HomeMy WebLinkAbout02-4038IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANI^
No. ~o~- ~o*~:
Civil Action - Law
KRISTA COOMBS, parent and natural,
guardian of KAYLA COOMBS
250 Pleasant View Drive
Etters, PA 17319
Plaintiffs &
Addresses
versus
KERRY A. SAINTZ
731 Harrisburg Pike
Dillsburg, PA 17019
Defendants &
Addresses
PRAECIPE FOR WRIT OF SUMMONS
TO THE PROTHONOTARY OF SAID COUNTY:
Please issue a writ of summons in the above-captioned action.
SCHMIDT~ RONCA & KRAMER: P.C.
209 State Street, Harrisburg, PA 17101
(717) 232-6300
x Writ of Summons shall be issued and forward~ ) Attorney (XX) Sheriff
Gerard C. Kramer, Esquire ~
S p~re~enature of Attorney
Court ID No. 44715
Date: g/.2..~ } 0 ~
WRIT OF SUMMONS
TO THE ABOVE NAMED DEFENDANT(S):
YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFF(S) HAS/HