports he h"" had fr.>ur to flve
IIrthroeeop1ell to the left. kntte Inoludln, other lIur,er1el!, lie
np!)rte a Sliker' II OY/l t W/\II fl xorl by /)1', IIf1rhert, lie rep"..tll
rllturnln, to hllavler ISatlvitlel! inoludinl remodel In, and oarryln.
huvy obJeots alld water Ilkil.n., 1111 reportll oontlnuecl knlle
probl.me followln, hili recent motor vehloular, .ooidllnt, He
I'IIpqrtll hili prellent ,oale inollJrJIl to be pain Irelt, bll able to
oury three hundred pqundl'l, to I", able to water okl onoll a.ain,
11111 vooatlonal ,oal inaludllll Ohllllglll, oooupatlolla, flndin, Bome
othllr tYPII of ~ork,
y"QJJNJ.'.lQHM-!
lie reporte workln. eS Il t,l'uok dl"ivflr for:' 1" year:'lI, Ot,hf'.lr ll'"H'
of work Inalude allrpentry nnd meohnlllo work. II" reports he Willi
.oln. to aolle,. for aaoauntlng and III a real e.tate .raduate,
lie repqrtll he i. not intereetf!ld in performin" a desk Job, lie
repqrtll an,er re,ardin, his life situation and .tress re,ardin,
prelent tamily relations alld loss of time from wo~k without pay,
On the Job dellorlptlon oomplet~d by HI', Barber, he reported hi.
prllllent employment 81 a truck driver for ^ & A Furniture 811 heavy
work, This inoludes loading and unloading furniture,
AOTIVITIES OF-DAI1Y.-1J~lng,
fAIN QUJBTIONNAIBIij
HI', Barber reported hie pre.ent dlsoomfort level as a 4 (some"ha~
IItron,) on the Bor, NumerLa Pain Scale, lie reportll hi. pain at
best I. a 3 (moderate) and at worl'll: a 10 (vorYI vel" atron.) over
the PliO!: 30 day", lie lidO red :/,/1 (I In , 011 the VI,lluRl allalo, soale,
fie .oored s total ot 15 on the HoOll.l Paln Questlonnalu, On the
nan.tord Pain Drawln., he r1epiated his pain all a .t.bbin, quality
throu,hout the l,tt and right lumbar relion "Ith burn in, In the
I>qsterior baak of hla left kM", lie soored a total ot 56 on t,he
Os"estry LOlf Baok Paln IHsabUit.y Quell Uonnllire, Hr, Barber
aeqrlld hi.h on the Beak D~pre..lon Inventory,
HI', Barber tollolfin, rev illw of tll... Funotional Capaolty and Statio
Stuh.th TesUn. COhSflllt shentll, refused to prooMd with the
testlnl, lie refused to .lln the forms and replied that he would
feel more oomfortable It he could dlsous. thi. with his attorney,
He lllaO reported he would not, b... able to afford the bill, lie
reperted fear and skeptLclsm regard In. benefitt!n, frOM the
/
,
,/
"""I
OUTP"TU"T Pill 810M, TIIIRI\PV
.Iok Ivaluatiqn ror~
'I
HIIIIIII
Dill ..rbar
llata r
10/U/U
1Igel
31
plaqnoabr
I'hy.ioiam
oocupat iOI' I
Chronio lumbar IItrain
1>1', <<Joodm.n
1\ I 1\ rurniture
81 oat. of Onsetl "17/2
lIow occurredl
In aotor v.hiole aooi4ent,
patient hit on ri9ht .i4.
sih of pllins o.ntral 1011 baok to down left le9
surgery I loeft kn..
x-rays I 1I01y spirit MIUI on baok
CflT soanl "/A Myelograml HI"
other. KIA
Past Modical 1I1sto"'VI
loope./torn ollrtilage
s inoe Onset pa in lIan!
Hon-lIignifiollnt, left knee history I .iqnifioant for
Rllt. Painl
o
1
2
/~~ .
. 3 ~',
\.No,!)
0~ Oh~n9:!.)
-- _.~-- --
4 5 .
(circle one)
(---~ .
~~
Ho
(oirol. one)
.
10
Is pain constant? y.a
Worso atl baqinninq
_lnt.nndO constAnt?
.nd of day nlither
'-
1I/f1? "0 Where? N/A
Most Comfortable position. Lying on baok
Least Comfortable position! bend, lIit to stand
What t the pain? Bit, transflrs
What I the pain? vioodin, molat heat
nOElS Pllin "wakon You et Night? Yell
Ooes Pllin t with cough? YIS Gl\no~o? Ye.
ll" you hllve problemfl with llown I? No
Lower Extremity pain7 LIft lower extre.ity
Medicationsl "lIprolyn, viaodln
flny supports? Lumblr ouahion
previous RXI Moculn
previous Baok Problems? Honft
Plltient's Goalsl "plin fr..," "Return to work"
01 POllturol rorwllrd he.d, flat baok
AMi Trunkl QljJlIl!;jj;y (em or degrees) Q.!.LQJJ.U
rn 0 - 20.
en 0 - 10. "11 with paln
l.F R 0 - U. 1111 1II0vlments are vary alo"
-.,
~
1:1'''"1 IR ,,,lo/lR",1 III Wlllkl
11I1I'1I1 IR ,ele/lllln" I', Wlllk.
"n<l"III/1IY level
, hili"" I"" ,1.1Y.
,L'YII pl'1 wIOI'k,
". III1Y IIlvl'lI wel'k ,IllY, 1'1111""1 r,111'
1'111 UL h')lIIR lit '''''' 11mI', l hllll'" I"" ,lilY
'" 1",,1 I/.L hl)llrl'\ III flfll' 11mI', 1 hlllll" I"" ,L,y
1,/1111. , lL h'," rrl III nn,t 11mI', II0hll"'/\ 1'1" ,lllv
,III VI' ,..!.- hlllll'l' AI ntH' llmr. ? 11I1I1l" I'" r IIIlY
1111 "./\. 1'II'llllllR
1111 ""RI rtrllflllR
'"' 1,,"1 1'II'lllll'A
1111 IrllI 1'11'1 IIIIIR
r.II"""""IR r!'!!!..l\'ll,~.IIJ!Ul,l! ,'.h" I' I ,lIyj,I,,,,J w! Ih 1"III"! I Iy 'I' 1,11111/1,\ 7",!..rhn II nllll .!!.~, ~,'JJ!)_.J."..d,I.lJ"a.!!
1""'.1 '. !!HIII,.".A_l'!'.".,I,,<I, . ....,. ..-
'" 'lilY IllvI'JI WII,k <lny, Ih,' .'11""1 "IIIH
11I'lId x .. ,"'1 III "" IIr('II" 111111111 v r 11"11 II'JI , I Y
1-''111,11. 11111 III ,1111 11I'('111\ 111111I11 v x r tI"I"rJlI I Y
kll"r' tlut III 1111 X ,"'(''.." 111'"1 II v r tI"I'II'1I11 y
('I !mh lI1lt i" " " ,~ II.'.'M' 11111" II Y rYI"II,,"11 Y
Ifilli'll 11111 III "" " """M' 111'"" I v rtl","rlllly
.'
rynwl x 11111 it', nil '"'('"'' 1.1111111 v 11""1""111 I Y
t:li"JlI I'on II rl/r.1ll Y'
f'llIIlI II,,, r 111111' 1I II III" II('C"" illll,,11 Y () I"" I I "'1"""11 v () Ihll "'1111 11111111'1 I Y
'''',1111,,''11 'ii 111/1 'II'r"" I II iii I I' \I Ii II". r '1"1""1111 y .l!, 1It/l .~nnl 1111111/' I Y
W;t\I<I/IYlIIII. lp'vl'1 J.L, lit" 'I<'enl'l 1011,111 y ..9., "'1< I I "'1111"11,1 Y 'i ilIA ClIll111I1JII1l1 Y
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S.pt.mber 11, 19,a
RII IARIIR, Dal. S.
533 N. Inola Drive
Inola, PA 11025
AOII 31
SSI, 111-l8-alal
STUDY' Mal of the lumbar apine.
RlrlARINO PHYSICIAN' Jonathan Tock., M. D.
CLINICAL HISTORYI Low back pain, right foot numbn....
MRI PULSI SEQUENCES 1 1. T1t T2 aagittal
2. Tl, MPOR axial
COMMINTSI Lumbar ver:tebra. au of normal dun'l
intenaity, height and alignment. Th.r. 1. a
focal ana of incrnaed ligna! intenllity within the inferior
.ndplate of T12conaiatent with a hemangioma.
Th. La-51 dilc h.. d.cr....d 119nU intenlity con.i.tent with
deg.neration and dehydration. Thera ia a diUu.. annular bul'll but
no evid.nce of focal herniation. The 11 roota are w.ll delin.at.d
without dhplac.mant. The L!I rooh an normal. rac.t :Joint
hyp.rtrophy i. noted.
At L4-!l the diac ia degenerative with a mou prominent dltfuaa
annular bulge indenting the thecal .ao. Th.re il no evidence of
focal herniation in the L4 roota and neural foramina are normal.
Mild facet :Joint overgrowth ia noted.
At L3-4 the dilo ia degenerative and dehydrated with a mild diffua.
.nnular bUl'l. alightly indentinq the theoal lac. Th.u i. no
.vid.no. of fooal diac h.rniation. The remaining lumbar dilo, .how'
moderately good hydration with the exception of early d.hydration
of the Ll-2 diec. There is no evidence of spi"al .t.noala. The
COllUa end cauda equina are normal.
CONCLUSION,
hern lation.
Degenerative bUlging L3-4, L4-!l and La-Il
dilcs. No evidenoe of diloret. fooal dhc
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moo Slvm.ld RIO'd ,.....____
06160 AII.rg, I VIii _._""
06166 A"",O'I ~. Viall _, __.
06010 All.", Inl"d",m~ 1,10_
OffiCI VlfTl
Hew'lIllnl
IQOOO .'1.'_,....___.
10010 lImIIH__..__
10011 In'l'm.C_...___
- 10017 1,lOndH_,_,.
-- 10010 CantJ""____...
= )(J71t 'IIMD__,.._._..
WILL CHILD 0fP1C1 VIIITI
NIW 'I","'
10761
= 10762
_ 107n
_ 10764
",17VII__
I,IIV'I..__
1-1 VII__
Under I V, .._,_.
hllblllll. PI"""
10711 11,17 VII_
107t1 I,ll VII
-- 101" 1,6 VII
- 00764 Under I V, ___
lMaRGINe' OffICI VIIITI
Now 01 hltblllhtd PII",'
\mOIl..., ke~,"I_
- WIOOUmer Mldlcli ___
= .llml'OV__
IN Of'1CI LAllOIlATOIl' TUTI
171011' OT'" CIIII_._
- t31/1'OIvalIl___
-- 171061' G,.m II~'_.
- llOUlP H.mIIOCl"_.
172101' KOH P"p_
1I11/l' Monotpol___
II 7011' "10.1.'1 _
1II101P 11II1.. P'Ip_
IIII1ZP SI,1p SOlI'" _
_ l,...zP UA C~II "nt_..
_ 1I0l01P t)1"~11I ___
_ 1~/lP U,lnt C"",__
1IlMUIIZA11OHI
10711 ADULT dT_
lilt I A""O'__
_. 10701 OPT _.__
10m HIB __
- 10711 ~,"JJ___.
= 10/0/ MMR
10711 OPV__
-- 107U ,..",.,..,__
= 1111I TI Tint ___,
. . . . ''''''''''''1 "lTlJAN THII 'OAM l'Q THI "I~'QN"T · · . ·
DtAONOI.
lQtI ""'_.______
"U AiI.,Vr. .---.-
m I AiI"V' AIlinil.
mo AI..." _
183 00 .IIlhm., I.lllnlle_
mo ".neIIltII, "....~_
....- l"l ....eNliI' Chr..Ie_
..,.. III 0 eNl
mo Qf
'~~'~~ moo Conjun"IYI",,' Acvtl_
lit OOPO___
ml COllOOhllfldlIUI___
IOU o.pllllon' IndoglnM _
26000 01....., Nan.lnIViI. _
192,1 Wt'd
7.1.7 "lOue
2710 ~,.,"'oI.lIIOItm'.__
lOll l"pa~lnIIOfl
m 1 ""Ii..
2110 Oblll"____
115 oe OIl...,lhrill.
,muhlpla III. ____
ll301 OallOpOlOIia
,Poll m...,....__
m 0 011111 Madl.
, ~'I IUIlll'J"'IY'__
ilIl 01 O"'il Madl. ' SerOVl_
V7U PAP
4U PhlrynOlil
V70,l A<lVIinll'III1l_,_
VIM FbJIk>. &...
.Imploym"" ___
11I1 1IIn~IIiI, Acult_
W2 SI,lIn, L.vmbe,
OllO SI,., Th,..1 __..
m,l URI
6",0 UTt_____
111,10 VII'r,ll.
V701 W'II Advll___
VIO 2 Will.."
..-. - -~_.-_..-------_.
LIMITATIONS AND INSTRUCTIONI ;~'~~-~'S BAlANCI_ .. milt.
---------.--.. -----;;--------- TOll"V'S CHARGES . .1.,~. I ')__
. ,J:.t!:.." I._~~_ LJ!-_I-'.i....-L.L.Ji.. -,'" . -
.,-'T-r) -r.'- ",-;i r"-- --- PAYMENIS U
!lL..._.'._,'JL:3...I<'4-:--._ MCMSA
,.J;t-_..--.!j-"--'-""'-fj';"---;-K;; CK'__._ CASH _ __
:-, '~--f-:-'--- I~'T!'::. BA~A"CI .~ ,/,.ll...._
RECALL . . .
0'" W..kl ,.."'_ Menll" I 0 NO, 232ISII" IllS NO, cumuo
,,-.... _'_I ~IRLAND'AIlIl.YPtlACTICI
......" ...-, - . __I -":;-o:-r;;' d 1'" iIONATHAN I TOCKS, II 0,
-. --...- -- -.e...LfJ!. '" RICIWVlL. DAVIl, '" 0,
=-----=~-~~..~.:~f:ti-.:rl.J 1~ ,., ~".. <.._, II V> LISAM OAVlS,MO
,,--- ---.:J/'T" - /. I , "'70V~llVRONl
---.. ...----. ,-1 --, '.1 ,-,I,) , "'''' .L~I/OIl.'S)SC.tLlu'~_------- lNOIA(7t1)~""~
.......~.....nl', ':').l:.I~--:::i.......~, N" n. ,.. ON
i.- , _ .I~ ,(jJ
ORAWINO ma
3UII M.dl.I"_____..
.-.- lUll BlueShlold..._".......,.._
SMlTN KLINE LA' TIITlNO
lOOIV P,.fill UI_ _.... _ ".
10011.13720,13S16
CllEMFb __.,,_.,..
CO'. 2 Plnol___
cee wllh 0111 ..,_._ ...
~dlI___..__
I'ec"."ltt _..._
OC BerHn __.._
1 OIT _,_..
3 OIT ___._.
ItarPII Cvll_,.._.
PAP___.._._.",
P'''lI.lncy ..___._ ,
ISarvm)
""0 PfCllh,.."bln Tlmt....._,_
Uln RPA _ .
"'" SO<! R." WIII__.._ .
17011 SI..',CvlI_._ "......
11011 SlOOf 0'1. . P.rt.___.
IW' URIA _._.._.._._.
Ulll ISH~_._.......",___
100 70 Thyroid Pon" _..___" _
IIlIS T.,'" Cholll"fCll .. ..
mOl
1602S
11I171
1000l
11070
"'60
Ill"
11260
III"
mOl
1)"1,,, 1',,,,,,,,~ II,." h~,.
'::JJ """, III F.Il0I" 111 I II"
F.1'o:"'1 Pfl ,,'1),''3
Il""" NK-III' 1:J2~!\'J" IJ", ~ n.",~'
Ot.IhI. ~, Illdh: ,u, 3 ~t
HOI"T AL II~YII:II
( ) IIoIy SPill 'lotp".I, Comp HIM, PA
( I 14."1'00'1 1I.."".t, 14l1ntbu,., PA
Adm.llonOI" ..__.....,_......__.._...
Oilll>"I'O... ....'_,_..._ ..".",
VOIII Ntwbcl. 1nI1111.. ._ ....... '"
.0120 ~illll_._.._........, ...._...
'OUO .,1.'___...,..,..._._..
.0210 ~1t'mtdi.1O _. .._.._......_
'0~10 i,ltnd.d ___..___._,
VOIOI CDnI~llnll'mtd___..__
80110 eontllllllltndO<!.___.._
VOelO C"'~I Com",,,,. _._,~
10110 (m", Am "'.mO<! ..___.
VOll0 Im..Am 1.1Indtd__,.._..
1\0211 01""..,.___.___
10010 aWl Aft.. on, "0111'___
tlOII SINiot IOpm .... ___
.00S4 SVII Svn, . Hold.,. __..__
."eo CIUI.., C."._____
HURliNG HOM! YIIITI
Skilled
1"111.1____.._......._._..
Inllrmed, _._ ...._._______.
h".d.d _..~_..._...
.0320
00310
10310
N., Sklll.d
IOl20 1.111.1__.____.
OOl'O '.,llm.d_____
10110 E,,,nd.d _._____
MEDICATIONS PutlCHAIlD
.--- --.-. - ._~----_._----.
-..----------
----_.,--~--.---------
..-.----.......----
'-/) II ~
6,,1 7,_,
c:'lI1 11l1-1ll';) P I
I""
~'F \\~ \,11 t
( \
')
,/
-., ."
",II I ~tll p..,t"".." ",.I~ I) 110
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New P,IItnI
eoooo 1,1" _._.__.n_.
toOlO llmllll4_"_.__,_._
toOI8 Inl..m.d.______
toOlI IlllndtL__.___
100'0 CalljIIn._ _._._
.'7" PIMD_.,____.
hlllbllthll4 PIII""
10010 "...... -m- 1-;;:-
100'0 1,1., ' f \' t ,,:,.::=
10080 Inl..m.d.:.:.-_
10070 Elllndtd___. -,-.-
10080 Coml'n._~'I1-':'::
mil PtMc----'-.---':'., '..___
1) ,
-I..: .
" -
Will CHILD OffICI VII/TI
Nt. p.llen'
t0781
10m
lorn
10781
tt,l7 V,,______
8,IIV,,__
',8V,,___
Und.., v, ___
hltbllthll4P.II",'
107" If.'7 v,,_._,_
10m 8,11 V"___
---- 10781 1,8 V"__
- 107.. Und,,' VI ___
IMlIlOINCY Offlca VII/TI
Hew 0l1.1IbI~'" P""'I
WIOO6 E..., keid",' ____
-- WtOOtlm..Mtd!cll ___
-- M8 1m.. OV
IN O"ICI LAIDIIATotIY TIfT.
1710'l' DTlI CUI__
'2IHl' OIu,o.._____
mom o"m 81t1n__
'!O"ZP Ht",.IOC.'__
.7'roZP KOH "'P_
.117ZP IolorlolpGl__.
.. roup "....n" __
.mol' hUn. PItp ___
.1I7l' 81'", 8,,,,,,, __
.llItl' UA Cu' . Ilenl_
lIoooZP l)1"~I~_
.10I71P Urine Cu~___
MlJNlZATlONI
t0711 ADULT dl_
.11& All.." ___
10701 DPT_____
10m HII .
1072' Inbn____
10707 1I11R
10m OPV
10m ",..".,..__
81515 II Tint ___
PLIAU AITU"N THII 'OAM TO ~ "ICIPTION'''' · · · ·
D1AONOM
71111 ,....
--- "8,1 All.."
.,..- ml AII.IiI.1lIllnlt1t
--- 3000 Anllt~
..-, moo Allllme, ..1rintIt.
'h'_ ...,0 "'/llIIl!tll,'"
--- '" I Itondllil, ClIv
--"'0 OAG
-- UfO (W
-..- moo ~unDt/lil 0 ,..
__I m COPD _
-- 73U Co.'Hhondrill.
---- "" Dtpwlln,
-,- '80,00 DWltIIt' NIn.lntuIn
=ml (j,~
710,7 'ell'"
==",0 ",.,1II1l1.....".
_ >\01.1 """"'11,"_
UU ",.1Int 0
:::::::: mo Obtllty
718,08 O.,....IIl'w.
omultlPtlilff
7330' OtIfGpDfllll~
, 1'0&1 m....,..,.. .
__._ mo 0IIt1t ,...
, Aculf ,"""..live
OIIllllltdlt ' ......
PAP
Phe,.,,,,ld.
f1auiln.I..",
""*" fmt
olm,*,m"'"
.81.1 ~lJIMII ' Mull
)( 1'1,' IlrIIn, rr-
oRO .'Siri; ..e
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"10 UTI
_ "8'0 V'I'nh~
VIOl W." Adu~
,-.-..-.------.- - vro, 1YtII""
~.
PROCIIlUllII
'MOO ~_._..___.
"8U AudIDm.,,.,__._.
JI030 ~ Dtpo/,lll4"" .0 mg ,"
'7 DO'liucllon (.",.) _ ...
Ai"8 8U/giell T,., h___h__
83000 IKG WllnI..p _____......_
15'02 fndo~p.____
WIl2& InII~ntpMn' ':IOOOcc__
" l'dthln(lttionl,_.__
12"1 I,. Ol.n_. __... .
12"0 H.m...ulI_._ ._...._
1n70 HtmIlO<\lh,'____._._.
10 I...~hln 8 Dreln. _,__,
:lOf~~jtclhln'..lllnl_._",...
'20 It,,,,'lon Rflltl' _.......
Jim IrjK....Io9'Oml.__.__
u"o PttIl/low_____._.
.5330 S~m~d FI.. _._,___
'5300 811mold Rllld ___....._.
Imo An"" I VIti _____
Ims Ab,i'I" VI,I. ._,___
150'0 AP'rwlnl"d..mtll,IO_
DRAWINO 'UI
,U15 M.dl'..._..,.__..__....,
--,_, 3U18 81lJ1llhltld____.__,
SMITH KLlNI LA' mnNO
10011 P,oPI. ..1_____
10011.117'0.135.S
ClIM Pk>> __-0_____
C.., Ptntl__ _...._.
COO wilh Dill ____
~------
fl'C1'O~I" ___._.____
OC !o,..., ___....____ . .,.
, OIT ,,___.___.....____
, OIT ______ __..
H.."", Cull.., _:m_. ..
PAP ___ __.._.
P,ogn.ney ___.____.
(S..uml
"8'0 P"'~lom~n Tim. _._._,._
.1512 RPR______,_.
8181' 8td ROlf Wn'____'
170'1 8'00I,CulI__,__
11018 SIooI O'I.IP... ._.__,
..U8 URIA----o-.---l'-'
..." ISH________
100 70 I~r~d Pen", ____ '
lUll Totti Ch~nl,,",1 ...L_~' ,
11381
15021
.171
10003
17070
12150
mil
.,,10
18118
..,03
HOtPlT AL I."VIC..
I I Half 8p1,III"'plllllo C"'" till, PA
( ) Ht.~b<J'1 Hotpllel, Htrritbu,g, PA
Admillionlltlt ..______._."._,_
Olllll""~::~ Newborn ~11.c-:=':=::
10m 1n1l1.1____.___...._____.
10UO 1,1., _,_0-_.____.__.
lotiO 1n1ll,"'lI4ltll__...__,
10"0 ...lIndtd __.--.'_
10101 COn.ullnl..med_.___
lOll I 0 C......h I.ttnded h__' _.___
10120 CclnIutIComl'tIIn_._,____
10510 Im..'".~I.med___
10870 I.... Am, f..1fndtd _____
10'12 Dltl/I"...
11050 IYO, Aft.. Oil, l......
110" 8ffVIot 'Oprn .... __..
11014 8,,,, SUIl, 8 HoIdllY' __._
"'10 C,III"I C...___
-,..-.--.-------- ,
NURtlNO HOMe VIIITI
SkiPod
Inlllal
Inl..m.d_____
hlfndtd .__.__
10320
103S0
10370
Non8kill.d
10'20 Inlll.,
10UO Inlt,!".d__._
10.70 f'''.d.d____.
MEDICATlON8 PURCHASID
311.0'
V7f3
..,
- VI03
-0- vro 8
LIMITATlONI AND 'NITRUCTIONI PR&VIOUS IALANCE
Li=r._t1.d:.'l44-' .#...... I I J.( )&lA'C1 CHAROU ~
_______m_._______ PAVlIENI8 o' --
f..j}~_, t -)4 0J. ,--...' \, ':.: ';CK;__ CAlli' -ry ~MlA
l.W~~' ~:)/ --- ----.- 8ALANCl /' ,-
14-.' ~ h'_ w.akI _ ",...11I. 1.0, NO, 21.U8... M NO, CU,8I
", ) Y CUMlIIlLAHO,NaYPIlACTlCl
=.~=-==-~.::::=~~:.-.-:-=~==;.:.. }..~, .. ()I''J " /.'/, ,~=~.,~~'~,D,I
::::::..:===:-=:=-=--=-==-\-:~, n I (,~ \f "I ,I ~ ~ / ~ I 7';~ LISAM OAIUD
___,.,,_______h..____, '-470 VmIY ROAD
:.:.::.=~==~-=:-=~=--:::::.:=-.- p l\~8{S(~A~~ (~~,::
roo II ~"I n'll.. ~."" ,...'J 9." hor
!l~3 "1"1 I,h EII"I", 0, I ','O!
fElI,)I", rn 17m.,
II...... Fh...\. '712..~'5!1A IIntl< F'hCltio
Oill,\! "r flll'lh' ,.~Il ~ 15,1
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i
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,
r"l.l,~nl Flr1''''I'~'' rh,,,, n rWI ( \
· "-.,LUI. II.TUAN 1HII '0"'" TO TH~Cl.PTIONI" · . · ·
HOIP1I4L II~YICI'
I ) I~ BpIIlllklIpll'l, c...p I~I, P4
I I II.",.lMJ"lklIpll.l, H.,ri.bu'l, P4
AdmllliGnDaIt ________..____ H _00 .___
DIII/w..O.I' ___._______.____.__
10m N..born 1nI11.1__ ____ ___
.. - .0110 '"11111....___,,____.,,____
.oa.o "I., __________
.ono '"1I'modllll_.____n___.
.0110 1,lInd1d __"n'_"__'
.0101 Con.ull ,"llImod___._._.
10110 Conlllkl"andod .____._,,_"
'OUO ColaultCom"..n_______
-- -"" .0110 1m.. Rm .,II/mod ____._".
.0110 I....Rm I'ilndod________.
.0112 Olldl...._______
11010 Bve. 4h.. Oft. Hcu"__
11011 I.,.,.,. IOpm.lam _",,__
11084 Bv... Bun. Uloid", ___
.1110 C,III..I C.,,_____
'ROC'OUIIII
.1100 ~~_"
.a6" Audlom",., n. .. ._
JIOoo Inja llaplI,todllll All me
II. Olllm.llon IWIII.)_
4.ii'1 IU'fIcoll,,'I_ .
.3000 I~O WI ,"llIp ,,_ .".
.110a Intfo4lp___ ____00'
Willi"" 'pln.ph'.. I'IOOOcc .
1.lIbIah.Htllanl II EIljalon IlaIiGnl __
'00'0 ......____.__00_00_ "ii. 1'I.cna"__._ _
t0040 "I., _.-,,-,-- - /4'- 'mlG II.mocc,II_,,_._,,__ __ ._.
toolO Inll,mld"_-i_/-1-1 " _ _ _ Imo ~'3______ _
tool0 IllIndld ____ . .)... 10 _. Inclllon .0.1.." _____"
tootO OtJtn(Ititt_-----4" ':......" lOt _,_ """lion, Jolnl__ _..._
M1741 PeMI ___H'''''' 1110.. leClrll~n Rapel, __. _
" ,.,e:.. - Jltiilnj~In""".Omg
WILL CIllO C)f"1C1 Y11l7' n .4110 P_fIlIo_____._
New ,.tlanl 4mO BlemolHIII.____
to7lt 11.17 YII__,,_ moo BI.moIdRI.1d .____
IOIU 1.11 YII_.._ .11I0 Aller" I~" __________
107U 1.1 YII ____ .11I1 AI"I'II. ~al..__ u_.
to714 lWl/ I y, ____ 11010 A"''V'Ilnlr.darmtl 1.10_
!mICI v."'
New P.tlanl
tooOO ,,'.1,,_ _.'''' ,
tOOlO Llmlled____ _".
too" 'nlllmIC...
. tool 7 1.11"'_,,_,,__.,
tooJO OtJtn(Ititt__,,___.
)(1741 ,1i';It_______
lllabh/led '..lnl
to711 11.17 YII__.
'~7U 1.11 YII__._
107U I.IYII__
'0711 Und.. I y,__
DflAWtNO 'IU
".16 M.dl"""_._,, __"_,,
3UII BIUlBhlold____n.__.
IMlTH KlINI LAB TIITlNO
1001' p,om. 1..____" _,,___
'001',f37aO.Um
CH!MPh.I____n__" H
mil c..aPanll_"__,,.__
16026 CIC wllh Dill . ,,__
.171 ~_.______
'000' 11..IIOIIIt._ _ ___._
.,0,0 ac Be,... _____ "__.,,_,,
m60 I aIT _________.__
111I1 , aIT _"__.___,,,
Imo H.."" Cull__ ---, "
11161 PAP ___ ""u_
1410' P,ognl....., .__,,_ _____
(Btrum)
11110 p,.II"om~n Tlm......___
elltl RPR ____00_
16161 Bed Rill WI"___._ ....
11048 81001.C'II_.______
11016 BIIlOI ov.IP". __no.
eWI TlRrA _..__.________.__
II'" TBH__m___....
10010 Th'lrold Panel_________.
n.11 701. Ch~..,OIOI _, . _,.
.MlIIIMNCYomca v.n,
~ 0I11111l1i11ltd Pallnt
WIOOIlrnar 4ceidln'_.
-- WIOOIInIOIMIdIolI__.
= IIIOIllmlrOV__
IN C)f"lel LAIOIlATDflY TUTI
.7101ZP OTM CuI'___
8347ZP olu,oll_
17a05lP Orlm SIIlin__
IIOUZP Hem.lllCri'_
172I1OlP KOH p"p_
.311ZP t.IonotpOI__.
..lOllP "....ney ___
17RIOZP BalIne Prep_
IIOIllP BUap ""In_
17t9tll' UA Oull & lena_
ItGOOlP \)"'~liI __
17~llP lhinl Cu"_
IIIIlUNIZA TTONI
to7t& ADULT dT ___
IBm AII""____
to701 OPT
10737 HII
.0714 ~II
'0101 MMA__.____.
10111 OPV.
10m ".",..,.,__,__
tlm II TI..
Da",~ 0 f~OA.O.IC/l
NURIINO HOMI YIBITI
SIIII"
00110 Inlllll____
.01l0 'nlllm.d___.__.
.0370 bllndld ___.._.._
NonBllllld
.0410 1n1l1.1 ___
.0410 Inlllmld
.0470 b".dld ____
MEOICATlONS PUIICHAlIO
~MIVI~N~ ~~ !:~T~~~TIONI
==r;~-1-'.ti (l ;;:;.-:----
-'------"--J5--==-
:T..:l."iiIi... fA MI ,. 7:. _
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, .' uJUd
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IIU Nllr,r.' __
-'"- 477' AIII"olllllnMIa__
----- "lO0 An'II~____
---- '13.00 ,.""".. ..1rIn1lo__
-",,- ....0 lIIollOhltll. ~
.-- .'1' "'onchl"" Clwotllol
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--- utO Of
- --- moo Conjun.tIYIla, Aoutt _
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iIIU .....Ion..".....,. _
--- 11000 1lIabalaa. NDn.1nIulIn _
.._~_. In.. "'~.'''__
--. 110. 7 ~...~
= mo Ittp,""oIl1tnllmil_
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m,
1710 OIlI.lty
711.~ OIIHlrlh,1I11
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73iI 01 Oallopo/Qlil
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m.o Ollila Ma4II
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412
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-- 116.10
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PREYIOUB BALANCI -{7-
TOD4Y'1 CH4RaEB~'-
P4VMENTB .~
CK'_._. C4BH _ MCMBA
BALANCI (IV "
10 NO. RU4'"es 8/S NO. cum4
cur.IIIlIl.AHO ''''I''.I1t1ACTICI
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4410 VAlI.IV ROM
INOtAPAIIWI
171 n 13211"
{t' ..f .'9 2.
Q:'3l>
(~( )
"'.' "
. . ~1A11 "ITURN THII 'O"M TO THI ~"TIONI" · , · ·
HO'''TAL "~YICII OIMHOI.
I I 11ol)o Sp,I, Hoapllll, Camp HII, P4 _..-:~ :'''r.-
I I 1t",I.lMJ'l Hoapllll, Hwri.bu", PA . .-- 477' NI.". ""'nHIa.__
Adl1l~uIonDtI' ---.----..---.-. -~ 300,0 Mlltr,
Dilen".. Dill ._-.-.- --- 413.00 AlIhm.. nlrllllla__
IO~II NIIIOlJotn 1nI.11________ ___'"_ .....
10"0 tnl'.1 "'.0 "'nohIHa. """'_~
..-. - .. ,,---,----- - ...., a/l,noillHa. CIvOllIa_
10340 Iii., _,,_______ "_,,
10al0 tnllrmedl'II______ _.: :::~ ~___
10m 1'lInd.d ---.~-- -__-.-._ '7200 ~UllCilYllIa. Acutt_
10.01 Conlull '"Iormod,,___._._ _
fOlIO Conllllll"ondod,,___~__ ... co 0_
'0"0 "-"I".-pt..n__ --- 7331 CollOohondrill.__
10lio im;;"'~I.mod __".-- lilt Depr..Ion. ........_
I n-I ~~ - 110.00 IliabeIaa.NM."*,,,_
10110 ""'...... ......___ _
10m DIId1".._______ _'" .121 fi,"'"".
11010 Bvc. Anll 0" Houll__ 1107 ,."..
1I0Il B.,.,1co IOpmIam ____ :~=: mo ~,*r:lloI."'.mle_
110'. SVCllI<Jn.' Hold..,. __ .011 ~""'''''O/l___
11110 C,III..1 C./I_____ U... t,tv-
111 0 OIll.lIy
71101 OlllOorlh,,".
. mulllpla .11.__
"'.01 Oalltlpomlle
. Poalmonope...__
__ III 0 01161 Mo.
. Acull ,uPPU"IYI_
31'01 01111. MedII . SIIM_.
VII.' PAP
III Phlrynll..____
VIM ""'line I'''''
V70.1 """'" bam
.Impioymant __
.1" BlnUlIIla. Acu"_
117.~ I"aln, Lumber
0".0 1"" Thro.1 __
.eu lJAl__
--- -- 111.0 UTI
..- 11110 V'llnllla.
V70' W.1t Adull
--,--,,--,,----- __ VIU W"labf
-:_-~- ~~~-=--===-= ----lU...l.":f.l. ~'(,ir+::r
.- ..,-..-.. -...,., .
'RooIOUHII
'''00 ~_..
mn Audlom.lry_______ "
Jlooo "'JaOlllol.todnlilOml._
11 OWII,ucllon (willi) _m_
4'"1 IUlIIc.t' 1"'1___.. _ _
UOOO IMO wllnlt,p._ .
11I01 IndoAlp___..,,____
"__u_ WI,1lI Inj IplnophrinallOOOcc_
..'llb!ahod P...., _____ "__ f...1on IleaiOll) """__'u__
10030 MrmI._.____ m.. I'll enl"_ _u_
.00.0 1'11'___- '!lil.E 'U70 H.moccuIL......
'0010 'nlorm~d' I . um H"!IC)cllIIlI,' _.____._
, 10010 I'll",," I ,~~:.'~: 10 __ ~1IIon' Orlln. ______
'00'0 CclmjJ _' '! I ...-e_ lOt _ ~jlcllon . Joint_. _ _, ._
MIt.t PeMI , .' - 110 l...,.lIon Rape,,,__ ___
JluO InjK..atov.Oml___
""0 P_fW_.___ _,,_
m,o BlemolHl1I .___H____
moo BIGmoldRllld __ __'_00
Imo AI."y I ~a1 _______
01111 4n1l1'/2. ~"',,_____
11010 A.IIV'! 'n""dllm" 1.10"
OffICI V.",
NowP.
10000 "II' ________
10010 Llmll"_______
10011 Inlarmld____
10011 1.llnHd ____,
- 10010 ComjroM_____.
= )(1141 PeMc______
WILL CIllO OffICI YIIfII
Now ,"...,
10711
.om
'071'
107U
'7,,"----
,'(J __~__
n.17 VII___
I.IIVII__
1.1 YI'
Undll I Y, ___'n
IlIlbIah" PI...I
10111 12.11 VII__
101U 1.11 yll____
-- 10113 1.1 YII
= 107.. Undar I Y, __"
IMI~IHCY Omcl VIIITt
Now or IlIobIlahld P....I
WIOOB lma, Acdd.., ___
- WIOOB 1m.. ModIoIl __
= _llmarOV___
'" C)f"1CI LAIOIIATOIIY nITs
"IOIZP OTM Cull____
mmp alu.o..
"lOll' allm SI,,"__
lIOIIZP Hlm.lOcril_
I1tIOZ' KOH p"p__
.tl7l' MonOlpOl_
..IOIZP "..".ncy _
-- .mol' Ulna '"p_
= .OI7Z' 11'" 1....._
.1tII1P UA Cull 1 11",_
= .'OOOZP l)1na~'1a _
_ 17OI7zP U,~. QuII__
IIllIJNIZATQtI
107t1 4DULT d7 __..___
"III AIII"'I
10101 DPT____
'01" HII_,,_.
10714 ........__
.0707 MMR__
110m OPV
'_ .om ~_._.
\ -'-- lUll II Tina ___
ORAWIHO 'III
'"IB M.dl,,,"__..___
'UII IlIuaBhlold..." ._"
1"'7H KLlNI LA' UlnNO
1001' PlOftI. ..... ____
10011,1"aO,.'1.6
ClIM PlJa ________
U311 C.U""lI_.."..",,.._._
non CIC "'lIh 0111 ____
11m CI1Ilm'fdlo_..,,____
'000' 11..lrolyll. ____ '_"____'
11010 ac Be,,," ,,__,,_ ___._
11110 I all ___.._,,___
mBI 0 all _______.___
11210 H.,,,,, Cull__.____,"
111I1 PAP_____".__.
UTO' P'lQnlncy __On
IB."ml
16110 PlOIh,ombln Ilm._... __.
11I11 RPR
11I11 Sod RI" WIII._..__ _""
lIon Blool,ClJlI__.. _"
IIOIB BIooIOY.IP.,,__,,__
U431 URl4 '_'''d'__
...., 1611______._ ___,
~:= 10070 Thyroid Pan"______
U.'I IOIaI Cholll'.,o' __ "'_,,_.
---..~.~_._---.---~_..-..-. ".-
P"'.I"''''' I""" Cl.f'II1IOl\lIl"""M'
~:H If,'rt.h F.MI'1 OI'I~'"
F.""I" rn ti'ln'l
....""" rhm,.' 11 ~. ,t'l!lll "",'k r"".,~.
!lilt_ IIf Bldh ,.U.:I 'Ii
_._._-,.,---~._-------
HUAIING 1I0Ml YIIII'
Skill"
10330
103.0
10370
lion $klll.d
10. ao InlllO'
10..0 Inlllmld_____._n
-:':. '01/0 E.lfndle_
MlDICAnONS PUIICHAlIO
Inlllll_______
'nl.,mld_____.
f'lIndld _.____
LIMIIATIONI AND INSIRUCTION. PREVIOUB 14LANCI
:s.Ji7'i------.rz;,'- ./_ <?~"Ij.,,- lODAYB CHARau____
------------..-:z-- ~,,'~ - "- PAYMENIS _____
_-.::L-1!_~?;;':"L.IJi_\'.1:l.H,,4c",^ CKI__~ C4SH _ MCN'B4_
_____" --------"-7:,(7;;,) IIr'A[ANC! ~;;> ~::::::..-._
,A!C~l~n'l' _ .. ,,_ WI.k. _.__" MJ~i It, \.. 10. 110. IUIUI. IIiS NO. CUll ,.110
,.,,- r , ~1~LANO'_YPllACI1CI
( " ., - -.':>" AIHAN.. TooKS, MO
".-". RlCIWlllOAVIB, MD
LISA M DAVII",,' 0
4410 V4LlEYR04D
EOOlAPA 110IlS I/tr'
1711) 73UI"
,:11 -. ~ ./
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.--- DOCIORS SIQ AlUM
o;~I' 113' l1'l.""
,,\~:
q.. /I.f.)~
to."
\'^J
r"'.I.,,,. p,.,.,,,r,. l1>'I!' rl Ijlj
· r'\LIAI. ".TURN THII rOAM TO TH.~.PTION"T . · . .
HOt"T AL IUYICII OIAONOI.
I ) IloI'f B~,lllklI~III, Cam,"", PA /OJ! ,..,..____.
I I 1l."illMJ'l IklIpllIl, Iletri.lMJ'l, PA .. - .-. IIU A11'::f.
Adr;:lJong-:' ,,---------._-----...-:~: ~:~; ~1"1I1--
01. ""10:1: N..bot'-InII1.I=~-:-__-=: --.. :::~ ~-:~~===
.0llO 'nlll.I..____.._.___.. '111 1r000000lla, C1wanl_
10110 l'I.'____._____m. ...-- ~1l0 CAD.
10110 Inll,mldll"_____.,,_u___ -.-- 11I0 Qf
G0l10 e'lIndadl_:;-,,_ _ ". - __-.": m 00 ~undvllIa' AaulI_
10101 Conlull nlllm.. ...,,--... co;
10810 Conlllll hlondld ,---- - -.--. ~~I :~IIon4,llIa___=:
GOUO ConiuitConl"'..._____. ........
10610 1m. Rm "'.mod -.---, :~ =~ Non.I1Mn -=
10110 Emili Rm, e,IIndod.___.. __
10m Olldllll.._____ =-- III I 1Jr9Ir-,.
nolO BY. All.. 0", Hcu"____ 710,7 ,.....
lion S....1oI lOpmIam _____._ == mo "'plldlol.lIrOiInlla_
11064 SVCl Sun, I Hold..,. ...__ IOU :t::.ioft
11110 C,IH..I C.,,__.____ 'II I
m 0 Obl.lty
711,01 OllaOlrlhrl".
. mulllpla.lI.
7:13 01 O'.......la
. Poal mll'lOllllM _~
,no 01111 MadII
. Acul. .ullllU"....__
061. Media . SI/ouI_
PAP ___
Ph.ry..I~'
Roullnllum
Ro<.t>a &.ll
.lm~m,"I__
111.1 81nuallla. Acull__
841,' IlIlin, Lumbar __
0'10 II,., Thro.'
IIU URI
1110 un
1".10 V'llnllla
__u____,______._ = VIOl Wtll Adutl
------------.--- __ VIIO. WelW.
-::::::.: ~ ..::-~=--=-= :;J:; :." -tJ'<1~,di~e~
'RooIOUllU
IMQO ~_._.
----". mu Audlomll'Y__ _.......
JIOoo In~ OopoMldlOl.O me __
17 O"I,..lIon IWI"')
4iisI B.......' T,ll'/ .. _
moo IKG Wi '"II'. .
III0a 1,.,,4Ip______.__
W1316 Inj Ipln""'''nIlIOln-.c _
II"'ed P...., '_::::;" ___ l'd.IonII..~nl_
toO~O ...... --- "..-- I ;.1 Iml l'Ia en." _... .
10010 1,la'__...LT,' ~/ 'WO Hamoa:ull"_"_,,,,
10010 'nll,m'(+VL " --" Imo Il.n~.'__
10070 1'"ndadL.......+, ~ 'j.::: 10___ lA:ilklnllllllnlQll._m
__ 10010 Comortitt__!L .;:. _.. 110I__ ,"jlclion . Jolnl___,
__ mil hMo-----r)"J. _. _.. 1110 __La.."Hon R.... u
'Y __.. _ JllIIl II; Kanalot 10 mi.
WILL CMU Of'.1C1 YIIl71 84 "0 p_ r.w _un._____....
1Iew'1IIon1 ".--- 163'0 BlemolHIII_."...
_ toll1 It 17 Y,,___. moo BllmDI4Rilld __. __"
- tom I,ll YII___ 16110 Mill' I VIII ___,__
,_ to7U t-I YII __.._ .:._____ 16111 A!1II1'/ h Vlo.________
to7U !War I y, ____._ _,____. nolO AliIV'! 'nl..darmlJIIO__
OPfICIY'''1
""PIIIonI
__ 1OOtI0 1'11'.__..._
10010 Llmlled____
- 10011 Inl"med.___._
- 10017 .....d_._".__.
= tOOaO eo."titt ___..
_ 11I7" PalYlD__._.____
IIl1b11ahod PIII..I
10711 "'7 Y'I____
107U 1.11 Y,.____._
-- 107" 1,1 y,. __-0__
= '0784 Undar I Y, ___.,_
..~INCY omeI VIlTI
,... 0/ lallbllhld P....I
WIOOIlmar 4ccId"1___
- WIOOlIm...'.... ____
- ItoII Imar OV
II DmCI LAIOIlATOIlY TlIII
17t01ZP OIM Cull_
- QIol7ZP OIuc"..___
- '7toeZP a..m SlaIn_
- IIOIIZP Hemllocril__
- 17U0ZP KOH PII,_
- .,,7ZP Mono.IlDI._
- 8470tZP "....n.., _
- 17lI0ZPlltna,,,,,_
= .mzp Sir., S..... ._
17",lI' U4 Cull I Sa", _
= lIIlOOZP l)tna~lla_
__ 17OI7ZPUrtnaCuII__
~TIOIII
to711 40U17 dT ___
= 1811& A11".'I___._
to701 OPI____
tOm Hie ____.
.0724 I-AII/III____
.0707 tolMA______
-- tom OPV____
- .07U ",."....__._
- I"" T. Tina ___nO
'_~__M""____' ___n_.__._'_'"
D~AWINO nil
'11 II Midi.... .
---- 3U II SIuI Sllllli::~ "
I"'TH KLlNI UI "ITlNG
.0011 PlOftll lee___
.0011.1'7tOII'111
CltfI.lPU ____.__,,__
mGI C.""n"'_____" "_
l60al CBC wllh 0111 ____
11171 ~________
1000' 111<1<01'11" _.______n
17070 OC Ik,"" ____"__"___"
mlo I OIT _________
Ul6I , OIT ____
17110 H.,,,,, Cull ,,__
11111 PAP____
1470' "'..n'"<"I _._
ISaruml
11..0 Prollllombl" Ilml
IIIU RPR________
11111 lod R.II WII'__
11011 IIDOI Cull ,__ _.__
!lOll BIoOIOY. I P.,. __
""1 UAIA _._,,___
IUU TBH_
10010 Ih'frold P'""'.._ _
IlUI To'" Chollll..DI
F'Gtltnl: [\1'11 Slnlll"IIl",.b..,.
'533 "or Ih F.n<l hI lTt" I',"
FtI')'"
rn l'l'l~~
"Me Nlclrlll, 1J2-~'5'58
1)0)111 ", IIIi'll!' ,M, ~ '51
I"" ~ (hrl'ot'
NURBING HOMI Vlllnl
Bklllnd
Inlllal_________
Inll,mnd...______
flllndo4 _____n_______.
10310
10310
10370
Non Sklll.d
10.10 Inllil'
'0160 Inllfmld_.
10470 flII""o4 ____nO
MfOICATlONI PUIlCHAlIO
11I101
V7U
m
V70'
= VIOl
t,---.--.--- .-------.
,
I-
...-- .~._-_._---_._--.--
LI""TATlONIAHD 'NIT~UCTIONI PREVIOUIIALANCI 4!f-
... "h_"~_'__ ......12 _
,1< LL__._.___________ 100AY't CHAROES. -
:f=:=~~.:---.----_.--,~= PAYMINIS ~fT
CK. CAIN MCMIA _
. J7.~~17!=~'2..~______=: eAL;~CI - ],.,t, _ I'>.. \J
". J-!..J
AlC4Ll )
. -0 Da,. ~ 1 ]lRkI -,_____ Mon". I 0 NO 'UIUIII lIS NO, CU,1171*l
.. I .711 t<J ' .~. , I ;.GuiiiiiiiilRD'_'~All~
" l,I,I, /1' "JOI!ATltANI.T~ltolD.)
I RtmmlUAIAll,Mt.---
' ,II,,'} US4MDAVlB.MO
/
, t470YAUlVR0411
,I , (' ~., . lOO\APA '/WI
.--L-lxx:Tiilii~ijjijruM--.-.-- Z (711) nUl"
/ {' 1.1 t,F,l f). f.{-)
,.1, ",. ',. (-, "1./.,/"')
. I"'~"U 'lSlI' 181-3'1,,2121 -'-
Ill.
,\ ,i\\
I,'
~'Ir
I I \ )
~ ,
I"IUI!lIlI. 1"""11'.. \III", f) 00
Of'fICIV."1
""'Plllanl
.??OO 1'1.,.____.._
10010 Llmll.d_.__
10011 III11,m.d__..
10017 I.llndod ____
'00'0 CornfJ"" _____
Ml7.' PIIYI.__......_.._
lll_h" '11I..1
100'0 t.tnI ..,,;, f/'
-.... '00'0 l'I"...--.~~:..1
-- 10010 InliI""d
-- .0010 11I.ndld_
= .0010 CornfJ""_
_ m.I PIIM/l____..
WILL CIlLO OffICI VII"I
New P.tlanl
to711 1l.17 VII_
t07U B'II VII__...
.01U 1,1 YII
10784 lWlt I V,_
lI1.1bllah" P....,
00711 1l.17 VII_._
.01U B'II VII__
- '0'" I,S YII
. = .0714 Undlt t V, ___
I"MINC' OfflCl V."I
New OIlallbl~hed ,,'ent
WtOO8 lme, AceId"I_
- WIOOIlmltMIdIcoI_
= tfOII'l",erOV___
III Of"1CI UIOllATOIIY "'"
I7IOllP OIM Cull__
12f.l7lP OIu....__
.71101lP 0..", Slaln_
.50UlP He"'"OCril_
.71lOlP KOH PrI9_
1IN17lP Mono,po'_.
t4701lP "....ney __
t7110lP UIne PllP__
~17lP II,ep S"'.._
.7IttlP U4 Cull UI.._
ItOOOlP t)1ne~'1I __
'/OI7lP thine CuIt_
IIoMJNIlATIOHI
10711 ADULT dr__
1111I Alia", ___
10101 0P7 ...__.._
tOm HII__
.om ......,.
10707 MMA.__
107ft OPV
to'" "--__
11111 II Tin.
~U..,l: 0",. ';(""Iey """b..,
~):) ,.,'. III F.MI" !lI'f',~
. · . . ,~.. "ITU"N THII 'O"M TO TH. "'~TION"T I . · ·
'~ooIOUllU
...00 M...."... _
falll Audtomll'L......_,_
MIlO Inja I)epot,ladJlll .0 me '.
17 O"',u.llon (W'"') _
A.m SUlllt.llr,I'I__...
13000 I~O .,lnll,p _ _
fllOa Indo 4Ip ____ __....,..____
Willi '" I",nep,nna 'tOlXlcc.
II l.litlon(lllion) _,,_.
'UI' 1'I.en.ri_._.____
IU10 H.mo.cu"__. __ _" .
IUIO 1.........,..'.._____.
10 1nc~1on I Dr"nlQl __
aoi-:::.. ""'lion. Jotnl__ _ ... .
110 UCI,"lonR.pol, "'_,,_
JluQ" "'K..a~IOml_n
11110 Pill fIlIo ___ _ _
.I1"Q BlemoiHl1I __..___
.11300 Illmold Rilld _______
11110 AI"" I ~Ii _____
filII AI"I'/ll ~'" __..
11010 4..IV'! 'nl..d.,m'" 1.10 "
DflAWtNO flU
,..11 M.dl.lI. __...
'1116 lIueShltld__
.M7H KlINI LAIlIlIINO
1001' PlOnl. "'_",,,..
10011,137a01131.S
ClIIMPh.I__.____.._.__
II,.. C.a' PInlI___._",__
flOas CIC ..Ih Oiff ___ _ H
MI7I ChIIrnydla______
1000' II..'"",.. __.... h
17070 ac Be,... _ ____
Imo I 011 .._u"_,,
UIII , an ______
11150 HII"" C~I_.___.".
11161 PAP ______
14703 P'lfn.""I..____ ___
(Serum)
11810 P"lh'om~n rim. _ ,,_ .
I~IU RPR_________
.1111 lod R.II W... .___".._
17046 SIIOI Cull.______ .
18011 11001 0'1. "a.. ...._ _. '
IIUS URIA_.______. _,
IU.3 IlfI___....
.0070 rh"o/dPanal__
U.16 lotal Chola"OIOI _
-.-----....----..
--- .-__...._______u__. .>_."
~=::==:=::=:::-::_:::Li::
~._--_. --------------.--.-----..-
._--_._-----~----_..-..
--~._------_.-._---
["" ,., ~'fl t 1fl~~
10M flhont 7~7 "!!I~~ 1I'1'~ r'l/~l~
I. 0' Ill" lh' JIll 3 M
PREVIOUS BALANCI_~4.
IOOAY'S CH4ROII
PAYMENIS
CK' C4SH _ MCIVISA_
P"" /\1""
---------"-----.------..,, BALANCE ~." , "
10 NO. aU.1101II liB NO, CU,II74:l0
CUMlI~UND ,., PIIA1lTICI
JONA nrAN I TooM~t M 0
R'ClWlIl L DAVB, MO, .
" J( I")'''~/.,' ";")/') lISAMDAVIB,MO( I)
. ,I, ."'10 VALlIY ROAll
.t .\ ,1e7 (' ,'i.( ./,~' .'" ," fNOlA,PA Iron
----!- D&loitSB~NAiUiiE'''--- .."';1 1,{~'7) 7321110
!l~" IRI"~_?I~I' ji\.'.:l,~- (1)-
I." :
HOlPl7 AL II"VICII
( , IIoIy Bpi/III"'""" Camp HlN, PA
( ) 1I11,I.bu'l Ifoopll"', 1..,,,.bu'l, PA
Admluion Dall___.. .._,,___ "__,,...__,__
Oi'dl"I~::: H"born ",".e.-.:::.::':
'OliO Inllial..._.___ __un_nun_un'
10110 1,la' ____.._.......".._"
10110 InIa,modl.1I ,,____ _____.__
10370 '1llIndad ___.n.______
10101 Co",uI' """mod___.__._
10110 Conlllltlllondlld _u__'___
lOUO Conl~ICom,,"n____._
10610 1m" Rm "I.mod _'_un.
.0110 I....Rm 1.1ondlId.._".__
10m VIId1I/gI___.._
11010 Iv. All.. 011. Hcull___
11063 BIl'lIeI tOpmtem _.__,
1101. Bv" Bun llloId", _,,_
"110 C,iIIcal C.rI,___.__._
NURBINO HOMI VIITI
Skill""
10310 Inlllal ,,___.______
10'60 'nlorm.".__,,__,,_.__
10370 ""ndld _____.
Non Sk,lI.d
10laO Inill.1 _____
10110 Intorm.d.==--_____....
10.70 Illandod _____.._._..
MlDtc4T10NI PUIICHABID
lIMtTAlIONI AHIlINIT~UCTlONI
'1 . , -----
-t -, t. l f L. '\.'
.: !~.,~ ~ '_~~=~~~_~_ 7=~~~
-- -'-" -t--:'i~- tf-t'T:r=~--
___ __ u _._.~-.-:.~__l_~l.~._u.~
RICALL
_"__' O"'._uu W..ko _,_ Month.
/J,
i' I 'I I,' f f (, ,I ~
I (-,
I"",.,~
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Y'IJ'
1"".1",", 11,,1.,,\1:. I~I'" 0 ('"
OIAONOIII
1QI' "..-----.--
III 3 NIIII'I__n__
417. NI.",o ""'nllll__
3000 M.II"1____
__'nO .., 00 41th",.. ..lrinllo___
,--... 11I,0 IIIondlltla. AcllII___
...... .... lronchUIa. Cllronio~
--,,- ... 0 CN)
----- 1If,0 CW ___,_
moo ConjUIIOIIYItIa, Acull__
m COPO
m 1 CoellMhon.rill.
".-- alu /lop_Ion, 1/ldofonouI_
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710 7 r.IIgUl
m,o 1~,*dlol."'oIIml'_
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341 I ....Ii..
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71101 O.IIOIJlh,lIl.
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"IIHIIIIII. 111'1(11 f .. Jhtl " fl'"" Ip" 1'1111
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1/11. ,,/\ III ", " Ii 1",1 'II , I I II,
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'I " I" I '/111 , 1'1.('1 I
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I I 1:1 "II " 1 '<I I, I I I, 1,\ 1 ,,' , I'
" I IIH I" I l't " " 1'1, , '" I I' " '111"1 I
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11)1, " ~I Jill) I II " I 'II 1',1" ,Ill ,. II
1,'11. IHI I" '. , I " Ii I , "I " I. I" " I , I
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II " I" Ii '11 " I, I" ,II 1,1"1
" 1.111 1'.1 ')'l 'I II III '" 1',1"1,1) / "f I I ,
"
", Iilltl 'II 11,'1/ II' " 11/1 " Ii :i I "
" 1/ I" I" I " I " "I
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I' 1111 " I, ,', I 1,1, "I I .',1 II III
I' I 1\11 " I, ,,, I I II 1111 III .111'
1'01, 111\ II I, " I,', I I I,ll I 1',1 I' III
" I, III! " I, I '" II 1111 '11',111.
,
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11111""111
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~ll C"~RQE$/PAV"ENrS
ITEMIZED
srATE"fNT
'''' II', ~ I / e ,; /"1 ~
nl'lllfl~lI, IIf'VI'IIIY IIMItIl,Il
"Atlun. IIAU B. IIAIIUllIl IIIIIII?
6J. 111111111 lllOl(\ IIlllVl
f. II III II I' A I I II ;! I,
'l'JI I III J fJ. ;! 1 ,'I I' 0 1 . l II; ~ ~ 1>8 I M:
1I(\1I'/lN.l1 IIR/II/!Il IW".
1 0 1 II rtH 11/1 I (I I: I: IIH tll IN';
" 0 nox fIR!> I
C:MII' 11111 1'/1 111111
III'l" , i:l nlI:J021l
I MflIOYI' Il I
r IINI' ~l r: III RlIf'flAC TIC c u/nc
HIli ftllNllIE ilOilO
ellMI' 11111. f'lI. 17811
III/I" "In
I) I 1\ 11110 !; I!. 1
U3~.~0 UUlIlUXllrrOIl or lUMOIIII B"llIr
I" ,I..' 10" 11/11;'" flA III
I ~'" . h "' I" III" III II I II I I II ,,/I Itl (V,' Il , t 11110 111111 c: )
03"j.0U M'" 111'11' !;I'IIVlI:l\I V..,llI'lIll(\
11/\ II: 0 f' 1 11:1 T U II I , II ~ /? 9/ ,,) ""M I II r. 10 'l;O 1111 r II r.111 ,,:?
.n__..~N..._._.~_..._..n~n__~M~n.~~n_~~.ul~n_~.~.~n..M.......".............."...
DAn
CPT
DESCR IPTION
· POS TOS .
~"ou'n
..~_..._...._.___..._..._..__.q"a...n~...~.___...__..........................".
I;! /Ill 19.! 9!1" 1 :) I 1111 If. II OV I: S I . 113 1 28.118
I;> / tll/92 !lIIIIII II Y f) Il (0) I.l /I lOR /1: rt Y I) III f. Il A I' Y . 003 I 10 . !Ill
1;1/111/9' 91111~ E' I' C I Il r c: /\ l nil M 1111/1 I II till I II . 003 I 111.11'
12/1,1/'12 9921 :) I M I I Ell llV I: Sf . 03 I ;i1l.II8
I'o!/III'J;> !J11I10 Y II ROC 0 1 1/\ rOIl/ c n Y 0 III Ul A I' Y . 11113 I Ill, ClI
l'l/1719;! 91111~ I r: e In I e/\I OJ II M 1111/1 r If NIIIIl . 11113 I III .111
1;?/ID/92 99213 I tlllfll lJV J:!7,f . 83 I 211.111
I O! /111/');' 9/8111 'Ill n 0 C II II /\ III Ii / C II Y 0 III r II AI' Y . 883 I le.II8
I:! / 111/9,' 9/11 I ~ I [r: I n I C /I I lJ II 1,1 II11A I II tlll~ Il . 8113 I 111.110
I;? /1 0/9;> 971 I II r II' C 'Ill C r; I'M /I I 'I tHlf-1l . 1113 I 21.1111
1:1/111/9;! 9911111 ""01' SLIP 1/ I ~, Oil r 110 S I~; . 883 I 311.U.
12/19/9;~ 9nlJ IIMIIU) llV E~d . ll:'l I 28.lle
I:? /1 9/'):/ 911110 IIY1lIl01:0'1./\lon/CRyortIERAPV . ..3 1 .....
, .'1 I "/'1;' ., I I III , II' r 11/1 c; ';' 'II /I I II II ')f II . 011') I '211.011
. ;1/ I l'/!I.! '11111 ~ I II , 1111 r: /\ I. !i" ',I 1111 A I 1"111111 . ell ~, I 1!;.lIl1
J:lI,/1/9;' 'j!);! 1:1 , I loll' I tI lJV I. ~ i I . 11:\ I 211,11"
I,ll ;?I/!);' 9/11111 IIYIlIlOCOII/l I on/ellVIII IIEIlM'V . 883 I 111.118
1201/92 9 7111 ~ II I r: , III e /\ I S' J M Iltlll r 'l' tWill . 093 I 1&.1111
I;> /;? 1/9;! uni 311f\" ~ 'tll I Ie /\c I IVIII F!; IIn I l r . 883 I 111.118
I' /" 1/')" 'Pj:l. 'J I 1M 11111 IIV I' ~i I . 13 I 28. lIe
I. I. 4.
12/ i' .II";' 11111111 IIYIIIlOCOI' /I I 1I11/l'rtYOllll,n/lI'Y . 103 I ".110
I;> /J:I/92 '1101 ~ I" I'r: 'R I r /I I ') II M 1It1/1'IHHlIll . 011) 2 311,UII
Ii! /29/9'1 99213 1.1 loll' Ell OV I. S I . 83 I 28.llt
12/29/97- 9711111 IIVllIIOCO'I/lIIIII/cnYllrtll'RAI'Y . 883 I .. .011
12/29/9'1 91111~ F I Fe, R Il: /I I. n r 111 IIN/I r r Ultllll . 093 2 311.111
I 2 /" /9;! ')')n :) , I II I ,r II I)V I:nT . IJ I 21'1 . III
I ~1/3 I Ill;? 9111.8 IIYIIROI:OII/\rOrt/cnYOIIIErt^PY . 093 2 ze.Il'
1;/ /31/9l! !1I111 ~ r: II: r. I R I r: /I I '1I1 M 1111/1 I IIf tlUI Il . IHI3 l 38.1111
I: 0 N r I N 111'11
...............__."_.........a...."....................."......................
~l till I 0' III 1
IIG!I.Il11
I ~I' I'.
.......,
,-
~LL C"~RO!S/P~V"EN'S
1 T f. " , 1 E "
Sr~TE"!NT
IIlIlI'l 1l1/0r,lq~
"MI'IIlYl'IlI
II!!>I 1 ;, 'I 7:1931126
'"SIIII"II 1 IIEVI!1I1 V IIAN/It,1l
I'AIIINI, IIAlf S. IIl1l1flEII? IIIIIII?
531 NOli III fNOI A IIl1lVf
IiNIII II /'11 IlII?f.I
!HIMIIlI 111.21211'01.2161111&911\1:
[JIII//IN.JI 00/11/'12 0111'.
rn. 1\1:11[11111 .I\I:CIII[NI INS
P (IliUM IHltIl
CIIMP 11111 I'll 1/011
INIlES r.IIIJlUPRAtTIC tUNIC
1~30 IllllllltE ilOilO
ellMP '"11, I'll. 171111
I I I /7 :11 ' ?I 21
1I11\l1NOSI~11
839.<0 SUOLUXIITION Of IUMOlln SPINE
12~.< 'Oil OACK PAftt
I;!~.h [JI'FP IIE'F.flIlE,1I '1'(\ PATN (Vlfl'lllIll)(\'NIC)
11:1'1.011 MUIIIPI F el'flVlcA' Vl'Jlll'IlflA
1111 1/' 0 f 1 Mn lilt I 1 0 ~ /? 'I /91 P JI" I N Ii 19 n III' 1 N 61 II 9 2
I) ~ TI!
CPT
...P.___...____..__~a~._~a_.~au_~am~_.....___..__..................M...........
I'MOUNT
!lEBCRtPTI"N
.. POS JOS .
_..~.__._._._..____"_._____.~an_aft.__a..____"_.N__.~._............__...........
1I1/1l~/91 99213
I'll/O~/q:l HIllII
1I1/1l~/91 971l1~
1I1/1I~ /9:1 9/&3IH,2
111/05/93 99213
el/1l5/93 971110
111/05/91 97111 ~
e 1/1I5/'}1 '175"'52
11\/117/93 99213
111/117/93 97111 ~
111/07/93 9711111
.1/07/9:1 9753062
01/011/91 99213
" I /IIU 191 !171l11l
el/00/9:1 9701~
1I1/~1l/91 975:.I1l5?
1I1/l2/9J 99~1:1
el/I~/!lJ H01~
81/12/93 97U9
1l1/l2/939l11J0
1'lI/l~/93 9921:1
el/I~/9) 9701~
01/1~/91 971110
1I!/1~/93 97!Hll1i2
1I1/11i/<J3 9921,)
8I/1l1/9) '171l1~
111/111/93 9711111
.1/lB/91 99?1 ~
IIMIHI) OV EST
II Y I) ROC 1)1 , A r 0 It 1 r It Y I) TI' E R "" Y
ft.H1RICI\l. STIM UIIIIIIUHlH)
KINrTl1: Ar.f1VlIlI'S nnnl'
I. Itll lEI) OV EST
It Y I) II 0 r. 0 l. l. A run / c n Y 0 rill' JIll I' Y
E I E C I n I C II L S TIM U Nil I It till 1'1)
klNE'lC AC'IVIIII"; IJIIIFr
lIMIT OV E51
f'HrnlcAI SIlMUIAIION (IHIIIIII'NtlF.lJ)
"YlJflOClll.l.ATOII/CflYO,"rRIIPY
KINETIC IICTlVlllf!l IJlllEf
IIMITEO OV ES I
"YllflIlCO'II\'lIlt/CflYII'"I.III\I'Y
1,11l:IfIICII' SlIM UIII\'"tllllll
kft/I'IIC ACIIVIIII'!, nllll1
',IMII OV ESI
I'lI'ClnICIII SIIMIII ArlON (IINIIIIFNnfll)
IIYI)IIIlCOI.I AIUII/CIIYO rllfltllPY
K IIH' III: A C TI V" II '1
I I M I r OV f S I
l'IU:'"lf:AI, 511MIIIIIIIIlII (IINlIlIrNIlFIJ)
II V I) R () r. 0 I. I A I 011 I C fl V n I II E fllll> 'I
klt/l'IIC ACIIVII1I'!3 nlllH
lIMIT UV 1'51
':'f1:1nII:A' 511MlJlIIIION (UNIIIII'NI)FIJ)
II Y IlII 0 I: 0 l. l. A rOil / Of Y n T Iff 1111 P Y
Itl rr: It M I) OV I'S I
CONIINlIfl)
. 03
· 1)1)1
· 11113
· ee3
. ee3
· ee3
· ee3
.. lllI3
· 113
· U1
· ee3
· "3
· 83
. 1\03
· 1\03
· 00:1
· 03
· llIl3
· 003
. 011:1
· 111
. 01\3
· 801
· 1lI\.)
. 1\1
. 001
. l\e1
· 1\3
I
I
I
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1
I
I
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1
1
1
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2B.U
10.ee
IlI.U
H). ee
2fl.U
10.lte
IIl.U
Ill. lie
20.U
l!i.ln
10. ClI
Ill. ..
28."
LIl.III1
11..llli
Hi. ee
211.1111
I!>.U
111 . lte
2~.1I:
211. II
I f" lie
IIl.lte
Ih.08
211...
In.Il11'
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111)....
......_.__.._._..~.....__......__~.._..~__.._.._M..............................
SUIl! Il rill. 1
1. eg" . ,.
-......
I"""
ALL CHARGES/PAYMENTS
IIEMIZED
~ I ^ , f M f N T
I) 1\ It' 1 II I / 1111/" 4
H'3UIIEO, llEVEll1 Y lll\/ltIl'lt
f' III II 1/ I, Il /I' [ G, II /1ft II!' II ~ I 0 III 1;1
I, II 1/011," 1'1101/1 IlIlIVI
E ,/III. /I I' /I 1/02 h
'j !; . I U I HI.~! I .' I I' 0 I II ,! ,)1; 110 f.\ II I /II:
1)11" /1Il,', 1111/1 119;> filiI'.
, fI S N 1 ,'I 7. :10 'n 7 1I
r HI" OY' fI,
In, 1\ 1'111' II /II. /II: t: I 0 I' II I 'II G
I' n uox UOtll
l: Mil' III fl_ I' /I II 0 I I
INNI'B C"InOl'RII(:nc Cl.Ulrc
Hlt! I 11'1101" R 01\1)
C 11MI' I)' I l.. 1'/1. 17 II II
II 1/1)1 ..1121
I) I /lllNII~ IS,
133'1.211 SUIlUIX/I) ION Of UIMBIIR SI'INF
7? '. ,~ LllI/ 0/1 C K I' /II N
I1~ .Ii onl' IllfF.llllfll 11'(\ I'lIltl (VI'nlEllflO(\!'IIIC)
')3').1111 HUI "''1 I' CEIIVICM Vflllt!IlIl/l
o II IE 0 r I II Sf n I 1.1. I II ~ /79/93 I' fill It! 1I 3" 9 7 10. I II fi 3119 2
--.-.....q..____.__.._______...n.=~_m_.~..-._~.~n_........._._~......_.........
DATE
CPT
OESI:RIJ'TlON
· PO!! TOS .
AMOUNT
......._-_..___.h._.__..__".~.._a.a~_D_~.n___."~~a_............................
II J /161 !I) !l/lllll IIYOIlOCOllIITOlI/CflYOlllfn/ll'V . 11113 1 1ll.U
61/IO/9J 9 7111 ~ Elf.crnIC/l1 ~HJt.t Uljll r lflHlL' I) . 11113 1 11\.011
III/IO/H 9/!l3111\2 KINEnc IIC TlVI III'S un IE,. . 11113 1 \(1. III
II 1/7. 1/9 ) 9!lJ13 II 1'1111'0 ov l-'. ~l r . lle1 1 20.""
1l1/21/!1I !1712A Ullll/lSOllNn . 11113 1 311.011
01/21/91 !) II\.! 0 52 ~ IIII' I IC IICIIVIIII.S nlll!.r . h) 1 111,1111
II I /;~ 1\ I!I ) 99213 l.lMI rro llV [sr . IlIlJ 1 20.110
II 1/211 19 I !JI \;? U II I 'fl /I SOIlIW . llll 1 311.11'
II I/?II 191 9/& :111 Kltlt"C /lCrrVlI1f5 . ellJ I n.IIl!
111/20/9) !ln13 l.JMlltO ov r :JI . Illll 1 20,011
111/211/91 !1/12A Ill. fft/lSOllltll . 11113 1 31l.'"
II 1"-0/9J '11'!IJIl!l2 KIIIE"C /lC rrVIIlI',~> nil IE I' . ell 3 1 J!l.1I0
1l2/l!1/93 I) 'l;! I :) I. I MI) EO 0'1 f:lf ~ "3 1 26.1'
1l:!IIlI/'JI " 11,1" III III i\ '1Il II IW . IlIlJ 1 :111.1111
112/UI'/UJ '.I /[, :Ill":? ~ IIH. , It 1\ (, , . '/I , II !, 1111 I" . 01lJ I Ih.lle
"'2/11219) '1";".1 I 1/,1 I r Ie I) 0\1 l: ~ i , . IIlll I 211.1111
e2/117/!)) !) 11 2U III11tIlSOlllW . ell 3 I Jll.lI11
112/11" 19 1 'J",! I J 11M II IlV [G 1 . III I :?1I.1l1l
II... /1111/9 ) !Jllll ~ t I u; r II I C /II !i I lIi11 I /I r 1011 (IINII1ft/lorO) . IIIlJ 1 Ih.IIIl
117/110/91 'J/1l11l IIYOIIOCOI '" I OIl/IlIY!)' 11I'f1/1I'Y . 1101 I 111.1111
12/1719) 99213 I I M I' 0'1 rSI . III 1 211.1111
112/1219) '1/111 ~ fI H'"'C/ll. SIII1II1 /II ION ( 1111/\ T " N I) I' II ) . Illl:! I 11\.1111
1l7/1~/9) 9111111 IIVOIlOCOII III 011 I lilY 0 11IJ'lI/lI'Y . 11111 I IIl.IU
117/1f>/!1I !.IllJI:) II Mil ov f'!-,' . 113 I 2".110
11"-/11\19) 971l1i\ f' F. C 1llH /II SIlHIII/I'IOU (1111/\ I IfNIlf.II) . llllJ I 111,110
112/111/91 9111111 II '1Ilflll CO, , /\ I 0 II / Cfl YO, II F II /II' Y . lle3 1 111.1111
02/16/9J 99211 11M II OV l.~1 . 13 1 20.111
0l/ Hi I'll 'J I III ~ t, l'I: In Hill !i I nllll /I r 1011 (1111/\ f I 1'1I0r n) . 1101 1 "1.1111
CO'" ltlllfll
.-.......n...-.__a~_._.~.~_.a~~upnr.~~u~~a~a~_.....__a..._...__.................
'3UO II) I/ll.
1.6!II.IlG
.,-\
I"',
~LL CH~RQfS/P~VMfNrs
IrEMllfll
ST~rf'MfNT
/l1l11'101/11r;/'.H
Jll!IUR I' II , IlI'Vf.1I1 V II^,'"~II
f> /I" filiI II AI l !). IJ /I II II r II;' 1111 1111
(i:lJ NOli III ENOIII 1111['11'
fllOl/l 1'/1 17l1<h
!H). \ III :10 21 2 I I' 0 I . n 1111 II Ii III /II:
UIITI/lNI, 81J/[U')~ GIII'D
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1'11'10'/f1l1
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I' 0 nllM !lOll I
CAMP 11111 1'/1 1/011
[NIH'~; C:llrlll)I'II/1CTIC CLINIC
1~JO 111[111111' nOAn
c: litH' 11111 . I' /I , \11111
/1 I 1/ :1/ - 7. \ 7.\
UI/lliNOSrGI
DJIl.~0 SUOIUX/lTIOII OF LUMO/lR SPINI'
I;~4.~ lOll 11110 1'/"11
72~.~ Ilfll' IIE,rR"!O IEO 1'/1111 (VrRlfllIlOClINIC)
O'19,0Jl MIIII""E 1:1'11'1[(:/1' vrcnrlllllll
n /I TI' l) F III ST n III, 0412 '.1/9:'1 I'R" IN r. 30 II 2 I "' 1t11l30 9 2
_._...._......~_.....a.M.._...~._a~maaa..._a.~~...-............................
D~TI!
CPT
OESCR IPTION
~ POS TO!! .
~"OUNT
.~....__....~__~._.u.m..___a..I~.~IQU~da......_.a...-............................
07.1\6/93 970\11 ItYIIROCOIIIIIOIl/I:fl'IOIIIEIlIII'Y . 003 \ 18.11I
1'1l~ 119/9) 992\1 LI M I r ov (:!Jr . 03 1 28. ee
02/L9/93 97014 [IEOIIIC/I!. ~"IMUIIII lOti (IINII I IE N/lE 0) . 003 I 16.10
112/19/93 971110 IIYIlIIOC I)(lll Ion I C IIYO I It!' III1PY . 003 1 10.00
'I' /"" 19 "1 99214 JIll ["Mil flV ( ~i , . 03 1 56.011
.. ..1. ..
0,11.12/91 9111111 IIYIlIIOCO',llllO"/CIIYOIIII'III1PY . Oll'l I 10.01
Il2/n/!lJ 97 01 ~ II [ C I n I C III. S I III 111111111""11_11 . 0Il3 1 ilL 110
0;1IJ6/91 9'121:) ( Jill r OV I: 131 . 03 \ 211.1l1l
0;II01h/93 970\ 4 E1rnR[!:/l1 '; I 11111111 I lOll (L1NII I I (tlIIE II) . 01\3 \ 16.10
8ll.1U/','j 97010 IIYIIIIOCI)t I III 011 Il.IlYO 11I[III1PY . 1101 \ \11.1111
0'1/1\1/93 992\ 3 I I M I I OV r s t . 03 1 20.110
03/111/93 97014 t11'l: IR tr. /II srI M III II' 1011 ( IJtl /II If IHI Ell) . 01\3 1 \5.1111
13/01193 971'1111 IIVIlIIOCOI.I.IIIOR ICIIYOT IIEIIIIPY . 083 1 11,"
II '1,1"1" , 'Jll,'IJ , "" I 0'.1 F ~i I , II J I ~n, '"
III /U11 <).1 '.11 0 I ~ I Ill' 1 III C III ',I 1111/1 ^ I '"11 (L1t1I1II'"I1I:II) , 001 I I!). 1111
111/11 ~ 1'1 I 'II 11111 "YIlIIOI:OI'III')lI/o:1lYO"".III1I'',' . 00.1 1 III. UII
II:I/U'.I/'J:! 9 9;~ 1 :'J II M II 1111 r'J I . 1\3 I ~11,011
1l1/09/!JJ 9101 ~ l: I( C, n I C /II ,-; 1111111 ^' 11111 (1111111 '''"IEI)) . 003 \ l!i. II 0
II',1/1I9/!I :1 970111 II V II II 0 CO, I /I I II 11/1:11 Y II I I" 11111' Y . 011:1 1 10,Il0
01/111 !II '.I'LI \1 I I'll I I,V l: !iI . 11.1 I ;?0.1l1l
8'1/1\1 C) 3 971114 r.L [C rill!: II' Sl"11/11IrJOIl (L1NII I HNOEO) . 003 \ \!i.00
01/11 /!) J IJ7 0 III 1I'lllIIOI:O'llIrllll/clI'IIIII1fIlIlI'Y . 1101 \ 10.11t
0) /I fl/" :J 9921J I'M r I f II flV f:(jf . 083 I 20.110
0311 Ii I 9 I 970\ 4 1'1: C In II: III !ll 1 H 111111 r IHIIll'll . 011.1 I lh,1I11
01/ 1('/93 971;>4 ICI' ~I II S '; /I Ol . "3 \ JO.1I0
IIJ/16/')') 12111) Il XII ^ Y r:,nV!l:llt 4 VIHIS . 011J 1 1;5.1+.
1I1/19/!Ll 99;~ I :J I J M II !IV f: ~) I . 03 \ ZO. ..
01/1"/'1 I 'HilI 4 Fl I: C I n I r: ^ , ')I 'Mill 1111011 ( IItI 1\ I I t:tlllf II) . 003 I \1, ,1111
CON J I till!' H
....._...._____._~N.U._.__...Q"...__....n........_~......................M._...
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SJ~TfMEHT
1)"'1', 01/0fi/1l4
"I'3UIIEIl, urVI'IH'( n"NIIFII
""111'10"),,,1' S. n/\/lIJfII ,! 101f1J~
I):IJ Noll "I 1'110111 IlIlIVt:
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!l!a 1111 '10.2 I ;, I "0 I . 1. 31\ 01Hi 0 1/\ C
""If 1111,', 011111/92 nil""
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OIPIOYrIl,
rD, UIIIl'1l1l1 IICClnl'''l INS
P 0 nox our,l
I: All!' 1111 I " II I lIH I
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:14 :111 r 11 JllIll E 1l01\1l
CIIMP lilli, "1\. Hill 1
7 I 7 11II ;, 1 2 I
III ACINOSIS,
1130.20 SUUIUXIITJON or IOMlllln SPIIIE
1"4..' 1011 Illlr:~ 1'11111
7:!4.6 Ilrrl' IItFl.IIIIIII 11'0 "111" (Vl'lIllllflOnl:tllr:)
1130.1111 MUI Tll'tr r.FIIVICM VI'Il'I'IlIl11
II /I J r 0 r III 0 T U I I, I, 0 4 12 !1/9 :1 P II . I II fi :10 9 2 I 11' I N r; 309 ?
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IIE5CRJI'Il0N
· POS ros .
~MOlJNt
._.>>._._._.....m~l_n__a.~"___~.n~~Q~~aA.aa~._uN~~._a~...........................
91/19/9j 9/1110 IIYIIIlOCOIIII lOll ICIIYO 1 III II III' Y . 903 1 ill. III
11:1/19191 97124 ICE MMiGlIlll' . 0111 1 20.11I
IlJ/;~2/l):1 99;' I 4 HIl E IIMIl OV (:':;1 . 01 I I>&.ee
Ilj/22/9) 911110 II 'Ill Il 0 C U, I II I 'H, I C Il Y U 1 III Il I\t\ Y . ell3 2 a,ll"
.. :1/;' 21 9 3 97014 1:'[[:lnlclI' G rr'I II/III liE tHlr II . 003 2 JIf.1Il
11:11 ;'t; 191 99213 I. J MI' (':U UV r S I . 1103 I 20,119
11:1 I ;! G 191 9711111 IIYllllOCUll II lun/cnVOlltlllllflV . 1101 2 ;/0, lie
II :112 fi 19 I '171l14 1'1[1:11111:111 ," HI II tl II , II' IUH' II . 1103 ;! :'".8e
11:1/ ;"1/9 J 99.' 1:) I I M I IlU OV t: [;I . 1103 1 ;l8.lIe
Ilj/;?9/!)3 91010 IIYIlIlOCOI.III rUn/CIlYUTlIEnllflV . III1J 2 211.119
'IlJ 1;!9/9j 971114 E1.EClfllclIl 131111 II/III 1 II' NU[ II . U3 :I JIl.ee
04/81/93 99213 l J M II r: II OV EST . ell:) 1 20.'1t
ell/el/93 971110 IIYllnOCOLLATOR/ellVOllIEnllPY . U3 2 211."
1I.I/IlI/') , '!llll"l l. I f' I: III r C II I '1' 1M 1I/IIIIlltlUrll . 0111 ;> 111.110
114/11!l/93 !192 L:J "HII'1I OV I. ~. I . 00:' I 2n.1I8
1l4/11b/9) !l7I1l11 IIYllIlUCn, I III1In/cIlYO'"I'IlIlPV . 0113 ;> "",011
llil/1l5/93 !) 7014 ['EClnlCAI 51 !Ii II till I T nUl! II . ell 3 ;/ H.ee
114/118/93 ')9213 II M " r:u ov f:fjl . ell:l 1 ?Il."
e4/110/93 9lllle IIYllnlll:Ul1 II llln/CIlVlJllIElIlIPV . 1103 2 "0. ee
114/110/93 91111 " t 1(' C 1111 e I\t. ')1/ M IHIII II UIIH'1l . 11111 2 :lll.IHI
04/1;>193 99213 I !In It. II OV (: ~. , . 11111 I ;'0.119
114/1 ?o/IlJ 918111 IIYllllllClH 11\ 11I1l/CIlYO 1 Ill' IlIlPY . lllle1 ;> .111.011
04/12193 9 7el 4 [ll'eln/Clll S' 1M IINII 1 IINUEll . 0113 2 10.ll0
Illl/H,/93 99213 , J M I I E II OV E 'j , . ill 1 I 20,1111
1I4/lf1/93 970111 II V IlIlOl:l1 I I 1\ lun/clIVO I I/EnllPV . llll:I 2 211. ell
114/H>191 911114 (' I I' e 1111 ell' ',II II IIIIIIIIl.tITIIIl . 1111:1 ;/ :HI. ell
e4/19/!l3 99213 '/MIII:I) llV ~' ~i , . llll3 1 20,1111
811 II 9/!LI 9llll1l II Y Ill' 0 C U, I III un I C n 'I U 1111' n /II' Y . Ul ;/ 211.1111
l:lINlltllllll
.._....._.....__.._._.tM~~M__.~~n"_..~_....~".....__._........_....._._..._..~._
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1:1I'1f' 11111 fill 17011
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71'1' 1/ 2121
1I11l01l0SIS.
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N.~I'~_Q~".mu~.~.".~.ua._.a.n__aa.=.~~nn__"'I~""n~nUl....................._n.......
I)ATE
CPT
I)f Sr.R (P flON
· POS TOB I
AMOUNT
.B~__a~U~~p~M.a___._.a...n__u~.lma~nnu."_p"A~aa_~._.............................
0~/19/!11 97 01 ~ r, l C 1 111 1:111 SliM 01111 III tHII_1l . lI0J 2 311.1U
0~ /,> :1/1):1 ~!.)2111 nllrlllH) 11'1 r: ~I I . 0.1 I 61.\ .110
1I~ /:!;! /1):1 !)/1l11l II Y Illl 0 c: 0 I , II , 0 fI/ Cfl v 0 III F. fill" V . 1103 2 28. lI0
O'I/'?:?/I)'I ')1111 ~ l'1 U: r 11 !CIII ',II M IHIIII I UIIII Il . 003 ;I 311 .110
(1'1 / 2 ~ /9:1 721l~0 Mn~v r.rflVICIII. I I ~t J r r () . 083 1 36, lI0
0~/n/91 7.' I 00 XR~V I 111111 II R I 1M I I r () . 003 1 46.U0
111/2\ /93 III PIIVMUII IllS 3 (, J'I 111 I ;'/1'. I '):? M III (\ 3 7 8 -53.110
11I!:'1/9:! III JIll Y tll tll 111'1 Jli l'J I'll 1 2 /11 . III 111I(\~86 .,11111 . lit
III/n /9:' III PIIVMHII- I liS :lfj J l) 1 J I 12/1'1/'12 IllIlj~06 -11!1. 92
1I1/.?!/'JI III 1I1l.IIIGIHUlr rono 1 VI' ",1I6~86 ' -) 2 .110
111/21/9:1 III pnVMlIll. illS 3 (111) IJI 12/21-n 1l116~01 .-1011.08
01/21/n Itl P~VMr:III-1115 :16 J.I I II 12/21/92 '11I6~OO .'30.U
" '/" '1/ 'I 1 III "AI'III'II I , t, ~i :1 (i ~ n;>" ~ I ;' I,') 'l :11 .100627 -1~1I."
Il.~ /1)<1/'11 Itl "A Y III /II , II ~; .11,.111.'11,1 , / ,) '. " III 'i' ,II 1l,Illl
0:: /I'J'J /')1 III P~I'llI /II 1/1'; . H, II ~~ " U /1 1 /" I M I lllin~ (If).oe
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o ,! / :! :./.1 J III pnVMllI , III" :Jr.11 ~1)!'I(1 1/1',/9:1 MI(l6!1~8 'li3.lIt
112/2:) 1'1 I III PIIVMUII I"'; :Jlif'UI)!lli I /111 ;'1 " 1I11l9H -1 ;:6. :'11
02/23/!I:! III 1111,111:.11-\[111 , 1I11e; I V, Mlllfi!l~9 .-26.liO
02/~1/')) III I' ~ 1"11 /II 1/11, :)(," n I)'; 6 I / ;> II ,) I 1111(1)60 -1&.00
II;! / ;> 11 !J3 III p~VMrlll (Wi J(, 1\" (J !" I f',![. ;'rJ .1 II 7 0& I -122.110
0:> /<' '/'11 I II 1I(),JII'iIIH III IlJl<lIIVI M111111!\ I - 31. lie
03/1 ') I'l:l III P~\'MlllI Itl'; .J h" :J I ~) h I / II L' Nlllnn26 . III , "II
8J/I'I/91 III P~VIIlIII 111'; II> ~ II ;> Ii I /1,' I,) 1 1116 f) 27 -(lI0.lIe
OJ/I '11'1'1 It! I'~VMftll INr; II, ~ II " I> ~, /1 ~ M 1117 161 ..10e,1I0
1I:l/I'I/'11 I ~ 1111,11/1.1 MI "' 1'111<1; 1 vr MIlI7I111 -- 31 ,lie
II 'T /1 "/'):1 III I'~V'1E tl' I It'; :tht1.J I /1'1 2/11/'1:1 M 101?!\ I .-li3,1I0
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6:1' "UIlIII [NI)l1I fnllVI'
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1llllt/llLII IIU/I/ln nilI'M
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l:/lt11' II Ill, I'll. 17811
11/11)12121
UIIH1NOSIG,
U1U,20 UUlllUXIITIO/l Of lllMOlln nl'llIf
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· POO TOS .
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._....._...._._......A....n..RuA~_~~n__.~.__._._.~.................N...........
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113/1"/9:1 ItI P II Y Ml'll! III'; :l1i~JI?6 ;'/l9/'IJ " 11l7~37 "1;~ 1 . 8 2
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11:1/1 I) /9 :, Itl I' II VMI'II 1 IllS :I U ~II ~ Ii ;! I ;Jfi / '1.3 " 107~38 -53.1ll
II ~ II 2/')' III I'IIYMUIl IllS III ,1 ~ II.' I Ii 1/ I I> I <)J 1111/7 311 '1115.34
II ~ II ;, If/" III IIII.)I/S 1 MI II I r OliO IVI " 1 1171 311 ..12.66
0~ 12'J/91 III PIIYIHtl' ItlS JII ~', I> '10 II 1/1 ~ " 107[\0 B -186.1111
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II ~ I ;!1/91 III IIII,II/,j I M':II I 1 111111 IV'. M 111/07.1 .. 6. OJ
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07/09/91 9!l U3 I.IM I' r.ll OV I: f., ee3 I :10,'"
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12/1'1/92 97111~
12/17/9;> <1921:J
12/17/9;> 9711111
12/17/92 9701~
12/10/9;> 99n1
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12/18/92 117111~
!?/lfl/9;> 9711"
12/1A/92 9ge71
12/19/9;> <1<1?11
17/1'1/9;> 9711111
1;>/19/92 <17I1A
17/19/9;> 971114
12/21/97 9<1211
12/21/9;> 971111'1
12/,/1/92 <17014
12/21/9;> 9751115?
17/2:' /92 <1 q? I :1
12/21/9;> 97010
12/71/92 97014
12/29/929q?11
12/,/9/92 HII0
17/79/9;> 971114
12/11/9;> <19'11
17/31/9;> 9111I111I
12/11/9;> 97014
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81/1~/91 9'IIVI
81/"4/93 971l~
81/14/93 9751157
Vll/15/93 99"13
11/"r;/91 91"IVI
11/16/93 97"1~
81/1&/93 9153V157
81/Vl7/93 99711
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11/0A/93 97511167
1l1/17/93 99711
81/1;>/'11 97"1~
11/12/93 91V11V1
"/1'2/93 97611//
81/14/93 99713
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tI/14/93 9'''\VI
11/14/93 97611//r,2
1//1/16/93 '19213
II /16/91 971//1 ~
tI/15/93 9'''\VI
U/IIl/91 9'1214
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ALL CHA"GEa/PAYMENTS
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STIlTEMENT
nil"'. 1I/r,/v/?/<J4
INSUnE!). IlEVERI v fJIINNfn
PATIENT. OAlf 'L IlII/lllfn2 IV/IAI?
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ENOIA I'^ 171121;
~StI81-:'R"?l?1 1'0' t23",""r,"I11f
OIlTf./INJ. 118/17/9~1 onl'"
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717/7.11 2121
DIIIlINOSI!1 ,
839.211 SlIlIUJXIITION OF IIIMAlln 9PHlf
72~,2 lOW nllr.~ I'IIIN
72~,5 OEEr ReFFn/lEn I Fn PIIIN (VFAtrfJROOFNlr.)
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DATE
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o II 'IF 0 r l II S T III I I I II 4 / ? q / q 1 P n" ItU, 'I V/ <J;> rrll Itl ~ 11'1 <J 2
-.....__.....___.____._~__.."n.~"~~~"_~.__~~..~_"__..~..._.._.__._......~._.....
DESCRIPTION
· PO! TO! .
A"OUNT
......_........_...I_____m".N_"~""n~~_~Q.a"__.""~_._..._...._~..._...._..__.....
111/18/93 97110
1H/III/93 91014
81/111/93 9761852
81/H/93 99213
111/21/93 971211
81/21/93 975311/62
11/26/93 99213
U/26/'l'J 9712A
111/2"'/93 975111
1l1/28/<J3 99211
111/28/93 9712A
11/28/91 <J76111";>
12/91/93 99?l:l
82/11/91 9712R
12/1l1 /93 <J1531r,;>
12/12/93 g9;>\1
12/82/91 g1l28
12/18/93 992\ 3
82/18/'ll 97114
02/08/93 gllll11/
12/12/9' 9921:1
112/12/93 971114
02/12/93 911110
02/\11/93 9921l
12/16/91 971114
12/15/93 g711111
12/16/91 CJ9211
82/16/93 97014
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1\33 NORTII ENOtll IlfllVF
EMOLII J'II 171'175
99.161..3"-2121 J'Ot"?1600R0111C
DATE /IN,', 1lf1/ l' /9? (\fll' "
I flA" 1 ,'l ?11l31l211
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,. 0 1l0X BfHd
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717/717 ?I?t
DtllGN09lS1
639.21'1 SUBLUXII'ION or IUMIlAR AJ'TNF
724.2 LOW BliCK I'IITN
72~.!\ DEFI' REFERnrll tfA J'IIIN (VrflTfnnOAFNTC)
A19.1'18 MtJl.TlPtf crflVIClI1 VFnTFfHl/1
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~"Ol)HT
.....N.__.....___.___..n__nn.""_""~"nn_"_ft_n._~"na-...........---.......--.....
1'12/16/93 971l1ll IIVllnOCOII IITOR/CflYOIIIFflIIPV . 1'IIl3 I Ill. I'IIl
1'12/19/93 99213 I.T M IT flV f'lT . III 1 :?fJ.1'I1'I
02/19/93 97111~ F.LFCTnTCIII QIMI/I/lrION ( 1I N /I I r rtHl F II ) . 1I1l1 1 15. ell
112/19/93 971110 IIVllnOCOL I. /I Ton /e nvo T IIF nM'V . 003 1 111.00
02/22/93 99214 INrFnMD OV ESI . 03 1 55.1lI
02/22/93 971111l I I V n n 0 C 0 L I. /I Ton / C n Y I) Iii E n /I P '( . 003 1 Ill."
12/22/93 97111 ~ FLFr:lnTC/ll SlIM IJN/llTFNnEn . 1101 1 a.1lI!
02/25/93 99211 1 I M IT OV rqT . 03 1 28. Ill!
112/25/93 ~701~ ft.fCTf1IC/l1 SI TMlll /lrrON (llNII T' FNnF n) . 0Il3 I 15."
1'12/25/93 97011l IIVllnOCOL I /lTlln /cnvnrllrnllPV . 0Il3 1 1Il.1lI!
1l3/1lI/93 99211 LIMIT ()V f51 . I'll I 28 ,Ill!
1'13/111/93 9711 ~ EII'r.Tfltr./l1 qrrMlll/ltlllN (llN/lIHNDF[)) . 001 1 U; . Ill!
1'13/1lI/93 97011'1 It V II f1 0 COt. I /I T () n / r: n YilT II I' n II I' V . 903 1 10.1lfl
1l3/1I~/9' 99213 t. I M I T OV E5T . 01 1 :lA.1lI!
113/114/93 9701~ E '.f. C In I C /II. STTMlll/lllON ( II N /I I T F tll! En) . 003 1 15.1lIl
1'13/e~/93 97110 IIVllnoco, I /ll0f1/cnVlllllFrl/lPV . 003 I Ill. Ill!
1'11/119/93 99;>13 I 1M J T OV Fql . 13 I 28.1lIl
03/1l9/'l1 9701~ FlEonlCIII SIIMllI/lTlI1N (I/N/I r 'FNnF n) . 0111 1 1/;'1'11'1
111/1'19/93 970 11'1 "vnnllCOII/lrOfl/cnVllllIFfl/ll'V . 003 1 10.1IlIl
03/11/93 99711 l T M IT llV F q I . III 1 2B,1lIl
03/11/93 971'11~ Flp.CTnlC/l1 SlTMlll/lrrON ( II N II rr FtHl En) . 011 1 1/1. IlIl
03/11/93 97010 IIvnnOCOl1 /11011 /cnVOTIIFnllI'V . 1101 1 1Il.1lIl
113/111/93 99211 I JMTTEn OV r ~ r . 003 1 :?8.1lI
03/1';/91 9701 ~ nFCTf1Jr:/l1 '1T 1M IJN/lTlFNnEn . 001 1 1'1.1IlIl
1'13/1f>/93 971 ;>4 lCF M/lAS/lOF . 1lIl3 I 211.1lIl
U/I.;/'!1 7701;1 xnllv r:rnVTC/l1 ~ v TFIIS . 001 I 55.1lfl
03/19/93 9q?13 I TM TT OV F ~ T . 13 1 28."
03/19/93 97014 r I, F r: Tfl T C /II q TI MIll /I TI IIN (IINII T 1 FIIIlF Il) . 003 1 15.1lfl
r:ON TlNIIFIl
......_~_...._....__..~"....~.~_"ft"~"...I.__._..__~_............................
'i1/nTOT/\!. 1
2.2111'1.011
~
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1 '"11f.0
nl\lI' I '1";/0;I/q~
JN~UREO, BfVfRLY nANNFR
PATlf.NT, nl\IE s. "ARAFR? 101AI?
1133 NORIIt FNOI A IHllVF
ENOLA PA 170;15
SSU61 <IR .2\ 21 PO, "?lri00rdIIAr:
OATf./INJI 0R/17/9? ottP"
IR5" I n 7J0'107~
FMPI OYFR I
TO, (\ENERAt AcclIlFNr IN">
P 0 1l0X RRF.I
CAMP 'tlLI PA \f011
IN~IF5 CItIROPRACTIC CLINIC
1~1R IRINOIF ROI\O
CAMP lilli, PA. 17Ut
717/117 ?171
OJAONOSISI
839,70 sUnUJXAIIr)N Of "'MIlAR SPINE
724.7 LOW nAr:~ PI\IN
77~.5 OEFP REfERREO LEO PI\IN (VFArrnnOOfNlC)
1\3<).08 MIH IlPlf CfRVrCl\1 VfR1FAnl\
OI\TE Of LI\SI BIll I 0~/?Q/QJ PR" IUfi1A9? In" /N!i1A'17
_.._._"._.~_.._~___._____n"..__~"n~n__."M__~.____g...___~._.___._.___._____...~
D~TI!
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DESCRIPTION
· POS TOS .
~"OU"T
...._.~....___.______"~__n._n__~~m.n_"nM~"~..."__._.._.___....____......____...
03/19/93 97010 IIVnROCOI LI\IOR/CRYOlllfnI\PV . 003 1 10.00
113/19/93 9712~ ICf M"~S^Of . 003 1 70.811
03/27/93 99? I ~ INTfRMII OV F S T . 01 I 511.U
"3/22/93 97010 ItVOROr:OI LI\IOR/CRYOlltrI1I1PV . 003 2 20,00
03/72/93 971l1~ fLFnR/CAt STlM 111111 r I ENOf II . 001 7 30.U
03/25/93 9921 J L IMT IFO OV r.sr . 003 1 ~R. 00
01/75/93 97010 flVOROCOlllIIOR /CRYO rlfFRIIPY . 003 2 70. ..
83/2F,,/!l~1 9 701 ~ FI'FCIRICIII .~ TIM IItlll II F Nor fl . 003 2 30,10
03/29/93 99213 L IMI Ifll OV f 5 I . l'l0'J 1 28."
03/29/93 91010 IfVOROCOll.lIlon/l'nYOllffflIlPV . 001 ? 20. ..
VJ3/29/93 9701 ~ ElFelR/CM STlM IINIITHNllffl . 003 2 30. ..
'4/01/93 99213 I. IMI IFfl 01/ F r:;, . 001 1 28. ..
U/01/91 9701 A IfVOROt:OIIIlIOR/t:nYOllffRIIPV . 001 7 20. ..
'4/01/91 9 701 ~ fIHIR/CIII '] I J M IINIITTUHlfn , 003 7 30. ..
14('5/93 99211 I JMJHll (IV r., , . 003 I 78.~0
04/011/93 97010 IfVOROCOlll\lon/cnYOllffnAPV . 003 2 20.80
84/011/93 9701 ~ El.FC1RICIII 5TIM UNlIllfNIlFO . 001 7 311.00
ll4/0"/93 99213 I. IMT IFll OV F'lT . 001 I 28,00
114/'8/93 97010 II V II ROC 0 II 1\ lOR / C n Y 0 riff n II P V . 001 :? ;>II.U
ll~/lll\/93 970H flfCIRIClI1 ,]TlM IINII II f' NllF II . 001 7 311."
14/12/93 99213 I IMI Ifll OV r", , All1 1 20. ..
04/1;>/93 97010 ItVOnOCOll.l\lon/CI1YOllffIlIlPV . 003 2 20."
U/12/93 9701 ~ f I. E C I R / C II I. S 1/ M UNliT IFNllfll . 00:1 7 30. ..
114/15/'1:1 992\ '3 lJMtTFrl nv F C;, . 001 I 211. ..
1l~/15/93 91010 IfVOROCOlllIlon/CRYOllfrRIIPY . l'l0'J 2 :?e.n
04/UI/93 97 01 ~ F' f C I rl J C II I .. 11M IINllllfNtlffl . 001 7 10. ..
114/19/93 99713 I J.MT.Hll OV f <; T . l'l03 1 2!l.U
'4/19/93 97010 ItVORllCOIII\IOR/cnYOrIfFRIIPY . 001 2 20. ee
CONT INIIFIl
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I'ATIENT. rlIIIF '3. nllnnFrl~ \0181?
531 Hon rll FNllllI UA IVF
fNOl1I I'll 11025
S 'I' I A \ -<I 8 ;> \ ;> 1 I' 0 I . 2lfi 0 0 .) 0 I/Ii:
OIlH/lN.T1 08/17/'1? 0"1"
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10, llFNfnnl. IIcCIur'Hl INS
I' 0 !lOX RAf! 1
CIIMP 11111 I'll 11011
IHHF'I CIITAOI'RIICT1C CLINIC.
14:1R rnINrllf nOllo
(:IIMI' IlIll. I'll. 1711I11
7171717 ;>1;>1
llIIIOHO<)I5,
fl3'1.20 5"""JXlIlIOtf OF IUMBIIA "I'IHF
12~.? LOW B/lCK I'IIIN
72~.f\ nErl' RfFF"AFO IFO PIIIN (VFnlfnAOOFNIC)
839.0B Mill nPIF (:FAVlCIII VF"Irnll/1
"liTE or Ill'll nlll. 04/;>'1/'11 PAl IHfl10'1? 101 INfl10'!2
....___.....__.~ft_N__.....~..___~mn"~_".""._...____.....U__...u................
DATI!
CPT
OESC'UPTIOH
~ POS ros .
A"OUHr
......__....__...__..N..."_."__M~~""n_____".~._n__.....................-.......
84/19/91 9711 14 f l fC TAt (' III 'II 1M IIHlIl1FNllfll . 003 2 30.llIl
04/72/'l1 99214 HHfAM" OV r'l T . 03 1 '15.08
84/n/':13 97010 IIVnAOCOlllIlOA/CAVOllIFnlll'V . 001 ;> 20.11e
1l~/22/93 9701 4 fir C '" 1('11 I '311M "IlIlTlfNnfn . 003 ;> 30.lllI
04/22/':13 72040 xnllv CFnVICIIL L 1M IHn . 003 1 3l\,llII
0~/2?/9J 72180 xnllv I "MOlin IIMllrll . 003 1 4f\.1lIl
8\1?I/'Il IN I'IIVMrNI IN"; 1 fi 1'1 11 I 1?/1',/'1;> 110f1170 .-1\ 1. lie
81/21191 IN PIIVMFHT IN'i 1r; 1'1111 I? 117 I A 110f\4Afl ..\ 06.80
1111;> t I <I 1 IN I'IIVMFHT IN'I 1/\ 1 '1\11 12/19/'12 11011~8f1 -IH.9;!
01/2 1 / 'II III IIll.IIlSTMftll ronolvr IlllGMlfl ...12.1lB
1ll/2l/9::! IN t'IIVMFNT INS 3639111 12/? I 21 1106487 -1Il6.ll0
01/21/':13 IN rllVMENI TNtj 1(; \9 III \2/?1/'1? 1106488 ..30.01
82/0':1/93 IN rllVMrtll INS 1(j~021\~ I;> I? '1-11 110f1f127 .-146.01
82/091 <IT IN I'IIVMFHTIN'; lr;~0?0~ II ~ '1 " 101H?! "6.00
02/09/91 IN I'IIVMfHI INS 1640;>0~ II f\ 7 110672? -98.ll0
02/16/'1') IN I'IIVMfNT -INS 1fi~0171 II ~ r; 1I1l67?\ -180.eIl
112/23/91 IN I'IIVMFNT INS 1fi411<lr;1I III II I'll 110694B -63,ll0
02/21/'l" IN rllVMENI INS lr;40'lf\fI III A 21 "10G'l~'1 -..126,32
112/23/':13 III !Ir)'III'IIMFHI ronnlVF 1106':14'1 ..26.68
02/23/'l:1 Itl I'll V MFtl I. IN'3 1 f; 4 0 '1r, I; 1/?l/91 110G'1fl0 .., 1'>' 01
02/23/':11 IN I'IIVMFNT TN!; 16~0'1..1 II;> " ~A 1107061 -122.ll0
112/23/91 III IIll,1IJ9TMfNI rrlnOIVF 111170'1\ ,,'31.ll0
113/19/91 IN t'IIVMFNI INn 11\4112f1 '/A I? 110682f1 ..11""
83/1'1/93 IN 1'lIVMFN 1 TN'i 1 I'; 411 ?G III ';> .. I ~ 1101\1\27 ..1 811 , ll0
83/19/':11 IN I'IIVMrNI INS 1/\ ~ 1121\ ?/I 2 1107 I f\ I -1118."
83/1'1/91 III IIn,ll)9 TMOI I rrlnn lVf 11117 III \ . 3 .. lIfl
81/19/91 IN I'IIYMfNl INS 11';01;>fI ;>1"/'11 1l1l72fil -1\3,"
r.llH T I NilI' Il
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rIlTlf,NT, OMf 3. fl^RflfR;> 101/11;>
6:H NOR T It ENlll1I IJnlYE
ENOllI I'll 170;>f\
!'l'9I\OI.1R ?I?l 1'01';>11;00',011\1:
II II TEll N ,J. 0 nil 7 1'1;> II R T"
IR~H. ;>1 ;>'1011;'>0
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TO. (\fNETlIII IICC/OFNT IN'1
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CIIMT' IIlI.l rll 1/01\
INNrs CltlTlOrRIICTlC CLINIC
1~18 IRINOlE AolIO
(liMp lilli, plI. 171111
717/717 ;>I?I
IIIA(\NOS1.51
819.21 SUBlUXATION or lUMBAR srINE
72~.;> lO~' BliCK T'AIN
72~.!; OffT' nHEllllEIl tEll T'AIN (VERrFflROllF.NIC)
819.1If.1 MIll TIl'l F. CFRVICAl VFnTrfl1l1l
nATF. or I^ST RIIII 0~/;>'1/'1l fill" INt\10'!;> lllll INll10'!;>
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DESCRIPTION
· PDS T09 .
""OI,lHT
.....___M..._._...___._n.ft~"._.__."~~__..___n._.._.....___..___..__............
13/19/93 IN PAYMf.NT INS 1 6 ~ 11 ;>1; ;> II ;> . I!; 11107352 ..116."
13/19/93 IN T'AYMOITINS 'II; ~ 11?6 ;> II !I I '!3 1110710;1 '1\1."
13/19/91 IN PAVMENI INS 11; 41\;>fi ;>/1'1/91 "\07437 -121.82
01/19/91 I^ ^O,llJSI'MENl rOllllIVF 1\07437 -11.18
113/19/93 IN PAyrHNI, INS 1fl411 ;>(, ;> I;>f\ 19 3 1107438 -53."
1~/12/'l1 IN PA Y Mr: II T TlIS 16446?7 6 3/16/91 "107711 ..1I5.1A
14/12/91 IA IIOH'S TMEIIT rOlllllVF 1\07111 '-12.611
1~/21/91 TN PAYMrNT tN<i 164r;6~0 A 1/1.~ "10755 B -till."
1I~/23/91 IN PIIYMfNr INS 164r,r,~0 B 3/9.11 "1971131 .-te6."
14/21/91 IN PIIYMENr TNS 'HI4"'6~0 A 1/19/9:T "107A27 -67.18
1~/;>3/91 1^ AIl,llJSIMrNI rO'H1TV~ 11011);>7 -&.82
1~/21/93 TN T'IIYMF.Nl 'Ne; 11\4"r,~0f1 1/;> ')?'\ .107828 -111.112
14/;>:'/91 I^ AIl.1U'1TMENr rOlln IVE "1070;> 8 -11.18
14/?'3/93 IN PIIVMF.N r INS 11;4r;r,~0 A 1/;' 9 I q 1 "l07'lla -18.01
14/?'3/91 TtI PIIYMFNT TNS 1fl4..,6 ~ I. Ii 41 f.I I;> "10111 ;>1 -<)1.25
"~/23/<)1 IA ^O.lU'lTMENT XFF n I I) PIITTF.NI -.62. 7 PI
0~/23/93 llE llr:n IT urn rROM II/Sl/Il 112.1&
1~/21/91 IA ^O,JUSTMFNr xrrn 10 rllTTENT -1&11.00
0~/21/93 DE llE fllT UFn rROM IN'll/A 11l6."
Pi4/23/11 I^ IIIl,llJ'] TMr N I Xrr:n I'll I'll! IfN T ..156.00
1~/21/93 llE OE 8/1 UEn rROM 'N'lUA 166."
0~/27/91 I^ IIO,JU'! T ME tll l"O r. OA IN'1 Rill -lflt\. U
011/1.1\/91 IA ^OJU'1 TMr:tH COIlIl IN'1 nA' 186."
18/02/91 I^ 110,)1)<; TMFNT xrFn TO rIlIlEN! -185."
011/1l;> 191 OF liE flIT X rr R rRIlM INSl/1l 1115."
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51\9.15
P~Cl" 1 "/JI.,.t,/lftl, ,.,.fttl II/O!.(r,m/D,Uti 11-1"" ..'1 '.Iftl, ,.
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ITfMllfO
8T~Tf"tNT
OIlJf.1 0"'/0l/'l4
In~1I1 ;>,1 ;>1811211
PIITtEN!'1 O/llf. '1. nllnllEn 181'1R~
633 NanTtI fNOI./I ORIVf
fNal/l 1'/1 118;>f;
981181"3B .;>121 1'0111
Oliff/IN). 0BIII/'ll onplI
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TO.
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l~lB IRfNoLE ROllO
CIIMI' ifIll, I'll. 17111
717/717 ';>\21
OIMNO'lISI
1119.21 SUnlUXllrION OF 11lMRIIR SPINE
77~,7 1.0W Il/lCK P/lIN
7;>~.'" OFEr nfFFRnEO 'FO r/llN (VFRIFanOOfNIC)
1139.18 MUlllrl.E CFnVIC/l1. VEnlr-nRII
O/lTf. or I.IIS1 RILL.
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DESCRIPTION
· POS T09 .
~"OUNT
..-....._........~.--_._---.._---...-.__.._._...__.....-"....--..........--....
111/11/93 99211 I H1ITFO 0'1 rSI .13 1 28."
11I/~~/93 '19211 IIMIHIl 0'1 E S I 801 1 28.80
IS/211/93 99213 l IMI IEn 0'1 fSI 11I3 1 28, ..
IS/211/93 99211 I IMI Iro 0'1 E"I 1113 1 28."
87/81/93 99213 I IMITEn 0'1 F S I 881 1 28. ..
17/IS/93 99213 I IMI lED 0'1 ESI 883 1 28."
17/89/91 997.13 I.IMIIErJ 0'1 E~lT ee3 1 28. ..
18/12/91 99211 I 1M liED 0'1 F'l T 11 1 28."
12/21/93 99211 11M rrE n 0'1 E 5 I III 3 1 28."
81/IS/9~ 9<)213 I IMI IEIl 0'1 FSI III 1 2B ...
81/18/9~ 99211 L IMI IFn 0'1 ESI 11I1 1 28.81
111/13/<)4 '1<)213 I.tMlIEO 0'1 PH 881 1 2 F.l, III
tl/17/9~ 9<)211 L I M I TEn 0'1 rST 83 1 28.81
8l/21/9~ 9921 ) IIMlIEO 0'1 FSI 03 1 :?II . ..
e1/25/9~ 99;>13 I 1M tTEIl 0'1 ESI 883 1 28."
81/27 /9~ 9921) 11M I lED 0'1 F S I 13 1 28,81
12/t1/9~ 99213 LIMITED 0'1 FSI 1183 1 28."
82/18/94 99211 II M I lED 0'1 EST 8113 1 28."
82/1~/9~ 9921 :) 1.1 M I HI) 0'1 E SI 1183 1 211, ..
82/17/94 99;>11 II M IIEIl 0'1 F!l I ell 1 1 2ll.ee
12/21/9~ 99?11 , IMllE1l nv ESI 1113 1 28.ee
'2/24/9~ 99211 , I M I r F I) flV F S I 8.3 1 28."
'2/211/9~ 99;> 13 llMIIEn 0'1 ESI 1183 1 28. ..
.3/83/94 9921) lIMIIEIl 0'1 F'H 81 1 29."
81/17/9~ 99213 I IMI HI) 0'1 ESI ell 1 1 2B."
1I1/18/'l~ 99211 , IMIHn flV f!; T 88' 1 2B. ..
81/18/9~ q 7 5111 KINFTI~ M rIll 1 TlFS 11113 1 22.1e
1I1/1~/'l~ 9q;> 11 IIMlIfn OV E 'I T III 1 1 211.118
CON 11 NUE n
........................ft....__~........._._...__...............................
'111nIO Till I 718.118
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3~3B rfllNOl! ROAD
CAMP Hill, I'll, 17811
717/717.2121
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724.2 lO~1 HIICK pIIIN
72~.5 DEEP REFFRRFD lEG pIIIN (VEflTFeROGENIC)
F.l3'1.0J1 MUl nrl.F CFflVICIII VFn [Feflll
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87/0&/93 99213 lIMI TEO OV EST 083 1 28."
IH /09/93 99213 LIMITEO OV F S [ 8113 I 28.1111
10/.;>/93 99213Ne NO CItAnOE ov 003 I
88/0&/93 99213Ne NO CHAflOE OV 11113 I
88/12/93 99213 lIMITEO OV EST 83 I 28.1111
17/01/93 PII PAYMENT PCI03 -28."
17/86/93 cn cnEOlr SIIOUI.O DE N /e -20."
17/09/93 CR CRron SItOUUl BE N/C -28."
18/12/93 PA pIIYMENr pel.!', -20. ..
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""
1111
nllructlC)nl
M pI,a a.)
Iftl"..1 You
,".
181.
"11,u,lIool
onpa,U..)
8Inllo
e~III"
I".
"11,uttlO~1
10paIUS,)
e....'" .ft'
II L.....
ftl
'"ft'''
I.. lI,mll
=' MOIl Ol~.,
"""'"'0"
....1I0ft.
!Step"U8
lor IIlIInllllo
dldutl hl.a.)
,
O'~1t a
MIR'"'h'''
D..."I'ftl
.1.11I11lI''''
....II.n.
Schedule A-..-Itemlzed Deduction'
.. Allarh 10 ",m 1040. .. ~..Inlt",'".n. 10' R.halultl ~ .n" ('.'''' 1&.11"
____..~,._.___...___.___ "I
--_....~._-,.__.,_. .. . .
h ",.le,lplloo m'dlcln.. Ind d'IIWI, i"'IIIII', ctollnl!, danlllll,
nur...., hG.pll.I., m.dlcftllnSlHswfl P'flfIlllllfl" YOI, "Aid, .Ie .
. OIh", (lIll-lncllJlII hU,lng 0"11, ct.n""",. .y..,...."
tran.po,taUon .nd 10d,lns, IIr) .. . , , . , , . , . . . .
I' ,-
I_ ..___ .
" "
;, ''''':t
' ',' '\'t.i,
,; '''/tl
" Ir!~'ll~'
i ',11,\
,
, ' "
J .'r
I,i"
.........................,..,
.
..........,...... ....,..,....., ...."..." .......... Jl
I Add thumounta on IIn" IUnd 1 h fnl", IhO 101.1 har. ,1
. Multiply Ih..mount on Fo,m 1040, Ii". )2, b'l7.5'!/, (075) , ,'_'
4 Sublr.ct line 3 'r.!lm Ilna 2, If n'o.~'_!~~!,!DJ!L.O., Tot.1 m.dlc.l.iid~ .n
S St.t..od 'oc'"ncomltl'" , _L
I RI.,..III.II'.., . , . , . , , .j_.
7 ~;:~A,~,,(.L~~I.~.I~~',~~~ ~~:~onol"onp.:t,'I.I',"',).~.:::::'.:
. Add tha amount. on 1!!J!!.,]..J!"o.y&l'L.!!l.t~!!J.'!J~!J1~!. Tol'
.. O.ducllbllhom. morti!s.lnlmll (lrom FOil" 1098) Ih.1 you
paid 10 Iln.ncl., 101111ullonl. Rlpo,t rl.dur.llbl. pol"" 00 IIn. \0. _h
. Oth., dldudlbl. homo mo'l~n~. IrM,III. (If "old to 0"
Indlvldu.l, Ihow thai o"lon'l JlB,,,p.,,d 0<1<1..,1.) .. ..""...
.
......................................................
10 O.ducllbll polnll, (See 1"II,ucllo", lor ,,,.eI.1 rul.,), , , ,.
II Daducllblllovlltm.ollrltr..t. (5.. I','g" 25,) ". ,.
Ut "...on!llole,..t you pII~, (So. P'R. 2~ ), Ll~~ I, '-'t9:J__
b Multiply Ihumounl on Ilnl \2a hy 20% (.20), fnl.rlh. ..lull · \
13 Add Ihl .mQunla 00 IInll 9. through !~'l!I...HE.:..!!ll.' Ih, tol.1 h , ,
l4 ConlrlbulloOI by cash 0' ch.ck, (If you ROV' $3,0000'010" 10
.ny ooa o'ltnlutlon, Ihow 10 whom you Rav. and how much
YOu ..v.,) . ........."...,,'.',......,.....,.....,..
U Otht,th'ncuh 0' chick (Vou mu,I.llo(h Falin 82831' Ovlr $MJO )
II C.rryovlr "om p,lor Yllr , . . , , ,
11 Add Ihumounl. on 110..14 thro.!!&lI).!L_Ent.r~.!~ltl h'", Tol.1 co III
1. C"u,"y 0' th.ft 10U(II) (.tI.ch fOil" 4684), (Sit PIR' 28 0'
Ih.ln'lructlon., , , , , . . , " ",.,
1. Movln't,pen... (atlleh Form 3903 or ::903F). (5.1 P'.I 26
olthalnll,uetlool.) , , , . , , , , ..
fel Unlllmbur.td .mploy.. .'p.n.... Job l,avII, union dulS. lob
.due.tlon, ttc. (You MUST altnch Form 210610'001' c.,..
SlIlnllrllctlont,) . .............",.....,...,.......... _~..o
fl Oth., IIpanl.. (InvlllrlIlnl, II> ",,,,,Mollon, ..f. d.po.,1 bo.,
tic,), lIlltyp..nd amount . ....., _ . .. .. .. . .. .. .. . .. . . ..
!.
i. Add Ihumoun'. on IInIl4,8, 1), 17, 18, 19,24,ood25,Enltrlhltol.'h.rt,'rIItl\
'nl., on Fo,m I04ll, 1101 34, Ih. LAnGER of thl, 10111 0' yOu, Illnd.rd dIlIuetlOll
, "om P'IO? olth.lolI,ucllon,. '_ ' , . ., ,,', .. II
,., P.,.-,~ 1l...lIft All '''''ea, II. 'arm 1040 ''''lru,".n., _,,,.,,,, 't~,"""(hMlI04O) ....
1M' le.co.' ' ,y,'
.
, ,
, I
..................,.....,.............................
.
U ~dd Ihltmountl on IInll 20 lod 21. f I1lnr Ih@ 101.1,
U Mulllpl'l Ih. ftfllouol on Fo,m 1040.1111032, by 2% (.02), ~nllr
Ih. ,tlUIl h@/I ,'" " ",',' ~
f4 8ubl,'cl II!}! 23 ',ofllllnl 22, Ent!!Jh.-,!!ult.I!.i!!!2.~' ItUJ.!!lI.r ,0. , , .
ts Olht, (from 1181 on P'.I 211 0' In!I'''cllol1l). lilt Iyp. Md 1010uol. ..... ........
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~ . . . ~, .
~
,...,nCRlh Charitable Cuntrlbutlont
... AII.r:h to ,OUI 'fd.,~IIJltOln' 1.1 ,.II"nU tltt lotll tl.lm....''''
.1.11 p,op"'V <onlllbo'._ ....... ,Boo,
.1:_ ~!.' ~!1!!.!!!.!n'I'0'"0n.,
t'(;" .1 '
_ "~"l~~~""
.
,!a . IIIf1W"-""-
....UU
'.. Includl'" S.ctl6n A only IItlll5 (01 ~/f"'JI~ of 51mllM llell1l) which hlv"1 tle"ntd value 0' $&,000 0' I'''~'
Item IIr .rollp .nd certain publicly 1,;,,"'<1 ''''l'IHIl,05 (,on Inltructlona). .
. ,
....., "
.. l"reflll.II.1I On Donlt.d Property
. .j
.~,
I
..) H'mI .nd .lidll.. 01 Ihl
don" ,",,"111111'1I1
II' OItC,lpI""'", _,'" ,.....", """hi
..,,'11' _ II",.,. .pa"" ........,
~.e"cr_~__At_G'Ol"H'NlI J ., .' ,
}fJW/fOGro... !;u,"-' , /-1,,, H(')(AIA,'JJJ.!t'~
Ct</d j 'S:r&t1J...J..L1t-LJ&U.tifmi1u'6
D _~qg_1>.I,)JbL.--IN DIAST R,( C;';) 8 B.ACi~L.Q..Q..tJ.lLNJt..
I GOb a. ~1.'...~__ :rn ~ .~ T R I t;' S 2, OED .H~~.oe.dAa~.F6T1'Y (1M/II J C1I1H,,.d-
/!!!!! CONfTIfI'l9!1!! '1}!!.{/J.rf_Ofl_O! JI~y.tnbe _pll"I'!"/"llm ,t."" 11',11, n v.,t-"~ .ol15og.qL~1L. -,
c.) OM....". flll)O.I..t(j1Jh,rt '(')"0\\'/1(11'1111") (')nnlllJl'~r'"I.,r C')'.I'm.~"vtrllll (~)M'Ihot_t.~Nthtttl'
CO"tfWtln b-, dnnnr uno , ~, ) by rlllllll' . ^dJlJ~I'd 1""11 "'...... ~Iuf
Y,iRl.o~~ r~OU(,~\'r \JARlb'-l~ _.F/S'JJ :'TlaM!lI~ WI-'-
A
.~l"'l..,".:rN_QU s.rg{! Sa
I
c
,', '
"-
,
-~'tl t1~tlT~::~~l ~~~n
Otlltr IlIlormlllon-CllmP.le.l.e Q.un8\101l 2 II yelll A.~VO les, ".lan anllfl.lIr"~II"'111I "rtlptrl~ IIlt'C1I~ flirt I.
_____S,ll.n.lplp.le_q~.e~lIl)1l 3 II '1l5ldcllonsw.er.e _all.ach_e~-,o' eO"I~lIu\lO~ II'{~ III flit I, .
. If"" thIn tM .ntlreInl"..tIn the propl/ly Is COlllrlllllletl t1iJ,iIlB llie '118" complete thl 16111l'lt1111i
II) bit, ItIl.r 110M P.rt I which Idelllilllllhe p'opelly (AlIOeh A uparAte ...IIMerlt II "ert IIlp",'" 16 /ll6rllhl" 61\'
property.)
(II) TOI.llmount (1IlMed as 8 ded"clro" fO' tlio,HOp""Y 1I',I"tllll Po1Illlo, IhISIA' yel, ,
lor tny prior III Y'.'(l) ____ /
Ie) Nlm..nd .ddreu Of Ueh orR~nl/nl,,>n 10 wli,dl .1I'y 'wh 'OIlI,ibiJIIOIl wn' iliAd. I" . prl61 y"r (1!I\Mpll.. 6t1ly II ell",,", ItOM thl
don.. OlJlnlrlllon.bove).
"
c",'ttiiTiOt""'jiiiiJiiiDnf"tinnttf"'"lr!
._-~-------
Nu;;;bt,.nili7.-.I- .__u. .
r;iy'; 'own:itil'~'nd lIP -~oll'
(d) The pl.c. wbere lilY IA"B'ble p,op.,I'I'. 10CAle,l", kepi ..." ._ . . .._ ________
(I) N.me 0180'1 pe,SOO. olli., Ihol1 tlie ,Ione~ Or~lllll,'li"", h",1I1~ nctl/AI P')5'""'OIl 0/ Ihe ~rop.,ty, __.
3 II condltlonl we,. .ttached 10 OilY rOfJllihll""" 1151""11 [>,"11, nll'WIl' the IOllOY/lfJR Iluntlen,:
(I) Illh.,.. ,ntrlcllon '1Ih~, lelllpOlAtlly nr p~'''',II'''''"Y olllh. "o,,"e's ,IBhllo 'JS' or dllpee. 01 the don.l.d pr~IlI"~t .
Ill) Old you .Iv~ 10 anyone (olhN Ih~n Ihe r!""..' ''''',\llIlnIIOlI 0' Anolh", OtRAIllttll6n plrllelplllnl wllh the eM"
o.,.nlllIlOO In Cfl<)p~'olive ""l1".""I~) II". fI"IIII" II'" '''''''"P frOnllh. riollnled p,or>trty Or l~ thl 1'0."'"1\1\ 61 'M
p,op.rly, Includln, the ,IRhl I" vol~ do"n"'oj "'''fI!''', I" n'~I/I,~ Ih~ ",n"My by pu,ehU' 61 oth'r."', or 10
d..llnt', Iht ptrtOnhavlnl( ~\Jct\ Itlf:orlllt, flo~""''iH11\. or riRtlllo nCi'lulre7 , . , ,
_(t) IIlher' I rtllrlcllon IIrnlllnR Ih~.~~L'~!'1!!_P!.!'fl"'!Y ."HnJ!.~llcI/IB'J!~L_:..._-,-,-,-. . , .
,., ,.,.,..,k "..udlo", Att NftUU, ... "1""'1 trUhurllfHU,
"
~6fJ\\ UU (M., 1617)
257
II, '~O" COIIHHlAIIGfj lV",", '''''~I, II,., "'I """""" II,
II, '1I1l0Yl aDI."'" mlNll1 I~OIl .CHIOUI.I 01", . .. ,''''''''''',,' II
~
I II, fA.Atll COIIHNUltOfI'llftl I' HlIlI.' 101 MIACH COP, 0' WI. 101m 01 lO~II,,, """"".""..,,,, II,
I I, INII~UI'C~'lth"'" ~ H.", 11001 """:".,, ,,",,",,',,"" """"""",,,,,,,. I,
a, OIYIOlNOIICDIftPII" .m.... I."" "001" """,,'"'' ,.
I'
i 'I .. Nit HIOtIlI '~Oll IUIINln, 'ftmSlrON Oft ".IIIC.m,"" Seht.,,, C ..,,., I'.ld," " In". .n ',111" ,," ..
N. tAl. OlII1C"~NOI CI '~oHm IC"'pNlI'~ I'.ldu~ 01, ..,,,, ",,,,,,,,,,,,"..",,,,,,,,,,,,,,,,,,,,,, 6.,
[ .0 MOl AlO II 1h\l1I11N' II,
It. ~MOUHI 01 4LLOW~11I1.ClUIIOIf 'Mil AmCHIO '~,IIIP'r\ II. lint 10j"",,,. 10
I a. HIT 1IICOII1,1lllM .,HT1.IlOYAlIIU, 'AlIN" AND C1lPVAIGHIS (Com,'''' PI l,h.d,l. II """"""""""",,,....,,,,, a, '
I, IIIAtI 011 I.U*, INCOIlI,earn,tll,'A 1....ut1 II ,,,,,,. "''''',,'',' """,,,,,..,,,,,,,,,,,,,,,,,,,,,..,,, I,
I O~MIIINO ~NO LOIIIAY WINHINOI ,,,,,,,,..,,,,,,, """"""."""""" """"'"'' ,,,,,,..,,,,,,,,,,,,,, I
I, HNHIYlYANI4 fA.4alIIHC1lIlII~!.! llntl I., 1,1,.!.,JLU, I Do nil ,"uClIOlIIII "'" '..",,'..' ....,,,
I, II, IA. L14111'tl' ' Mil OII1NII 'IIvHI~ lln.",. ,Oll'"""",~,,,,,,,,,,..,,,..,,,,,,......,, '" "..' ...'....
tI, 10lAL'A INCOM,'AlII WlIHHllO ",... .n..... W.hl '''' ,,,,,,,,,,,,,,,,,,,,. .. "",,'" "",,,.., tI.
II, M 18fIMAlI0 1M ""'MIII11 ~1llW._tIon P1Ym..~ 'nd III"." ","" !r.m 1116) ." ., ""., ".", II,
I tl. IAUI PAlO IY PI AIIIOINII 10 DlHI~ ITATfllCllmflllll PI Seh,"u" G .nd 1I11'h IIhll ""1'1 IIlu,"' , ".""".1, II,
. III, I~. 'O~OlvIHln CLAIM'U ON PI ICH'OULI" IC...,I," PI SCh,",It IPI,,,,,,,. '''''~''=''-'''' "..,.., a
J III, HUMII~ 0' O"INMNTI CUIIIIO ON ,~ ICHlOUlll'" . II.
III, 10fAlINC'OMU'IOAII0 ON lINI . 0' 'A ICHlOUll ",,"'" ., """,,",,", II,
II, .MIlOYII'"' INC.NltYI 'AYIIINI molt lComplfl.1A 8,...". WI, ,,,,,..,,,,, ,,,,,,,,,,,,.",,,,,,,,,,,,,,,,..,....,,,, tl,
la, tnJA~ "VMINII AND C~"1T61~I'llntl 11, II, 1I,.!!!t..lli=",,,....,,,,,,,,,,,,,,,,....,,,,,,..,,,,,,,, " .." It
Ill, tAl OUIII"""eI LInIIlI,M 1I.,10111l1I.hlllllllll. " P' D.plflm." .1 1m"",,,,,,,,,,,,,,..,,,,,..,..,..,,..,,, It,
II, ovt~AVMINI ,1",'eI LIftI 101," LIn.III.",,,,,,,,,,,,, . . """""""""" .." "..,"..
I 'II. ovtAPAYII'N' 10 II ~"UNIllO ".....,. ""11111 "Iun. ""~J . ",,,,,,"..,,, II',
1111, 1M.,.,..", 1'0" WllITlIllllllltO IITIMAlIO 1M ,,, III
.
, . 110 0 WlLO moum eljllmv~lIolr JUlrO..""..,..,,, tll,
I II . I '_'"11111'" ......... PI. ,,,,.., "'dll'n, ""~"""'I .......11.., 'b"~"", IA' 1111. ...1 II ., .......,. II ....,
.Ion.. 'I~~'- "",. -.-l'"""--~---r"'''..~ ...,- O.~' "
~'rI .111. Ijl...,..I~.............NI_1 _--- r.;;;;;; ....'". .,.. N
_ . ~ · ". _ 'X. l LOC '1, .. ~.'-:'i
.~
.......
.
.1989
O"'C,.. 1I ONL Y
COMMONWULTH 0' rfHNSYLVAHIA
Indlvldull-lncomeTax Return
;l/t N 1I.18lf,.. JI~ I, "". ~ '1, tUtU
0,....' "" ,.., O.'Otlll,., 111"111II 4""h.d
.11., lnll.' , III _
,"'... t'OUf" 1M. CU'IIIY IfU....."
...11......."'"'''111
flU". ,,uu : le,*k 0..1
. .. .....
I 0 ....., ,...,.lfiJllDn
U 0 _,'...._.._
.."'" - ........
, D .....~...'u,.'..........
, 0 _.....,..._
DooO"Oo... 0,,;
",,"'I. II.'.': IC.... ,
I . ".....
, 0 ,....... flU...... . ". .
. 0 .........
~
UU'A I:
,...
5AI..~AlA,v_.
..."., - - -
..
.11
, ,
"
1M
"".",,"lIIIIt II IUI 011 011
",OllI.HIt I~ I...,
"
'LIAII ull tOUR mlm
ImOL OIIU'U IDOl
'llAlI,
. IOUILl IHIU nuuu~,
. mUI ALL n'VI'"
totUlIIllItI
. 'IU ,." .'Mo.
",
811II INCOMI IN'OAMATION WO"KIHIIT - 1..,1 _ J lIIt",,_
H.IIlttT/ ~__ UN , ~ ~. Bi""dltl
H''''I,t, ._,______________ UN .__' , ,___ _ Ii"" dl"
WAG'" AND wrrHHOLDINC) IN'OAMATION(~htcll boK "ptnllon plln bOK on W.,ia ohtckld)
~.:: ~='-3~' -:W:~i~;;';'~,. · ~:~":'''-- ;;:. - '~
~.Jl'ft"wil.lLI"NI _ :'(" ..c"A .ta"'~C.D .
f-.
"1II1 ~. · Mi1:
,'a. . - FICA . + ' " . ""'"''''''
'" , '" .'
I~
~ ~~a:,: INCOMI r~::b11 + Ftdll.' NonllMlbII IOCIAL ..0
~ FanTIK -Jr -III T'K T I.
"a.o.i CfA w ,.
o
SO
"NON~"
11\11' tl31 16t1..1\6I '''1IIllII1d 601In*'
. 111M, Do Il6l MJdf lilt 101111 f_
. IrMIUf\lIry /lOlMItl6I\..
.._ ,.... '"_ . .. 'Ma
I. 1M'
^-~.,.....i,,, ~ .....'- 'Ht
IlO IInl II 1t0 ""'..!L .
'~'," .; ~, .' .~".' "" ",' ,
.:~L.'".,,'.,.j."'..,i",;',~ _. ,._, .'"
+ ~ldl;~;' "":.~;';I ...,. T*bblII !;!.~- ~o.
Tu tlM rllteltt, ,..,. lIhi' ,lO
II
'.. ,,1_.-
I I,
DINDS - OTHER DISTRIBUTIONS ON STOCK
,.,., Fan TIK - 0'011 T ~ aro'l 8
+ Fldlrl'
TIK
I
+ CIPlIII
Olin
: Income -IM==
..,-. 1'....1
I I
I I
Ie - llnel 'Ind!!.:.., I
MI W~2P Ind 101tA IN'ORMATION
~IY" a tnlt olOlal1tbutlO!!. - aroaa T - arOIl s
L
\
I
D; 'v.. -.-ltIcomIlOlIlP'liIlriItapltcl-
'''7;'0IM ..It;.. ,Il or 171, Form 1040l MIl flirt ... hIlnI
~LDINa NOT LISTED I!LSIWHII'II
~All' 'IAOlI
"'* A throuoh E, Itd'rI'"~Umn)
+ Fldlrll
+ SIIII
..nMAtID TAX PAYMINfS
~0I1'1.: III Ouln.. (lnCUlIINI
-
Ind QI.rttr "'''",,,lOnt
3"' QUlrlII ......... 10
- 4~1111" ''''-lItt
II'DlldgIllrFTHr
. : IlIItt'nltl 101 , In 1 VVO
, . : ~I" IIltml.. lOr , In 1 VBV
J: I n
I """AI
fld, '04o-.e~III1'
Oil'
"'Id
+ S"I'
t'K
+ FlIdlrl'
TIK
.1--.
- (
+
+
, 111I. laM COMnnl
~"IIU.
11IAIl1L-
, , ,
IItA
~ 101
I
+ Non.
tlKlbI.
~
lJNIM'LOYMIHT ALIMONY
. COMlIlHtAflON "'id 0
I AmOUn11Tl ,., Of ~ DIlIltaen:
Amount (8 P.riOd IllUlriif
TOI"I Y',I Ilr Amounl
..'0 ,
~'O~MAnOH ___
'081 tu U'bUlIy ii1i
Ftd'rll
SIIII _ f':mn, 'W.eDJJt.~iT.
) D'" ,HUII.net ~~!'~jii t~~f'J~! n
cfUI !If" lit ,,11d Br:~ '1:I='.r
Ftd.r.' n "If 01 ',O.m K II0nlld
SIItO
10-
I.
l
I
J
~
t"
',t
'\',.
.~,!},
',I,.
I I'
I" LA
'A 11025
ll. I.'. ...... .., .. .."
t.,. - ~... .n1 "II 1""I"ln
~, e,'1t "",,"'1 .......
t... II.,""''' 11I\YIlt.1oI.... __"':"",;,(
.........
"
. -- .,',.'----~.~ .
OM. NO,
"
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I"
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II
l
n.,uullIl.!11 nllb. "."'II~ l.l'.,11111 """~",,,,, .."I, ". "II (.1)) a G I
Ivldu'lln9..'!m!1.~-"-eJ~!_~___''2.JUlL_
'''t1h'JIIUj" -llIe 11,1911,., ."'; ~:!;! ~":'''~~R _ RT _ s oit~!~-'!'c 0 I. \"""
v~ ll\-38-2121 371-510-1523 S2& 50 I ----
DALE S . WANDA L BARSr" t R}IonI)
" 533 N [NOLA DR O1.S _.---
~ [NOLA PA 11025
,,..14,"116' .. Uo '10" wlnl $lln R~;-,~;;;ii'- .--------------.---lX
.'""" CIIII,., ., "ql!!! rt!'!!!Vo.!8_YE.!H_.8P'lIJ!. W,!"I.' )1.0..010 11118..'!!)1.'!LJX
I AlII."
. .- j( M."I.d '1IInllolnl "Ih/lll (r''v.'n il t)nly olle h,'llloron,,)
J ",."I.d IIUnl ^'Plr.t. IlhHn Inlt, lPOU,,'.IOtl.llttUflly nn .ooy' Ind 'un "'llW~.tf.......... .,-.,..." 'w'
4 11..rtnllllll".holrl (w"1I qIlA"')'''. p."OIl) (~..III"IIJ(II,",,) If 1111 nllllll'/lfllIlt/klnII rov'~hlldlltJt",.wtdt;llltl'M, '
.."r., rhUrt'" 1111111lt h"" ,._. ..._..M______ ." ~,",,""I . ~.". .....1 ,- '
__~_.~ __~ _.q~.!.!J.~~nw.!!!1..~J~I~.~~')~!~~.,_'I_IE~~~..(y.~!.!pou..dlfd.l~ ),lSHI",tNCUanl,) ., -_..-",-..,~~..._..~....,.t.i~
II 00 YllIlful' II ~nlll'Olllt (RItch ".. yll'Jt PA,..nt) r.AII ,;hllm ynll "'. d'JHU1dflf11, dG~Dh""t:k &bit 8A.}, !lOM.
tum,Uona nl/lh.""nI0(h"klt'.II'''0''"n.31honp'I.~ , ' , , , '. , , " B"''' ~
180. __.b__1,'l ~pOI'" .._,.. .. '_ ' . ..:.._:__:.....' ' ',:-,:""":,,, """""-'
ll.lrucIIOIlIl) II D.p.nd."..~ III ~~tf~ I)) II.,. ~ olnld.. dtptndtnl I ~~. "11'I= fl\J1ItI
Itlh,",II"" '""""'''''''''''1 ",;;'i'-.':".."""",~I':~'i~~--' ('I~~~~" _ . ~L ;.'1:""....
~iL;TJt~f\r.. ~/1 J?!.I~tL/.fJC:_!!''-O ~~ 1.""11I L
.J}m~11 "lP.1_~'W'."'- 1z.z!('~Lfli.t ..eN!'-" ...." UI.UbIl
SH~_..!_1,.f.JM:t!U I f71(.I~ff,.r_~l!.~'=__ ~.........
I.. -'-.... _,,_,_ '-'-'_,.,.
: -- ---- ' ~........
, .[1
libel
UI.IRS 'aUI
llth.nltlf,
Ill.... prlnt 0'
1'1"',
,"in. allln
Chltk n.'y
on. bol,
=01O"'ha"6
"~aol., I..
I~ UttlOOI
I~t.,,".
""18 "'.ell
C.,. 0If:i
'~m.W..~O,
'no W.I~ ,,.,
"~dtlnGIllayf
rOII;';(~',
~_..
"'....
,H&ch [hpt:k
0".0"''1
ftldlrll.,.
Ad'O"'"''''
10 ntOm.
l~"
In.III/"'I\o. )
" I' 1. I
,1~,I, j '.11 '
",i,,'1
.. II ~ow child dldn'l hI' ....,1111 you hilt I.. rll\illll'rl.H Y'lIH Ih1Ilfnrf..l1l11ndttf' p".1985 ,.,..m.ntt l!PIkl ftft1t
._tll)t'll1u!!.'b.r.'!'..el_~'-'E..upna cl..!!.~~.~l_l ______u__. . '.' 1.",,,.1
7 Wllli~'.IAI.f'f., lip.. fltr. (IItlMfl rl1,m{~' W 2) , , I
I. T...bl. Intl,.~t hu:mtlll (ltf..n "'/.'f fl .'1I/H"/III,. n if fly'" '.101'1)
.. T.lu.,m,.lnl'fullncl1mt IlCJN'T lnr.turll'l I'IJllln. ~.,l .~, J _._.
. Dl'lrd.nd lru:l)m.(6/M "rMth 5011'11111'1 fJ If rJvl, '4(0)
to r.uhl. ,.tundl ol.11I11! lllllt II)rBllnl'I}I11flI.,~I'~, It "ny, 11\1111 wor~~h"pl
II Allmooy ,'(IIVI~
lit BI~.ln.U Income or (hl88) ("tlMII ,r;f/ll'rlult' C)
U C.plt.t.aln of (In..) ("tlltrh 51'11'/fll/,' /lJ
14 (Ipn.l..ln rtl..lrlhu1Iol1" 'lnl r"nrllh'lllltllll'p II (~I1P IIl\hIJrllonl\) I .
18 OIl1t, R'lI08 0' (In"'.)('//,I<h /11,,,'.1 1'Il)
III Tol.IIAA dlltrlh,lInn. I'~II
171 Tntal ",n"on.."~ .n.lliII" 11,1
.1 nttll., rt,~.nl." plUto".hlpl, ....1,11",.., 1/II~h, Iltr.
.t '"rl11 Inr.r)m'l)r(lnI\8) ("',t1t ~rllI"'!1"'"
'0 Iln""'l'Iloymilnl rornpftll!\aUnn (In..", ,'111 1") ("I"P 1I1I\hwlmll") I
II. ~rllllf(""l'/ht".r,I'(8"'nll""I1""'1 . [21.1
b Tfl..hf"lilf)lIfll,I"l1y.holl1l~IW'1f~~III'I'I("""'II~II"r't,r"l~) . , . , ,
12 Otllf' Inrn",. tII.tfype "net ~ml)IJIlI .,",, Inr,lrltrtlnl1~), ,
II Md I". "I1l)un.~~ 'ho~.r2J!L~~_~l:'L!.11111 (OIUI1."ll .'~~!!!2~.' -' I!lrg~J&I!JJ, .T}!I,"~." l?~' 'elM t",.IM
14 A.lmblnud I1mpl"y.... blJ"II'l".Hlf rl1~'" 'uml r."m t' I Wi 111\" 11 24 .._._ _.____
ISa Your UM rll'durlllltl, "nm jIlnn11rnl,II" wllI~~.llIl,'1 2$.
e ~I1OiJU~'81"A d_rtIJrtU)Il. hnm flf1plu ,\1111' WIII~~Il""I ~Sb
,. ~"'mnlrJY'fIll'lIl1h IIl'lw.nrl'tlrdll' 111111, hf\lI1...,nt~..hf'll'l ~,
It ".nth "Hlrflm.nl pltU1llnrt 1\'11 'rnpltl~I'd 'iF P Ilt,fllr lion .. . ~1 .
fl P.n.lly Dn ""y wlthffrllwAlnf ~,1~lnp~ ·
'I Alimony Plllrt (l.rlpl,.llt'lIll1'1t 11011111" _.__
llIM '1)t:1.1 ~.rlJ'lly 110.. ' !..) ~
'~lIn"1!!~.&'!J_'L!J.I!!!~'_.l""'_lnl~I_~,~lu!!m.!.~I', ,
II StlMrt<:1 110' 30 I,on! Iln. 21 1/'" I, Y"'" ,rtJuatld I~"neomt, '111111 /In, II It.. 'hill t,l,Slll
.1'td.r.ftlh1,fftd""'''ytllJ ~,.,,"r"'/l"'II/tl,ntll,,(',..rfjt (I",.. M)I" r".t"dtlJt:tftwl8. I I I ~ .
." ..1
. .J.::;.;.
....
..
.
..ll
I
......b rI'H"hh~IlJl1nllt11
17b l.1l.,bllt jIltnnu"t
(ntf,fdl 5t.h'tI1lIlt')
'......'1'...,..
, ~::t==tt
'''ml~O(l''') N./!].___~)I.lt_~.._S . .,.G,tl~ 'l.."_~______.sstL.iJl 1-/"'/
., Amount '10m IIn.'1 (.,III'S'td .rlm i/lrIHII'), '. """"". .J.--L
aI. ChICk II LJ hUll. ~~ 0' nld" I I 01i",1, r] "ou" w..~, n, nlil., [J .lInd, ~
Mdlh.n''''hllo'ho.."hICklllll"',nl,,IIi,'nl.lhll', . , , , , ,~, . LIlA __
. ".oma~nl (au,hll '01/' p..anl)"n d,'1II vo"... dap,nd,nl, thl,HI" , , . It. '"I
I "'IOU "' ",."Iad IIIln. . alpOlll1 "I,,,,, .nd 'OU, ..,.,u.. lI.mllll doducllon.,
0' ,0t.I.". dUII,.,.luI .II,n. ...lllfllfIJ/:lldllll end chIck h.,.. , .. I.. tl
34 lnla"h. { . y,,,,, ''''''"d dUu.llo" "",m II1Iln""""""'I, OIl ..1 }
,..... . Vo", "ami..' dadu.llon. (110m Il<:hodllla A, ""1 '11
or: II ,0111,."",., .1I"h 5rli"ll/l. A ."d .hock hl'l. [ ]
.. lub""tllnl 34h0m lin. 3', lnlll Ih,,"1/1I h... ., ,.""." "
$I Mullipl",,980b"hHlol'I"U"'b"nl..,,"pllnnl<lllm.donlin.~a, , , , , , , , . t
17 ,T...bI""""'I, 9ubl..c1l1n. 31 IIollllln. 38 lnla, 'h. ,""11 (II 111I Iha" "'0. .nl4r .."') 'b~
C.ulI.",,, undll '1' 14 .nd 'Inu h".lIIo"lhln ",000 01 InvH'm,nllneoml, clift. h.1t .
Ind 'N In.lluollon.'o ... " YOII h..1 10 U" "or'" .SI8 10 lIav.. Y'lU' 'U,
.. lnlllt.., ChICk IIIrom" ao' T..labl.,' r I," R.,.ll<:h.dlll.., or [J 'orm 11I15 , , ,
" AddIIIonIll "'111'" In.'ruclioo,) Chnrk " I,o,n [) form 4970 0 FlIII\l ...,~
ria
COrll,lI.
lollon
CI,c11 III""
~H OW
(.:!Y MFS
Credit.
(SN
1nI"'.:1\OI" )
Ol~tt
,....
(I1lCludtllll
Adv.",.l'C
"'"".nlt)
..,lI'Itlll'
An.th Form.
W.t,.~.20,
I"" ",211
lof,onl,
Ro'und 0'
AIlIOllnl
You OWO
.1....
Sian
Hor.
""
"1"''''1
II.. 0."
1*'
,....,
40 Addlln.. 38 and 39 (nl..lh,'ol.1
-------
41 C"dll lor child and dap.nd.nl "'. ""P'"'' (,ltlCh 'orm l'441)
U C..dll for Iha .,dllly 0' ,,,. dIU"r"I(."",,/, Sch.dlll. R)
., F.'.',n I.. "I<lIl(.ltlCh 'orm I II~)
.. a.nll.1 bu. In... ,..dll Chock II hnill
[) Fo,m 3.000' UFo'", (.,..rlly)
48 C,.dlt for prior Y'" mlnll11U", I.. (II""rh , rum 680 J)
41 Add IIn.. 41Ih,o"h 4~ ("I..lh,'ol,,1
47 Bub,,.et lint 46 'rom IIn. 40. [nl..IIl.!.!.~~!!!!~l..!.!.!.! Ih.n '.'0, 1I!!MJ!lll
4. llo1l'I,np1oymanl I.. (."lCh S,h.dlll. Sf)
4. A11l1nlUvI minimum ,.. ('''''h'orm 62~J) , I
10 Racaptu.. I.... II" Inllructlon'l Chock II "Oill' I I fOllll 4~~~ d FO:IlI 8.'" :
II lloc,.I...u,II'II.. on lip Intom.no' "po".d 10 amplo,.. (./llth 'orn!4 131)
It fl. 00 In IRA or I ou'"l1ld ..IIIIII"nl plnn (.,,.,h '0'''' ~32q) ,
-.' ,
H___.
-~~
~,-
.~
o
.. Add IIn.. 4/1hlOu,h ~" Thl"1 ,ourt.!~ll~
14 '''',,"n,oml III wllhh.ld (IIln'l " horn f'n"n(.) 10'l9, cb.ck ~ []) _~_
ee 1988 IIl1m.lld I.. paym."I. and .",o'lnl.p"II.1I horn 1987 lO'urn ..~I
I' rerntd '"lorn. cr.dlt IlIe. If'8Irw:IICln1) -ll
87 Amou"lplldwllh'orm4e68(1l1",,,on'POI1P.I), 17
.1 I.ult loclill..cuutY'1M .nd RRTA t"l wllhh.ldfIUU' ItIMrur.IIOrll\) II
It ClOdlllo, ,.dl,llI.. 00 lual.(.It"h ''''HI 4/16) , $I
10 n..ulllld Inmlmanl comp.n, mllll (",tnrh for'" 2439) , + 10
II ~dd ""4' 84'h"u,h 60. Thill a!!JolI! lolal III
It "lInl 81 I. 1',," Ihan lI"n), Inlt' ft IlPAlJ).
lit Amounl ollln..a~b.Il"UHO(O TO Y ---
M Amoun'o"lnIUlo~tl7ymlI'l'llfIj""m"adl.. .-~
ee IIlIna 81 "'I'", Ihln IInl 61. .nl., AMOUNT YOU aWl, AII"h th.,k 0' mOnlY did" '0' '"11
amounl pa'l.bl.,o "lnl..".1 Rmnl/' ~...i"." W,lIa 'Oil' '0".1"'""''1 nllmbel, d,,.lml ~hon.
number, .nd "191S Fo,m 1040" 0" " , , , , , , , , , t
Ct'l.(k .. U l"Oft'l1 ';UOCZ'lO'.~ .1t1(~I'd 5.tllllhlJtl!OIlI ""iU,: .
Und., plnllllll 01 ptrju.y. I d.da,. thltl tll1~" .M.llIllfd Itlll "Iu.n and 't~omJllnyl"llChlduItl1M4 "."",_""1 .1\4 '0 I~ Nit., My a,,~ Inti
belltr, Ih.,.,. IIVI. fl).r.d, .rIft C'omplttt n"rl(jl.1lllltl 01 p"p.'" (tlttl.r thl" '''PlY'') t. eMtd nit tlln,or",.Ue" Of wttlt:h ""'ttt hit.", a......
YClll,.tn,h." Oltt' M~hM:\
1~"C.1( 4Ift','eIl
'. ...""",,.;;---
~mJijc '- N ..,...,tr-
" fur,
~.,t 0 /11 y'" '-II I.!1:.!.
J:~:J...,.,~~" '
~paU1.f. iia;iirijiiiiljniiiiiiTlj,", Irr)Hi ;lltJ-;'i "~;l)
------
II ",j f1.. (<..
. H~Jfll.oCK
,..
_'In"....
IIiIItU
,""' 2441
,."":-"
,., I
"-1 ' "
, M'fF""'" , ':."
e._.....-.. ..,1'.,
Q"'~m, .'l"" ' I,"~ .'
-~@8 '
I,
Credit for Child nnd Dependent Cnr. !xpeneell
'\
. AIIl<h 10 'orm 1040,
. ""n.lludlon.,
"0111/' YOII p"d ,~.h W~,ft 01 1M or more/n ~ c.lloml," qllo1rfor '" "'I",'lYIdu~1 lor "rvl," ",,,ormtd In yom ho"",
yoll mil" /II"n .mployn"n' ,.. roll/'". Go' 'orm 942 lor rl"'~III.
I [nl., nllmber 01 qll.lI!yh'l pellons who wert cMod '0' in 1988, (5..ln,lIucllonl '0' d.llnlllo" 01 qu.II'yhl
C'ullo", To qll.II/y, Ih. p.tlon(s) mil' I hove .IMrod tho U"" hom" w,th you 11119/18,
I ,[nl., Ih, .rtlOllnl o'.qu.IIII,d ,"ponalS 'Iou Incu"ed and eclu.lly pAid In 1988 lor Ihe ell' Gllh.
gu.II'yln. p./lun, (S.. Wh.l Art QII.III1.d hp.ns..lln Iha lnal,ucllona) 1)0 nol,nl" morelh."
t2,400 <'4,800 If 'Iou paid '0' Iha car. 01 Iwo 01 "''''. oU4111ylnl parlons) , , , . , , . . .
,. You mu.I,,,I., your e,m,d Income on IIn, 3a See IIno 31nslrucllons 'or d.llnlllon 0' ..mid IntOml
" 1I'/OO.It marrled.nd IIl1n,. IoInl ,olum 10,191\8, enl., on IIn. 3byou, 'POI/"" ..mt<! Incom' 'nd/<<
,. (S200, '" S~OO" 2 or 010" em line I x nUlfllhnpou.. wa.. .II/denl <lI' dlllblld)
. " you ,r. m."led IIlInl , lolnl relum, compere Iho .mounls on IInll 3a and 3b, ,nd .nlll lh.
Im,lI" ollh. twumounla on Iln. 3c , ' . , , , , , , , , , , , , . . , , , ,
4 ," 'Iou Wife unma",.d .lIhund 011988, COl1lpnl~ IhonmounlHn Ilnu 2 .Ild 3e, }
end enler Ihe emell" of Ihelwo smnunls nil IIn. ~.
.11 you". m."lId IlIln, 'Iolnl lohlln, compole Ih. omoulll, on line. 2 and 3<, and .""
enl'r th, .m.lI., 0' the Iwo amounts on IIna 4,
5 [nlar dtelm.' .mounl 'rom tabla b.low Ihet .ppll., 10 II,. edlult.d B'n!S IIlCOI11. on Form 1040, lint 31
"".a U III O.,lma' .moun\ll' IlIln. U III O.elm.llmounltll
OYIP- Bulnul - ow-- "'i'iiinOr
o~..- 0""--
'0-\0,000 30 $10,000- 22,000
\l~:ggj~ ~:m ~X W~8j:gg8
4,000- &,0021 26.000.28,000
&,000 'IB, 28 29,000
B,ooo-20, 2~
Dt,.rtlYt.nt of ttl. ".111,1,.,
lnl"'I,'It."",,,1ItrYIU , .__'_.__
"trn,U),UhO.,untotm HMO. . _j
V/1I.E ~:; I",) lilt ,,';h..
-----~-.-'_.... --.
3
,...;
a4
,23
.22
21
,20
6 MUlllply Ihe .mounl on line 4 by Ih. d.,im.1 amounl l)lllln. 5, and .nl., Ihe I. suit , , , , , , .
1 MullIP'y .ny child .nd d.pend.nl urn ",pens.. fOil on Ilhat YOlI p,\lllln 1988 by Ihe pere'hlll' thl'
applies 10 the .d/usted "o,,'n<nm. on you, 19B7 rorm 1040,1111.31,0' FOlln 1040l\,IInl 13, tnl.,
lh. ,"ult, <Sill n. 7Inst,uclionlfo, Ih. ,equII.d ,I,\I..,,,onl), , , , , ' . , , , , , , .
. Md .m<llmls on lines B .nd 7. l),.II,. wo,~.heel ".Iow to I'N",.lh. A",nunl of credll you c.n clalnl" you
a..sublecllo .ltemallve minimum 10. _" ""."".", .,..+
AMT limitation on Credit
rlr&l rOlllpl@htlll1l! I twlow. You mu~l rOlllptl'tl) r nrl11 ()~r) Ilf
. You Iilod Schedule C, Il, [, or [(r",m 11141)). OR
. If line I below II 1110t, Hum: $112,r)1)O ror p\inMI!.'I I}t 11I"iltl of
hou~t~ tl50,CkJ) for rHlmlPd 1lI~I\IIOlnlly 0' 1'11lnllli(ld wlltfl'hl'Hl1r),
or "5,1IW lor m."i.d Wlolseporal. 1
1I.Itht,of 'hlt'~ 8pplle.. to you, r.mllplnll'f "mm fJ;>lilltnr1IIRh
hnlt l!\. Then, onthl'WOI~'h~ltt ''''pllflf!'' ') Ihrolllth f) Bl\IIRI\111IPt:lly
10 lin.A.
If ntfth., 0' the Above 8p"IIP~ 10 you, rIJ/lIHIIJP. willi Illll' { of tl1l1
WOIksh..1. You nl.'ISIIII o...rllo R~I [mill (,~r,l .
1, lnh~, 'h. "mount hum rnrm '040. tI'I',1 ?J,
plu" .ny hu e"nlpl Int~,e'lt "')111 IJlly,l!tl
n<lll/Hy OOIl"'I"ued .11., ^"R'''I I, !,)P,.,
end .ny nltt operallnl k)I\" rj.rfllr.llllrl
, (nlltr: S30,0Q0 I' \Inl'" or hl!~d I1ll1nWfl
I10Id '~O 000 II m.,,'~rl IiIII1R 1'''''111 ,"
qulll'l"" ilrldow(,,); '" sm.ooo I o",,,,,,,t
IIlinl s.plfll~'"
3. Subl,Ad IIna 2 I",m IIn. 1. " Ih. "<,,,n ,<,
"'0 f)f ,,~. .tOP Hl"l, Fr\tfl' rill Fnll"
)lMO, Ilr,. All.. the IInlfllJtlI nl VIllII' n"1111
~ht)wn on "~p n off'mn '''-'1 rllhPrvw,,. ~Il
no '0 IIn.A . .
3'(~~1
,/ /(W;
o
,., '.,.,wo,. "'dUI"on Ad 'N';;,oi.--- ~..ln'.'I;u;'li~tU
Hltl IOAO,2I
t)
4 [ol.r Ihe Amount 'to'" [0,,,,1040, IIn. ~O,
5 M,,'llpll lin. 3 h'l21'" (21) ,
r, S"blro'" 11m' 5 f,ollllinl 4 (111.'0 0' 1111,
Itflterlluo) ...." ......"...
ro",p",.lIo, B 01 Ih. wo,ksh..1 wllh Ih. ~mount 01 credllshowll
or' Flltlu 2-'-'l,lfnl! 8,
. " 110. & (.be..) It ~,. th." ,ou, ertdft, '/<lu do ,,"I "~I/' 10
,olllpl.l. fo,m B2&1..Eot~' on [01l!11040, line 41, Ihl .mount of
yo'" ",dll ,hown on 'o~n' 2441, 110. 8,
. II your or...ft II IlI61t Ihln Ih. 'I\IOUrll tlfl M.. (.bov.l, lal Fo,m
e~r,1 n"'! complete 1I1~rt'AJlh IIn. 1 e. Thinlllure l~. lIo1in "', you,
t:rfldlr,,~ rollow.'
A, Fill.. n"I<lullt Irom [llIm 1040, IIn" ~O
8, Filler Ih. ,,,,ollnt rnlm Fo,m 61M, line 15,
C, M..hllunl .rlIdft, $ubl.Ad Iln. n reom IIn. A
(II /rr" or I.so, elll., "'0), .
r.nmp.,. the credit ynt. 11,11 IIlu...rf on 110. 8 01 'ornl 2441 With
1111. r. .I"I/e 'nl.( thi""ort.~ lwo.",ounlson IIn. 80l''''ni
~Hl, 0.1<1011 'orm 0, line 41. " lint C lbo\/e I' Ihi I...llet
.11",,"'1. nl'owrlll"~ to' In thA Inn m.rR'n nhl to line 41.
'-'1"."'.
. .,0," IUtliiii;
..."
,
',. '~'I.-,~" ;-,/
.",e'AL UII eM!.'
I,
II
*'
"'......
COMMONWIAUH 0' 'IMIYLYANIA
,ndlvldull Income Tlx Rlturn
III 1M laullli "., Jinu~ " 1111 ' o.um"bal ,11, 1011
0",... 'III ,.., L.lR"1I111 '" htlnliln 4""~d
___ _ "11,lndlng ___'.___".._ ___, Ige
. III U I
l....nIIHlIIt'''Il'...,ttu,") otl
.:!J7f I S'~I 1'-""
!iif1i tAR-II.' SUR r "tR 06 r,;m.....,
Riiii UtE3~-~ l~lNo~^L DARIlEIl. j...-"--'--
llIjli EN~l~ E U A OR PA 11025-lll1 lljr.4i---
,
I
0_"".,.../1,,...__,,
,.1IlI"""..... ,
II .., IT:11i1)-
...
" I III ,H I UN I I
1 !..l_1.. ni'jl.'"r ,~---.=
1.lhIU CIIIJII'"P'guv.",
't. /1- {"'u
I
. 111108II
I IIM.rtII, '.. """ !at"n
M '[) M.rtII, '... ....'" IloIlIIn
111III........ ______
, o_"...Il"..n
11111I0:, ~m, ,C""I Onol .=
1.1_
, n '-Hili Ill..... ' '11M _'-___~ It . "
111_ .,
va",
1itif4 DAJ i"~"
11lI}.'1
""111~"'" 111J~,.,t"
,
,
II, ollose COMftNBAIION 'W..... ..I"~I, lip., ." I
Ib IMI'lOVE IUIINUS IXftNSIS lROM ICIIIOIIII Uf
, I. [__J.. 4 ~) ,
.Ib ____ '
..
I I'. IA~AllI COMftNSAIION tUnt It 111I lint 101 AlI~CII COpy OF W'h 10 BACK Of lOAM
I INIUISI ,Compl'" S,h.d,'. A II "" 1400) i,
! " OIVIDlNDS tCompl.l. S,n.",1I111 "" 14001 ."""".""" ,
I Nil 'llOfIIl fllOM IUSINISS, 'AOmSIOH OA FARM (C,",pl". Sen.dull C ondl" S,htd"It f, Inlell III K.1I1 I,
I Ii. BALI Oil "CIIANOI Of PAOPfIlIY IComp1l1l PA Seh.,J,I, III '"'''''.:J.!''''''''''''''''''''' II,
6l, AMOUNI Of AllOWASlllKClUSION fROM Arrn';IIFO P~'91P"I II, Una 101 Sb [~ ----=C OONOlA!URDIDDCtlllllll,
I Nit INCOMI FAOM AINIS. ROYAll!!!, PAl!N1S ~NIJ CIlPYRIOIIIS (Compl'l. S,h.dUIO I), ' S. _,'
.. 7, ISlAU Oil IAUSI INCOMI (Compltl. PA Scnldul.JI """",,,,,,.. "
I OAM'lING ANO lOIllAV WINNINOS I
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I Pllt~~!l~d~'}..!~~t ".~.'!!~I,~,!!utn
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It Tm8LtOlMPlNIlATION 'hU""I1n'lbJ
AtT$,Wr~'ro CkOFTlfI ront,!
, NETPR I SF 8 N SB,PROHSSIONonrM1M
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10. Add"'Uh""'OM.Y""'. .
.
It. /It 411lA tAltAILr INCOME I~d<lllnl. Ie, 2,' .'", 10'
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I YOU MVltf eoMPl.m fOe ~NIi ""'" 8cHIOULF. Sf> 19 UerD
101, H\JMlI" ()It DlP!NDlNt8 CLAIMf 0 ON ICHF. IllIl E 8P "" . ...,.,..,
""'. M'tAL IM:CMt A8 Il!poMtD ON ItCIf'llIJI.E SP 1lIlI' ... .......",,,.
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Your Statement
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St.lement d.1l1 I ype of polley Pulky nUlllblll Pulley pcrlC/d
01/13/93 'IRSOHAL 56-2H-18 3 02/17/'3 TO 01/17/'3
AUTOROIILI
Name ^genlllJme
DAHHIR IIVIRLY J IR/GHTIILL-PRRKIHS I H8 AOIHCY
THIS 8TATIHINT 18 rOR YOUR RIHIWAL POLICY
CQVIRING A 6 MONTH POLICY PIRIOD.
YOUR TOTAL BALANCI IS
YOU MAY PAY THI TOTAL BALANCI OR PAY IN
2 IH8TALLHINTS.
TO PAY THI rlRST IHSTALLHINT (INCLUDING A 3.00
SIRVICI CNAROI), 81HD US A MIHIHUM PAYMINT or
PLIASI MAKI YOUR PAYMINT BY 02/17/93.
THANK YOUI
$256.00
U31.~O
I"
YOUR RININAL POLICY WILL 81 MAILID SIP^RATILY.
YOU SHOULD RICIIVI IT SOON.
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ACCIDENT
. 'INSURANCl
.36 WALNUT STRIIT
PH~DILPHIA PA 19106-3186
~PINNSYLVANIA U~NIRA~
~'INBURANCI COMPANY
PI,IJ'POI'
Type 01 policy
Policy number Polley period
RPA 1l6-234-18$1 02/17/93 TO 08/17/93
RINIMAL PIRBONAL
CIRTlrlCATI AUTOMOBILI
Nlm. Ind add,ess qt Inlured
ABlInl nlml! end add,el! "Ienl code
426953
DANNIR .~VIRLY J
6460 WIRTZVILLI ROAD
INOLA p~ 11025
BRIGHTBILL-PIRKINS IN8 AOINCY
1300 MARKIlT ST
POBOX 17
LIMOYNI PA 110U
Oe.II'1
I
I
. PASSIVI RISTRAINT DIVICI CRmDIT APPLIIS TO PIRST PARTY BINlrITS.
YOU MILL RICIIVI A SEPARATE BILLING STATIMINT.
YOUR COVERAGI STARTS ON 02/11/93 AT 12101 A.M.
THI rOLLOWING PORMS AND INDORSIMINTS ARI ALSO PART OP YOUR POLICYI
MOOlA A01Il1. IL0910" A1661. A79.5 A7969 "
A7872 A0306 A7956 " A1261 " A0338 A7657 "
M303
THI LOBS PAYII ISI
VIH.l YORK BANK' TRUST 1123 N.GIORGI ST. YORK
IIA174015
THIS IS A RINIWAL OF A POLICY ORIGINALLY IS5UID 02/17/87
THI rOLLOWING WILL OPIRATI VIHICLIS COVIRIO BY THIS POLICYI
OPIRATOR 1 BIVIRLY J DANNER 08/01l/159
SIGNATURIOr AUTHORIZID AGINT (POR Naw DUSINISS ONLY)
THIS SICTION POR COMPANY USI ONLYI
CO VIH BIL POL MDL COMP COLI. A/P UM UM UIM PIP PIP OPT T/R
PO DID LIM
09 1 3 062 077 9 I 0 6 01 1
09 2 3 0 9 0 6
P/I OP
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10'
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PAGI 2
'om> PMSlO 7,88
0I/l1/1t 18.~.' I
atlI$lIAL '4'
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IL .. to/HO 2ft
lid. .t,',)
, 'enh.ylnnl. Nollee
An Inlurance Complny, III I.enls, employe.., or aervlce conlrldors acllnl on It I behalf, m.y prOlllde.
..rvlc., to reduce the likelihood 01 Injury, death or lOIS, These 1I",'e.. mlY Include any of thl lollowlnl
or related ..rvlc,,'ncldentto the Appllcallon lor, Inuance, renewal or conllnuallon of, a polley 01 'nlur'~clI
1, lurveYI;
2. conlultallon or advice; or
3. Inlpecllons.
The "Inlurance Consultallon Se",'ce. ExempUon Act" 01 Pennsylvania provlde.thatth. Insurlnc. Complny,
III Ilenls, employee. or service contractors actlnll on II. behall, II not liable lor dlmalll from Injury, death
or 10" occumnl as a result 01 ilny act or omission by any person In the fumllhlnl of or the f.tlutlto fumllh
theae I,rvlcea. .
The Act do.. not applyt
1, If th. Injury, death or 1011 occurred durin II the aclual performance 01 the lervlces ,nd was cau..d by
t~e nelll/lence of the Insurance Company, III allents, employees or servlce contractors;
t to consultltlon "Mces required to be performed under a wrlllen service contract not related 10 a policy
of Insurance; or
3. II Iny acts or I)mlsllon. of the Insurance Company. lis Illents, employees or servlc. contr,ctorl Irll
judlclally determined to consUlule a crime, actual mallce, or Ilran nelllllence.
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Inllructloll 10 'ollcy Wr'lerll AlIach the Pennsylvania Nollce to all new ind renewil pollele. ind renewal
certificates lnsurln. rlBk. located In Pennsylvinl',
IL It leMO 2.. (Ed, 01 81)
G^\
CINIIlAL
Al:CIDlNr
INSUIlANl:1
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Dea, P.nnlylnnll Pollryholderl
The 'aw. 01 Ihe commonweallh or Pennlylvanll give you Ih. rllhllo choo.. 'Ither /)1
Ih. followtnl two lort opllonS!
/II, "lImlled Tori" Opllon ' Thl~ form of In~urlnce IImltl you, rtght ,nd Ihe rtlhll 01
members of your household 10 leek flnanelll compens'lIon lor Inlurte. caulld by
olher drlv!'rs, Und.r Ihls form of Insurance, you Ind olher household melnb.,.
covered under Ihls policy may le.k recovery for all medlcll and olher oUI.of.pock,t
expenles, bul nollor pain Ind sullerlng unl~" Ih. Inlurlll luflered fall wflhln the
deflnlllon 01 "se,lous Inlury", al sel forlh In lhe polley, or unleu one 01 l.vIIII
olher exc.pllons noled In Ihe polley appliu
8. "full Tort" OpUon . This lorm of Insurance allows you 10 m,lnl,ln In unreltrlct.d
rlllhllor YOIJrlelland olher members or your houl.hold 10 eeek flnlnelll
comp.nllllon for 1r1lurllll Cluled by olher drivers, Under Ihls lorm of Inlurlnc.,
you .nd other household members covered under Ihls polley mey teek r.covery lor
III medlclland olher oul-ol.por.k.t expenses end m.y a110 leek flnendel
compllnslUon lor p.ln and luflertnl as a ruull of InJurtel e.uted by other drive".
If you wtsh 10 chanlle Ihe tori opUlln Ih.1 currenlly applies to your policy, pleae
contlct your a8.nl.
A7t8' (11-90)
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Amendm.nt
Of Policy
P'owllon. .
Plnnlylvanl.
A.lSt
PP 01 51 O' 92
~
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PP 1)15108 n
I. O.lInlllona
The D~lInlllo"s secllon Is amended u follows:
~. Dollnlllon lis replaced by Ihe following:
"Vour covered aulo" means:
I. Any vehlde shown In the Declarallons,
\I, Any of the followln" types 01 vehicles on the date you become Ihe owner:
a, ^ private pusenller auto; or
b. A pickup or van Ihal:
CI) Has a Gross Vehicle Welghl nol eHceedlnll 9,000 lbs,; and
1m 15 not principally uled In any "bullnelS" other Ihan farmlnll or
ranching.
Thll provision 12) applies only If:
a, You acqulro Ihe vehicle during Ihe policy period;
b, You ask UI 10 Insure II within )1) days afler you become the ownerl and
c, With respecl to a pickup or van, no olher Insurance policy provldet
coveralle for Ihal vehicle,
If the vehlclp. you acqulrl! replaces one Ihown In the Declarallons, It will
have Ihe same coverage AI the vehicle It replaced, You mUlt Ilk us to
Insure a r!!placemenl vehicle within 30 days only If you wish to add or
conllnue Coverage For Damage To Your Auto.
If Ihe vehicle you acquire Is In addlllon to any Ihown In the Declarallons,
It will have the broadest cover aile we now provide for any vehicle shown
In the Declarallons,
3, Any "trailer" you own,
, 4, Any auto or "I railer" you do not own while used as a temporary lubslltute
, , for any other vehicle described In this dellnlllon which Is out 01 normal use
because of Its:
a. Breakdown;
b, Repair;
c, Servicing;
This provision 14) does not apply to Coveralle For DamaBe To Vour Auto.
I. The lollowlnllls added 10 Ihe Dellnlllons sedloo:
k, "Noneconomic loss" means pain and suffering and other nonmonetary
dlltriment,
L, "Serious Inlury" means an Infury re.ullln8 In death, serious Impairment pf
body luncllon or permanent serlOUI dlsflllurement.
II. 'a,t A . Liability coveral_
Plralra~h ~ 01 the Insuring Allreement of Part A Is replaced by the followlnl:
Inlurlnl Alr..ment
We will pay damages for "bodily In/ury" or "property damale" for which any
"Insured" becomes lelally relponslble because of an auto accident. We will
sellle or defend, II we consider appropriate, any claim or IUIt asklnll for thest
damages, In addlllon to our limit 01 liability, we will p*y all defense costs We
Incur, Our duty 10 sllllle or defend ends when our limit of liability lor this
coverage has been eMhausted, We have no duty to defend any IUIt or seUre
d. lOll; or
_. Deshucllon,
Pale 1 0' ..
AOISI
PP 01 51 08 92
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1"'*1
AO,S'
PP 01 51 0892
any claim for "bodily Inlury" or "plllp"'ly damalle" nol covered unde, Ihll
policy,
III. ParI E . I)ulles AfI., An Acdd.nl Or lOll
Part E Is replaced by Ihe 101l0w1r11l'
Dull.1 AfI., An Accldenl 0, lOll
If An accldenl or Ion occurs, lilt' followlnll must be done for Ihe terms of the polley
to apply:
A. We must be notified promptly of how, when and where Ihe acddenl or 1055
happened. Nolke should aim Include Ihe names and addrem!1 of any Inlur.d
Jlerson~ and of any wllne~~e~,
.. ^ person ~eeklnll any roveralle mu~l,
I. Cooperate wllh us In the Invesllllallon, selllemenl or defense of any claim
or sull,
2. Promptly send us copl,'~ of any nolkes or lellal papers received In
connecllon wllh Ihe acddenl or los~,
3, 5ubmll. a. often a~ we reasonably requlrl!'
.' To phy~kal exams hy physlclam we select. We will pay for Ihese
exam~,
b, To examination under oalh and subscribe Ihe same,
4. Aulhllllll' u~ 10 obtain,
.. Medkal reporls; and
b. OIher pertinent records,
/I, Submll a plOof of los~ when required by us,
c. ^ person seeklrlll Unln~ured Motllll~b Coveralle must also:
t, Promptly nollfy Ihe police If a hll-and.run drIver Is Involved,
2, Promplly send us cople~ of Ihe lellal papers If a .ult Is b'ou~ht.
0, ^ person ~eeklnll CoVerBlle For l>amalle To Your Auto mu.t allol
t. Take rea~onahle steps after lo~s 10 protect "your covered auto" or any
"non-owned aulo" and Ihelr equlpmenl from further 10.1. We will pay
rea. on able expenses Incurred 10 do Ihls,
2. promr.t1y nollfy the police If "your covered auto" or any "non-owned aulo"
I. .10 en.
3. Permll us to Inspect and appraise the dam ailed properly before lis repair
or dlspo.al,
IV. P.,I , . Oenet.1 Provlslonl
Part F I. amended as follow.,
A. The Termlnallon provision Is repla,:ed by Ihe following:
Termlnltlon
c.ncell.tllIn."lI~ polley may be un<:elled during Ihe polley perIod II follows:
t. The nar\'led Insured shown on the lledaratlon. may csncel by:
.. Relurnlnlllhls polky to us; or
b. (/lvlnll us advance wrllten notice of Ihl! dall! cancellation I. 10 lakli
effoct.
Palle 2 of"
M'"
PP 01 ~1 oe 9~
2, We may unclll by malllnlllo the named Insured .hown In Ihe Declll'lllonl
.llhe .ddrllu shown In Ihls polley:
I. AI IeI'I IS daYI noUce 01 cancellation:
It) II noUce I. ellecUve wtthln Ihe flral 60 days Ihls policy Is In eff.ct
and Ihl. I. nol a renewal or contlnulUon policy;
(2) For nonpaymenl 0' premium;
(3) II Ihe drlv."s license 01 Ihe namlld Inaured shown In Ih.
I)eclaratlons has been suspended or revoked aller Ihl .n,ctlve
dale II thl~ polley has belln In lI11ectle.. Ihan one yell; or IIlhe
policy has been In effeel lonller Ihan one ye.r, slnc. thl 1111
anniversary 0' Ihe orlBlnal ellectlve dlle: or
b. Alleasl 60 day. notice If the policy WII oblllned Ihrou.h malerlal
mltrepresenlatlon.
Our rlllhl 10 uncellhls policy Is subleello Ihe IImllltlon. contllned In Ihe
applicable Pennlylvanla Slatules,
N"nrtn.wal. II we dedde nolto renew or continue Ihls policy WI will mlUlo
Ihe nlmed Insured shown In Ihe Declarations at Ihe ,ddreu Ihown In this
polley:
1. AllellSl 15 days notice be'ore Ihe end 0' Ihe polley period:
a, For nonpaymenl 0' premium; or
b. II Ihe driver's license 0' the named Insured Ihown In Ihl D.c1l1'ltlons
has been suspendlld or revolced a'ler the ellecllve dlle II thll policy has
been In elleclle" Ihan one year; or II Ihe policy has beln In ellect
lonller Ihan one year, since Ihe 11$1 annlvellary 0' Ihe orlBlnal ellectlvl
d.le,
2. Alleasl 60 days notice be'ore Ihe end 0' Ihe policy perlod In all olher
ClISes,
However, our r1llhllo nonrenew Ihls policy Is subject 10 Ihe limitations
conlalned In Ihe applicable pennsylvanll SlaluleS.
Aulomatlc TermlnaUon. II we oller 10 renew or continue Ind you or your
represenlatlve do nol accepl, Ihls policy will Ilulomallcally lennlnatl II IhlInd
0' Ihe currenl policy period, failure 10 pay Ihlrequlred renewal or
continuation premium when due shall mean th,1 you hive nolllccepled our
offer.
II you obtain olher Insurance on "your covered aUlo," any .Imlllllnlurance
provtded by Ihls policy wllllermlnate 1$ 10 Ihat lulo on Ihe ellectlvl dill 0' Ihl
olh.r Insurance,
""...,
~
Olh., Termination Proylslons.
t, We mlY deliver any notice Inslead 0' malllnlll. Proo' 0' mlllllnl 0' any
nollc. Ihall be luWdenl proo' 0' nollc..
2, IIlhls rollcy Is cancelled, you may be entllled 10 I premium r.'und. II '0,
we wtl send you Ihe relund, The premium relund, II any, will be computld
accordlnlllo our manuals, flowever, malclnl or ollerlnllo make Ih. refund
Is nola condlllon 0' cancellation,
3. Th. ellecllve dale 0' clncellaUon slaled In Ihe /\OlIce Ihall become Ihe .nd
of Ihe policy perlod.
Altlll
PP 01 51 08 92
PI.e 30' 4
, Endura.m.nl
O.n.,,, Accident 'nluranu
comp.ny or Ameri..
flra' ,.rty
..n.f1I.
Cover'I' .
p.nn.ylv.nll
A,..,llev, 7.90
~
".....
Th. C .md.n "..
Itllu..n~. ""oel.llo"
PlIlnly'vanl. CI."....
It,,",en.. co..p."y
,.tom.c InM""
C.mplny 0' IIl1nol.
-.-..-.--------------.----
The Deflnlllons and General Provisions ollhls polley apply unless modified by this
endll""menl.
Sch.dul.
Ilslc Ind Add.d flrsl Plrly IIR.lItl
The limit. .etlorlh on Ihe dedaralluns palle are the maHlmum limit. psyable lor the
bene'lll shown,
combination first Plrty l.n.lIls
MaHlll'um Total Slnllle limit
o Opllon 01 $277,500
The comblnallon Fltll Party Deneflts Opllon Is SUbll!ctto the lollowlnlllndlvldualllmlll:
l,n.lIls Limit o' L1lblllty
Medical EHpense Deneflt No specllled dollar Imount
Work lOll Deneflt No specllled dollar Imount
Funeral EKpenle Benefit UII 10 $2,500
Accldenlal Death Benefit Up 10 $25,000
Nol': II Added Fltlt Party Beneflls or Comblnallon First Party Benefits are not shown
as applicable In Ihe schedule or declarallons, only Basic Flrlt Party Benellls apply.
I, D.llnltlons
Wllh respect to First Party Oenellls Coverage:
"Ihe Act" means the Pennsylvania Motor Vehicle Financial Responsibility taw.
In addition, the lollowlng words and phras",s are defined lor IIrst party benellll
coverage, They are In quolallon marks when used,
"Iodlly Inlury" means accidental bodily harm to a person Ind that person'l
reBultlnglllnell, disease llt dealh;
"Inaur,d" means:
I. You or any 'Imlly m.mber,
2. Any other pefSlln:
I. while occupylnl your cov.red lutOl or
b, while not occupylnl . motor ",hId. II InJured IS a relult 01 .n
accident In Pennsylvania InvoMnl your cover.d lulo,
II ~our cov.r.d luto Is parked and unoccupied It Is not a motor vehlcl.
Involved In an accident unless It WlS parked In I manner as to crelte .n
unreasonahle risk ollnlury,
"Motor v.hlde" means a sell. propelled vehicle, operiled or des/llhed lor ule
upon public roads, However, motor vehld. does not Include a vehicle
operated:
t. By muscular power; or
2. dn rails or tracks,
"Yl)ur cl)v."d lutO" melhl a motor v.hld.:
t. To which lIablllly cover'Bll under this policy applies and lor which IlpllCUlc
premium Is charled; and
2. tor which you melnlaln lint petty bllnellls coveralll required under the Act.
Pa81 1 III 5
A11111tev. 7,90
~
-
~ 'f
II. ..nellll
A, ,..Ie Plnl Puly ..n.1I1
We will pl'/lhe Oasle flrsl Pllly Bellefllln Iccordance wllh Ihe Act 10 or lor In
"Insured" who suslalns "hodlly Inlury" eauted by an accldenl arls"'1 oul of Ihe
malnlenlnce nr use 01 a "molm vehicle,"
Ihe Basle Fin I rarly Bellefll com',ts of a Medlul EHpense Benelll.
lhe Medical Expense Benefll coIIsIsls of reasonlhle and nete.llry medlcll
expenses Incurred a' a resull of Ihe accldenl for an "Inlured'.:"
I, care;
2. recovery; or
3, rehabllllall()I1,
lhl. Indudes remedial care and Irealmenl rendered In accordance wllh a
recollnl,ed relllllous melhod 01 heallnll,
Medical expenses will be paid If Incurred wllhln 18 monlhs from Ihe dale
of Ihe accldenl causlnll "bodily Inlury." II wllhln 18 months from Ihe dal.
01 the accldrnl causlnl "bodily Injury" Ills uterlalnable wllh reasonable
medical probability Ihal furlher expense, may be Incurred all.r Ihe 18
months as a result of Ihe "bodily Injury," medical expensel will be paid
wllhoul IImllatlon as 10 Ihe lime such further expenses are Incurred,
I, Add.d flnl 'arly len.ml
II Ihe Schedule or Declarations Indlcales Ihal Added flrsl rarly BenefllslJlply
we will pay Added Flnt rarly Benellls Instead of the Basic First Party Benelllto
or for an "Insured" who sustains "bodily Injury" caused by Iln accident arlslnll
out 01 the malntellance or use of a "motor vehicle,"
These beneflls are suhlect 10 Ihe provisions of the Act. Added First Party
Benellls conslsl of the following" shown as applicable In the Schedule or
Declarations:
,. Medical Expense Benefit as described In the BII5Ic First Party Benelll;
2. Work Lou Benelll consisting of:
a, Iou of Income, Up 10 80% of Ilro55 Income actually lost by an
"Insured" as a result 01 the accident; .nd
b, reasonable expenses actually Incurred to reduce 1055 of Income by
hlrlnll:
(I) special help, thereby enahllnllthe "Insur.d" to work; or
(2) a suhslllute to perform the work a sell. employed "Insured" would
have performed,
HOWever, Work Lou Benefit does not Include:
a. 1055 (If expected Income for any period followlnllthe deeth of an
"Insured;' or
b. expenses Incurred for service. performed followlnllthe de,th of an
"Insured;" or
r. any Iou of Income, or expenses Incurred for services performed, durlnl
the firs I S worklnll days Ihe "Insured" did not work aller the accident
because of Ihe "bodily Inlury,"
3, Funeral Expense Benefit, IIctualexpensea Incurr.d for an "Insured's"
luneral or burtalll "bodily Injury" resultlnll from Ihe accident Clu.es their
dealh wllhln 24 month. Irom Ihe date of Ihe accident,
4, Accldenlal Dealh Benefll, II death benefit paid II "bodily Inlury" resulllnll
lrom the .celdent cau.e~ the dellh of you or any "Iamlly member" within
24 monlhs from the dale ollhe accident.
Pal' 2 of 5
.......
r ..,
i "
C. Cl)mbln.llon ",,' ,.,ty ..nllllt.
II Ille Schedule or Decl.rlllons Indlcllel Ih.1 Combln'lIon fl'll Plrty Benelll.
Ipply we will pay Combln.lIon flral Parly Benefllllnlllld of Ih. Bulc 'Iral PII'Iy
Benellllo 0' 10' an "Inlu,ed" who IUII.lnl "bodily Inlu,y" c,uled b111/l
aceldent arllln8 out 01 the malnlen.nce 0' use 01 . "10010' vehlcl.,
Comblnlllon Flrlt Party Denelll. Ihall be lubledlo I m'.lmum lolllllnlle limit
01 lIablllly wllh Individual 1110111 10' Ipeclflc ben,flll U Ihown In th. Schedule
0' Declarallon" We will only pay comblnallon Flral Pllly Beneflll fo, expenl"
0' 1011 Incur,ed wllhln J year, lrom the dale 01 Ih. aceldent.
Thllle beneflll are lubledlo Ihe p,ovlllonl 01 Ille Ad, Comblnlllon ",,1 PII'Iy
B~!J1ellll conslsl 01 the lollowln8, II described In Ih. Bulc Flrsl P.rty Benefll
and Added FIliI Plrly Benefits,
I. Medical hpense Benefll;
3. Work lOll Benefll;
3. Funeral hpen,e Benefll; Ind
4. Accldenlal Dealh Deneflt.
bclullonl
We do not provide beMfIIs lor "bodily Inluryr"
I. Suslalned by any person while Intenllonally causlnl or I\lemplln. 10 CIUI.
"bodily Inlury" lor
a. hlmlell;
b. hersell; or
c. Iny other person;
nor will we pay In Accldenlal Death Benelll on behllf 01 Ihll pellon,
3. Sustained by Iny person while cOlnmltllnl I lelony,
3. Sl,Illllned by Iny person while seeking 10 elude Ilwfullpprehenllon or
Irrell by I I,w enlorcemenl olllelll,
4. Suslalned by Iny person while 10111'11 linin I 0' uslnl I "molor vehicle"
knowtnlly converled by Ihal person, Howeve" Ihl. e.e1uslon (4) doel nol
.pply lor
a. you; or
b. Iny "Iamlly member."
If. SUllllned by any person who, althe lime 01 Ihe .ccldenlr
a. Is Ihe owner 01 one 0' more relllslered "10010' vehicles" and none of
Ihose "10010' vehicles" have In elledlhe flnlnelal responsibility
requl,ed by Ihe Ael; or
b. Is "occuPyln8" a "malo, vehicle" owned by Ihal person fa, which Ih.
flnlnelal responslblllly required by Ihe Act Is nolln .IIed.
e. Susl.lned by any person malnlllnlnl 0' uslnl I "molor vehicle" while
loclled for Ilse .. . ,esldencll 0' premises,
7. Susl.lned by Iny person Inlu,ed " I ,esull of conduct wtlhln Ih. cours.
of Ihe bUllnll1l 01 repllrln8, seIVlclnl or olherwf.. mllnl.lnlnl "molor
vehicles," Thl. e.c1uslon (7) doe. nol .pply II the conduct I. off the
business preml.es,
e. Suslllnlld by . pedestrian II Ihl! accldenl OCCUII outside 01 Pennsylvan'a.
this e.c1uslon (8) does nol apply 101
a. you; or
b. any "family member,"
t. Sustained by any person while "occuPylnll"
.. . rec,eallonal vehicle de"lIned for use off public roads; 0'
b. . motorcycle. moped, or similar-type vehicle.
A1IS7 It.v. 7.90
P'II 3 oB
A1IS71tev. 7.90
~
-
., ,
10. Cluled by or a. a consequence olr
.. dlscharllll of I nuclear welpon (even If accldenlll);
b. war (declared or undecla,ed);
c. civil war;
d. Insurrection; or
.. rebellion or revolution,
II. From or as a con~equllnce of the 101l0wh'll. whelhe, cQnlrQII,d 0'
uncontrolled or however causedr
a. nuclear reacllon;
b. radiation; or
c. radloacllve contamination,
Limit Of L1.blllly
The limit 01 liability shown In Ihe Schedule or In Ihe Declarallons for Ihe first
plrly benellls thaI apply Is the most we will pay 10 or lor each "InSUred" u Ihe
,,,suit 01 anyone accident. Th's Is the most we will PlY regardless ollhe
number 01:
I. Claims made;
3. Vehicles or premiums shown In the Schedule or In the Declarations;
3. Vehicles Involved In the accident; or
4. Insurers providing first party bene Ills,
II Combination First Parly Benefits are afforded, we will make available alle"t the
minimum limit required by the Act for the Basic filiI Party Benefit, this provision
wtll nol chanlle our total 11m II 01 lIabllllY,
Any Imount PlY able under filiI Party Beneflls Coverage shall be e.cess over Iny
amounts paid, payable or required 10 be provided to an "Insured" under any
workers' compensation law or s'mllar law,
Prlorlll'l 01 Policies
We will pay filiI parly benefits In Iccordance wtlh Ih" order 01 prlorllles leI lorth
by Ihe Ael, We wtll nol pay II there Is Inother Insurer It a hl8her level 01 priority,
The ",.1 catellory listed below Is Ihe hlghesllevel of priority and the I'ourlh
category IIsled below Is the lowesllevel of priority. The priority order ISl
.I,.t The Insurer providing benellts 10 the "Insured" " a named In8u,ed,
IIcond The Insurer providing benellts to the "Insured" as a flmlly m,mber
who Is nol a named 'nsured under anolher polley provldlnl
coveralle under the Act,
Third The Insurer ollhtl "molor vehicle" which Ihe "Insured" Is
"occupyln8" atlhe \Ime of the Iccldenl.
'ourth The Insurer providing benellts on any "molor vehicle" Involv.d
In the accldenllllhe "Insured" Is:
I. nol "occupying" a "motor vehlcle/" and
b. nol provided first plrty bene Ills under any othe, automobile policy,
In this priority, an unoccupied parked "molor vehicle" Is not a "moto, vehlcl."
Involved In an Iccldent unless It WI! parked In a manner as 10 c,elle an
unreasonable risk of Inlury,
"'ie 4 of S
.~
prlylvanla Surchar..
DI.c1oture Stat.m.nt
'GA\
C.nm' A,cld.nt hnuren"
Comp.ny 0' Am"ICI
Th. C.l1ld.11 fI..
Inlu,.nu Allncl.Uon
"."lIIyIV.I1I. (J.".,.I
'nlUr,IIC. comp."y
I'olom., '""Ull""
Compll1Y OJ IIl1noll
,--_._._--_.-._._-,_.__._~.---_._~--.-----_._.....
In accord.nce wllh Pennlylv~nla law. we are rrovldlnB you wllh an eKplln.lIon of ou, S.f. Urlvlr InaUrlne.
Plan, under which your polley has been ratel , and the pian'S effect on you, automobile rate In the eve III 01 a
chlllllble .celdenl(s) Indllll convlcllon,
Wh.tla th. The S.fe Driver InSUrance Plan (hereafler referred 10 15 SOIP) uses past e.perlence
Safe D,lvlr (aceldl!nts &, convlcllons) II pitt 01 the dele,mlnalloll of your premium cosl. The sysle,"
Inlurane. described below has been established under which those driver. Ihat have no polnl'
1'1"11 receIve Ihe 10WUSI premlllflll,
, "sher premiums are dlarBed lor 01 her drivers baud upon the numbe, of polntslhey have
accumullted during the e.perlence period, The eKperlence period Is the thrill year
Interval between Ihe date 01 Ihe Inlllal claim plymenl resullln8 Irom anyone accldenllnd
the dlle ollhe appllcallon or the preparation 01 the rUJlIwal,
Premiums lor the lollowlnll coverlges are allucted: l.Iablllty, Flrsl Party Benefits Ind
Coveralle lor Damale To Your Alllo,
A. Chlll..bl. Accld.nl'
Points are alllllned lor each accident that occurred durlnl Ihe e.perlllnce period, '
Involving the appllclnt or any resldenl operator. while opera tins a private passenler
IUto,
1) One poInt Is asslllned lor each auto Iccldenl Ihal results Inr
a) bodily Injury or death resultlnB In any plld claim, or 'n a paid clllm fo, damllle
to any properly Includlnll his or her own In e.ceu t)f $400, II luch accident
occurred prior to December " 1988
b) bodily Injury or death resultln8 In Ilny paid c1llm, or In a paid claim lor dlrnale
to any property IncludlnB his 0' he, own In Il.cess of $600 II such accident
occurred on or aile, December " 1988
c) bQdlly Injury, death or property dllmllle claim resulllnB In a paymenl of at le,,1
$650 In e.cell of any deductible or sell. Insured ,etenllon fa, alan) IccldenUs)
occu,rlnll on or aller July I, 1990
For all subsequenl claims Iln Iddlllonal accumullllon 01 $650 In IIB'ellte
paymenls must be Incurred belore an addlllonalsurchltBe can bl ASselSed,
.. convlctlona
Points shall be ASslBned lor con~lctlons durlnB the e.perlence period lor molar vehicle
violations of the applicant or any other currently resldenl operalor as lollowsl
1) Three poln" are ASslllned lor conviction olr
a) drlvlnll while InhlKlcaled or under the Influence of drugs, or
b) failure 10 stop and report when Involved In III Iccldent resulllnl In bodily
Injury; or
c) homicide or usault arlslnl oul 01 the operltlon of I motor vehicle; 0'
d) drlvlnB while license Is suspended 0' revoked,
2) One point Is asslBned fa, conviction of any olher movlnl traffic vlolallon under
Section 1532 01 Pennsylvllnla stalutes resultlnlln Illspenslon or reVOclllon of an
operalors license.
C. 'Ic.pllon.
1) No points Ill' IIslllned fOI accldenll Incurred by an operator demonstrated 10 be
I nlmlld Insured or a principal ope rill or 01 an IUto Insured under a seplllle policy;
and
2) No polnls are ISslllned lor accidents occurrlnl under Ihe followtnl clrcumstlnceSI
a) auto lawfully parked (II the plrked vehicle rolls from Ihe parked pOllllon Ihen
any such accldenlls charlled 10 Ihe person who parked Ihe lutO); or
Pile 1 of 2
DrMn.
It.eord
Polntl
407... 7.90
"".perlenced
Operator
Point a.
Surchlrll
Calculation
Milt 7.90
........'
~ f"
b) the appllclnt, owne, or ()ther re$ldenl operalor reimbursed by, 0' on behalf
of, a person who Is responllble lor Ihe accident or hiS ,udllm,nt alalnatth,
person; or
c) lulo Is Itrurk In Ihe re.r by Inother vehicle and the Ippllclnl or other ,esldenl
operalor has nol been convlcled of a movln8 I,alflc vlolaUon In connection
wllh Ihll arrldenl; or
d) operalor of Ihe other auto Involved In the ,ccldent WIS convicted of a movlnl
traffic vlolallon and the Ippllcant or rl!sldenl operllo, was nol; 0'
e) luta operated by the appllranllll any ,esldenl operato, I. slruck by I
"hll.,nd.run" vehicle, lithe accldenlls reporled 10 Ihe proper authority wflhln
24 hours hy Ihe appllclnt or resident
I) Iccldellts Involvlnl danlllle by contlcl wllh animals or fowt; or
II IccldenlllnvoMnl physical dim age. limited 10 and clused by Ifytnl l'IVllll,
missile., or falllnll object.; or
h) accidents occurrlnB wher, using aulo In rllBponse to In emerlency If the
operalo, of the lull) althe lime of Iccldllnl was a plld 0' volunlee, member
01 any Police or Fire Deparlmenl, First Aid Squad, 0' any I,w enforcemenl
'Iency, This e.cepUon doel nol Include In Iccldelll occurrln8 afler Ih, luto
celles 10 be used In ,esponse 10 such emerlency; or
I) Iccldents resultlrlllln an amount plld on behalf of In Insured under BIlIc,
Added or ComblnaUon First Plrly Beneflls coverlllls only, Ind the appllclnt
0' olhe, resident In the lime household WIIIIOI II flullln conlrlbutlnl to Ihe
lccldenl BlvlnB rise 10 the claim,
II There wtll be no surcharlle Ipplled II the Com piny Is reimbursed by or on
behall of the named Insured or other resldenl operalor 10' Ille,,1 60% of Ihe
totallmount of the paid claim received Ihrouah subrolaUon or from a
seUlemenl or ,udBment aBalnsllhe Individual resronSlble for the Iccldent.
k) There will b~ no surc~arJe assened as a result 0 a Flrsl Party MedIcal c1l1m,
IIlhe principal operator 01 Ihe luto has no surchar8e for In accldenl, but has been
licensed less than Ihree years, one polnlls asslBned,
The number 01 points assigned del ermines Ihe surcharge. The lollowtng shows the
surchllll' as I percenlage Inr.reue of the bale premium.
PercentaBe Increase of Ihe B"e Premium
SDIP One MulU'
Flclor Car Car
1 Point ,40 40% 20%
2 Points ,90 90% 45%
J Points 1,50 150% 75%
4 Points 2,20 220% 110%
'WIth two call Ihls surcharlle applies to each Clr, II Ihere are more cars II applies to the
two cars with hllhest premium, Usullly Ihese are the hl8hest valued cars.
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vary for other conslderaUons such II aile, se. or marllalslalus. Therefore Ihe doll a" 01
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However. the percanlaa' 01 surchar8e when compared to your lotal premium, whIch
does recolnlze Imonll other thlnlls your DII", se. and marllal stilus, could vII)' somewhat
from the above cited percenlales.
You mlY be able to determine the points .."IBned 10 you by looklnll al your polIcy. The
front pale InformaUon mlY Include. six dllll code such u 8111.10. The 1111 dlllt shows
Ihe points, The zero Indicates no polnls In Ihls cue.
For more Inlormlllon aboul these sutch"I", please conllct your Illenl or company.
COPyrtllht. Insurance Services Olllce. Inc., 1984
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DJlJ.1 8. BARBeR,
PLAINTIFF
I IN THI COURT or COMMON PLeAS or
I CUMBIRLAND COUNTY, peNNSYLVANIA
I
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I
I CIVIL ACTION - LAW
I
I 94-634 CIVIL
V
CHARLIS A. WINTZBL,
DBI'eNDANT
OIlDI. 0' COU.T
AND NOW, FBBRUARY 24, 1995, the above-oaptioned matter
ie hereby oontinued from the Maroh, 1995 Trial Term by
agr.ement of oouneel at plalntiff'e reque.t, couneel to reliet
the caee when ready.
By the Court,
\ \ .~ ~~
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Harold R. She.ly, P. .
Robert J. Mulderig, R.quire
For the Plaintiff
Micha.l B. Soheib, Require
'or the Defendant
Court Adminietrator
uld
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DALI S. BAJ\BIR I IN THI COUR~ or COMMON PLBAS or
PLAINTIff I CUMBBRLAND COUNTY, PINNSYLVANIA
I
V I
I
CHARLJlS A. WINTBll. I CIVIL ACTION . LAW
DI..INDANT I
I 94-634 CIVIl. TBRM
NUlIID.D ORDU or CQURT
AND NOW, HARCH 10, 1995, the above-captioned matter i.
hereby oontinued from the March, 1995 Trial Term by agreement of
ooun.el at defendant'. reque.t, noun.el to reli.t the oa.e when
r..dy.
By the Court,
. };~ //
P.J. ($
Robert J. Mulderig, I.quire ~ . II, I I
for the PlaintiU . - l~a I~~ :~ I'Mr
Miohael B. Scheib, I.quire . (~o.~ III ]/ 3/14hl
For the Defendant /'\) u. I:l
Court Admin18trator - C"f'I pL1t1 ~.. l;i"1t 3J'l/fS
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2 DEPONENT DIRECT CROSS REDIRBCT RECROSS
3 Gary Lutt~rtnOBer, M.D. 3 14 2'7
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CENTRAL PENNSYLVANIA COURT REPORTING SERVICES
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IlTl:PUI.ATIONS
It is herepy stipulated by and between the
respective parties that signing, sealing, and certification
at'e waived.
GARY LUTTERMOSER, M.D., called as a witness, be in
duly sworn, was examined and testified, as follows I
DIRECT EXAMINATION
9 BY MR. MULDERIG r
10
Q
Would you please state for the record your full
11 name?
12
A
Gary Kenneth Luttermoser.
And your business address?
13
Q
14
A
I have two. r work at Capital Recovery Center,
15 and I don't actually know the address; and I also work at
16 Mechanicsburg Family Practice, 122 South Filbert Street,
17 Mechanicsburg. So there's two.
18
And what is your area of expertise?
I work in family medicine and I also have been
Q
19
A
20 involved in chronic pain patients for four or five years. I'
21 not sure, I'd have to check when I started doing it. I guess
22 I should get that information.
23
Now, Doctor, it's been stipulated that you're a
Q
24 medical expert in the area of pain and family practice,
25 correct?
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o
Did you examine him and find any physical cause
2 tor this pain?
3
A
Did I make a dillgnosh of what wall the cause for
4 the discomfort he was having?
5
o
Yes.
6
A
I did not have a specific reason for what was
7 causing all his discomfort. By that I mean I did not say
8 there was a disc problem causing it or, you know, like a
9 fracture that was causing the pain.
()
10 0 Did you discuss with him any accidents he had?
11 A Yes. Yes, I did, briefly. I did not go into
12 detail. the accidents when I saw him, exactly what happened an
13 transpired, even though I do have some information on that.
14 0 All right. Was a physical therapy evaluation
15 conducted by your office?
16
A
I have to check. (Reviewing record.) 'lee, there
17 was.
18
o
And did that show any limitations on his abilities
19 because of this pain?
20
A
Yes, l.t did. It showed that he had significant
21 flexibility defects in his trunk as well as his neck,
22 shoulder, and lower extremities. And there was Iltrength
23 asymmetry between the two lower extremities. There was also
, ,
V
24 he had some positive findings for disc and SI joint
25 dysfunction, period. And they suggested that it possibly
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8
1 herniation. Now, you don't necessarily have to have disc
2 herniation per se, not that I've seen this, and you can still
3 have disc disease, okay. So an MRI doesn't tell you
4 everything,
5 Similarly, a lot of peopl~ will have disc problems
6 but you see that by MRI but they don't .... a lot of people hav
7 disc abnormalities by MRI but have no symptoms. So this is a
8 helpful test, okay, You also go by the clinical findings in
9 patient too.
o And was this in any way resulting flam the
accident?
A It's .. - usually .. - let me check somet.hJ.ng. It
would depend when the MRI was done. By that I mean you can
get degenerative diseases from trauma previously even if you
don't break a bone, so
MS. GRABr For the record, I think that the MRI
17 was done in September of 1992.
18
THE DEPONENT I Which would be one month. Probabl
19 some of that was there beforehand. But again, it's one of
20 those things that you can't necessarily say absolutely becaus
21 you don't have one from before.
22 BY MR. MULDERIGr
23
o
Okay. What.'s a rotation abnormality of the hips?
24
A
Pardon me?
25
o
It goes on, it says the lumbar films show rotatior
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1 they had basically none, if I'm reading this correctly. It's
2 hard to compare lateral flexion because I compare it in
3 degrev!J, they do it by - - r mean some people do it as a
4 standard reach, how far you can reach down to one side. So
5 you'd almost have to take the patient: and have them reach that
side and see if they can correlate. Grossly, only from
looking at what they said, there might be some subtle
differences that I found his reaching to one side or the othe
side were not quite the same. lateral bending.
Q Based on the information you had from u from the
report --
A This one here (indicating)?
Q Yeah, the October report.
A October 10, 1994.
Q Has there been any marked improvement in his
condition?
A No, not that I could see from what they're saying
here on this evaluation. And no, there's no neurological
19 testing or anything else done in this. This is just really a
20 physical examination, range of motion.
21
In your medical opinion is the results of that
Q
22 test, are they still caused by the motor vehicle accident in
23 '92?
24
Yes, from the information that's given here and
A
25 from the history given.
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1
Q
How long would this aggressive therapy -- what
2 would you expect? How long would that be requirod?
3
A
That's a very hard question to anower, because
4 everyone progreooes at a different level after this long and
5 you really have to do it by let's see how you'r.e doing. If
~ you reach a point where they're not progrossing then I think
7 there's a point where you say this at least modalities that w
9 use here should not be done, okay. We should try somothing
o
9 different because you're not progrossing, So there's -- you
10 can't go unlimited even though a lot of times patients feel
11 more comfortable with continuous therapy. But you can't do it
12 forever if you're not making progression. And a lot of this
1.3 stuff - - a lot of these therapy can be done on their own at
14 home,
15
MR. MULDERIGI Thank you. I have no further
16 questions at this time.
17 CROSS EXAMINATION
19 BY MS. GRAB I
19 Q Doctor, just so that I am clear, you've testified
20 that you saw Mr. Barber on two occasions?
21 A That's correct.
22 Q One in July and one in August of 199J?
23 A Uin-hum.
24 Q And you did not see hint in 1994 I is that correct?
0 25 A When he had this physical therapy eval -- no, I
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1 A As early as when?
I
2 0 1985,
3 A Oh, I - - I'd have to check it I'd have that
4 information. (Reviewing chart. ) You're talking about low
.4"'tI.
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5 back pain prior to his motor vehicle accident?
6
7
o
A
Yell, 1985.
I don't think I have any information. I haven't
8 looked through this in detail but I don't think I have
9 information prior to -- I have something in 9/92.
10
Q
11
A
12
o
o
13
A
That's after the accident.
Right around that time, yes.
The accident is August of '92.
Let me also look at my
I know he had
14 significant left knee problems.
And in fact had had, you know, aeven or eight
15 0
16 surgeries
17 A
18 0
19 accident?
20 A
21 Q
22 A
Yeah.
-- on the left knee prior to the motor vehicle
That's correct.
All right.
The last surgery in '87 to '88. I do know he went
2J under rehabilitation and basically got back a hundred percent
24 pain free from his knee. And I'd assume that would also
v
25 involve his hip. This was in '89, from information he gave
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1 experienced with his lert knfle, that. when the lert knee
2 bothered him he tended to tavor the other side and that threw
3 his balance otto Is that a logical explanation for his low
4 bal1k pain?
5 A At those partiGular times?
6 Q Yes.
7 A Yes, it is.
8 Q All right.
9 A Maybe that's why he didn't mention it to mfl. But
10 I can't say for sure.
11
Q
Okay.
All I know is that he did say he was a hundred
12
A
o
13 percent pain tree in eight -- I said a date. '89 he went
14 under rehabilitation, basically got back a hundred percent
15 pain tree.
16
Q
Okay, On the two --
17
A
And overall I said the character nature ot his
18 pain had not changed because he: did occasionally have a littl
19 pain with his knee on and off even after that time, but it
20 would go away.
21
Q
And on the two occasions that you examined him di
22 you perform any tests?
23
A
By that what do you mean by --
X-rays, did you order any MRls?
24
Q
.
U
25
A
We ordered some blood tests. We did not
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1 perform -- no x-rays done. r uBed the paBt information that
2 was probably present in hiB chart since hiB moLor vehicle
3 accident.
4
Q
So is it fair to say, Doctor, that everything that
5 is contained within your reports of August and July 1993 and
6 everything about which you've testified today is based upon
7 what Mr. Barber told you?
8
A
Not completely. I did have information from some
9 other reports in here and I had reports of an MRI and Btuff i
10 here also.
11 Q But you didn't have records from Dr. Tacks
12 who's who has beEln treating him for problems -- a back
"'.......
U 13 problem since 1985'~
14 A That's correct. I did not see that information i
15 here.
16
Q
And do you have records from Dr. Rex Herbert who
17 was the orthopedic physician who has performed the numerous
18 surgeries to the left knee?
19
A
No. That was told to me. I might have had dome
20 information in here that that was done. I'd have to look
21 through.
22 Q Okay.
,
'...;,,)
23 A But I don't think I have a specific report from
24 Rex Herbert. It would be my plan -- can I add a comment
25 here? It would be my plan if I were to give someone
CENTRAL PRNNSYLVANIA COURT REPORTING SBRVICES
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1 aggressive physical therapy before I would obtain x-rays
2 because you don't necessarily do any surgical event or Burger
3 procedure unless you know someone can't respond to the
4 physical therapy.
5
o
Now, you talked about the results of the MRT., the
G September 1992 MRI that was done?
7
A
8
o
Yeah.
And that didn't show any discrete bulge but it
9 showed degenerative changes?
10
A
11
o
That's correct. That's what the report says.
Right. And you said that, I believe if I
()
12 understood your testimony, that you just .-. you explained
13 degenerative as arthritic changes; is that correct?
14
A
That's what they're usually seeing. They're
15 seeing some bony abnormalities, not like a fracture.
16
o
Okay. And what is your testimony with regard to
17 whether or not arthritic changes three weeks after an accident
18 would be trauma induced?
19
A
You can -- any time you traumatize a joint you ca
20 get arthritic changes. How fast they occur, generally not,
21 like, overnight, okay.
22
o
23
A
What about in three weeks?
That is fairly quickly to happen. But I don't
24 know if I have any research 011 that, okay, to bl! qui te honest.
v
25
o
Now, you've been given a copy of what appears to
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~ place4 under result from the motor vehicle accident of 1992?
2
A
AEI far aEl the information that I had at that time,
3 yeEl.
4
Q
And what information waEl that again?
The information basically from -- baElically from
5
A
6 '92 to when I E1aw the patient in '93.
7
Q
And that waEl not any of hiEl medical recorda, that
o
8 was baEled upon what Mr. Barbet' told you?
9 A Well, now, there is some -- there is an evaluatio
10 on the patient in that information sent to Dr. TockEl that it's
11 in here,
12 Q Okay.
13 A Do you want me to find that?
14 Q Yeah, I'd like to know what you're talking about.
15 A Most of the intormation I have here is from the
16 physical therapy that saw him, Maureen Donahue. Where was
17 this from, McCuen and Associates. That's right -- that's
18 where he had his physical. therapy from, that evaluated him an
19 gave some infolmation, I also have some letters that
~o Dr. Tocks wrote to a Mr. Breski and also even Dr. Herbert
21 about his low back pain,
22
Q
So you agree then that the low back pain predated
23 the motor vehicle accident?
24
A
No, no, no. That's not what I said. I have a
~
~5 letter on September 28th that he -- Dale Barber, was involved
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1 in a motor vehicle accident, came to my
Dr. Tocks's office
2
one week later. lie saw them in that
when he was involved
3
in the motor vehicle accident he didn't sustain jl.lst low back.
4 pain at that time. He also hit a couple other places on his
5 body.
6
(;I
All right. But Dr. Luttermoser, understand that
7 what I'm asking you about --
8
9
Do I have information?
A
(;I
before the accident, what do you know about
10 this man's medical condition bofore the accident, if anything?
11
I know very little.
A
12
All right. And despite that is it your testimony
(;I
o
13 to a reasonable degree of medi.cal certainty that the physical
14 restrictions that Judy Cook found and are on this functional
15 capacity evaluation are the result of a motor vehicle accident
16 that occurred in August of '92?
17
A
The physical restrictions that -- I can only say
18 from when I saw him back in '93. You're looking at the '94
19 ones. That's correct.
20
(;I
Okay. Are you willing to testify then concerning
21 the 1994 evaluation that's signed by Judy Cook or not?
22
A
Well, I didn't actually talk. to the patiant. So
"
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23 you have to really go through her on that. I did see the
24 patient in '93 and I also reviewed his -- his physical the rap
25 evaluation at that time.
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1
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2!l
Okay, So you're not willing and don't teel
2 comfortable to state to a reasonable degree of medical
3 certainty whether or not the restrictions that Judy Cook fQUn
4 resulted trom the accident because you didn't see him at that
5 time?
6
A
I -- that's correct. 'Cause I don't know what
7 happened to him bet.ween August and, well, it's been a year an
8 a half now.
9
Q
All right. I,et' s go back then to your final --
10 the last tim~ you saw him is August '937
11
A
12
Q
A
0.""
I'
13
That's correct.
Okay.
But I think her evaluation is probably very good.
14 She didn't say where the restrictions came trom in that
15 evaluation either.
16
o
17 saw him?
18
A
19
o
So back in August of '93 the last time that you
Right.
And the last time that you've said you feel
20 comfortable testifying about functional restriction, can you
21 tell us
22
A
23
24 point?
o
25
Okay. Go on.
o
-- what his restrictions would have been at that
A
Be a sedentary level. In fact, a functional
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1 capacity was filled out 8/11/93, actually was signed by
2 Dr, Tacks but probably because it was sent to him, very
3 similar to the one of 10/10/94,
4
o
Do you have a copy of the August 27th, '93
5 evaluation that you're referring to?
6
A
Yeah, I have one right here.
Can I see it?
7
o
8
I -- I'm just giving you the final sheet that
A
9 you're looking at.
10
That's fine.
o
11
A
Some of the poundage is a little bit different an
12 this one's a little bit more expanded. I think it was
13 thirteen pounds compared to five and nine. And I'd have to
14 look at th~ breakdown of the sitting, standing, walking. and
15 driving, et cetera. I have not done that, You have it there.
16
o
Were you aware -- excuse me, Doctor. Were you
17 aware that it was Dr. Tacks's opinion that -- that given the
18 medical history and given the fact that he had treated
19 Mr. Barber for cervical and low back probLems for eight, nine
20 years that he wasn't willing to -- he wasn't willing to autho
21 a report which reflected that the cervical and low back
22 injuries were as a resul t of the motor vehicle ace ident?
23 A Am I aware now, yes. BUt was I aware before, no.
24 MS. GRAB, That' B all I have. Thanks.
\
V 25 MR. MULDERIG, May I see that what you're reading
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THE DEPONENT: Do you want me to read it or not?
2 BY MR. MULDERIGr
3 Q Read it silently.
4 A Okay. (Reading document.) Yeah. I read what it
5 says here, yes.
6 Q Okay. Now --
7 A That says --
8 Q Don't read it allowed.
9 A No. I was going to make a comment, but I guess I
10 shouldn't.
11 Q All right. Now, in your opinion did Dr. Tocks
12 make any opinion one way or another or was asked to state
C') 13 whether his current condition was the result of an automobile
14 accident in that note?
15
A
By that note he says since he was -- did not see
16 the patient he was unable to make any judgment. I may have t
17 read that letter again, but that's what: it says, and therefor
18 he referred him someplace else. But he said he could not mak
19 a judgment because he had not seen him.
, ~
~
20 Q And that was in '93?
21 A That's what it says. Yes" I have all information
22 after '92.
23 Q And in fact you were the doctor he saw at that
24 time, were you not?
25 A I saw him in - -
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Atlf.lul thlll IIl11nll tlme, '1/')1'1
A
I HI1I1IIU 11 WIlli, [' cJ have to look at the date ot
3 the note.
4
5
6
7
8
Q
Oktly, 110 l)lHlll~/Il.ly that statoment tharll was
doterring t.o your lud\Il1l01lt tinct 1oI11ying that he hadn't seen him
in a wh.l.le 011 that. i1nd ho deterred to youl is that correct?
A It il1lJllllllI t.hat. yes.
0 All d'.Ihl., Now, let's go to the physical
9 evaluation of 10/ to/')4'?
A Okay, phyulcHl t.herapy evaluation, okay.
o On rmgo two t.here, I believe it's page two, there
ill IIIl 8f1f1UUlll1lent?
MS, ORAB, AI thia point I'm going to object to
Pl'. ',ut.tennouor t.lHltHying further from the 10/10/94 report i
light of hlu lelltimony that he did not see the patient, he was
not I1wa 1'0 of th ill report, and I don't think that he can
tastify from it.
flV Mil.. Mtll,llRR lO,
c.l !)ocJtor, thifl report was llrepared by your office
20 heral I.ll that correct?
21
A
One of the people that work in here in physir.:al
22 thorapy, that'll cell'reGt.
23
Q
And ae IMrt it ill part of the medIcal records ot
24 YOllr pat lent?
25
A
It wile placed actually in iI new chart on him
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CBN'l'RAI. PFlNNSVLNANIA COURT RBPORTING SERVIeBS
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because he was being -- his case was reopened. That's how
thlllY do that.
Q aut it is a report on a patient of yours at this
facility?
A I --
MS. GRABl I understand that a phYBician may
7 testify from the records of other physicians.
8
THE DEPONENTl No. Actually he was not a patient
9 of mine at that time --
10
MS. GRABr Excuse me. I want to make clear my
11 obj action.
12
THE DEPONENT I Excuse me.
13
MS. GRAB I What I am '. - I understand that
14 physicians are allowed to testify from records that they
15 generally rely on in making medical diagnoses. My objeotion
16 goas to the doctor's specific testimony on cross examination
17 that he's not willing to testify about this functional
18 capacity evaluation because he didn't soe him at that time.
19
THE DEPONENTr In fact, I'm not trying to disrupt
20 things, I'm only saying I have in n~ appraisal on 8/27/93
21 patient followed with private medical doctor for all
22 particular problems both concerning dysthymia and chronic pai
23 syndrome. So he wasn't actually my patient after that
24 particular date and he had probably seen -- hopefully seen
25 Dr. Tocks after that.
CENTRAL PENNSYLVANIA COURT REPORTING SERVICES
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31
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1 BY MR. MULDERIGI
2
o
NoW, you ~ely on these reports when making
3 evaluations?
4
A
I use the reporta along with my own intormation
5 when I see patients. So it's a combination just like I do all
6 laboratory teats,
7
o
And you have read this report?
I've read it today, I don't know if I read it in
8
A
9 detail before.
10
Okay. But today you've read it? Is there
Q
11 anything
12
Quickly. yes,
Is there anything inconsistent in that report wit
A
o
13
Q
14 what you're testifying as to the patient'S condition?
15
A
1'he condition
16
MS. GRASr Object to the form of that question.
THE DEPONENT I Pardon me.
17
18
MS. GRABr I'm raising an objection for the
19 record. You can respond.
20
MR. MULDERIGr Go ahead.
21
THE DEPONENT I From the information contained in
22 this physical therapy evaluation appears to be very similar t
23 th~ information and physical therapy evaluation that was
24 obtained on the patient back in 8 -- in 7/8/93.
'\J
25
MR. MULDERIGr Thank you. I have no further
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1 questions.
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MS. GRABr I have nothing turther. Thank you.
(Whereupon, the deposition was concluded at
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CENTRAL PENNSYLVANIA COURT REPORTING SSRVICRS
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"""'1,,
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____,___.__._ ._..__. ... ... .............mm._...'........._....__...._ _ ....____,..__,..__...____.....ll,_
COMMONWIilAl.TH OF llIilNN9YINANIA)
) ss
COUNTY OF CUMBERl.AND )
I, HBATHBR L. BOYBR, RPR, a Court Reporter'Notary
Public authorized to administer oaths and take depositions in
the trial of causes, and having an of fice in Mechanicsburg,
Pennsylvania, do hereby certify the foregoing is the testimon
of GARY LUTTERMOSER, M.D" taken by Plaintiff at CAPITAL
RECOVERY CENTBR 415 Fallowfield Road, Mechanicsburg,
pennsyl vania.
I further certify that before the taking of said
11 deposition the witness was duly sworn, that the questions and
12 answers were taken down in stenotype by the said
13 Reporter-Notary, approved and agreed to, and afterwards
14 reduced to computer printout under the direction of said
15 Reporter.
16 I further certify that the proceedings and evidence are
17 contained fully and accurately in the notes taken by me on th
18 within deposition, and that this copy is a correct transcript
19 of the same.
20 IN WITNBSS WHEREOF, I have hereunto subscribed my hand
21 this ~ day of April, 1995.
22
~~,{nj~h ~l ./)''''f~--
N TARY PUBLIC (
23
24
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~I (~Ir' ',.', ,I '!",1J1"IWJ, .1.'. '1~1l'h'\I' (,r F 1'If:. Ill.
25
My Commission Expires February 14,
CENTRAL PENNSYLVANIA COURT REPORTING SERVICBS
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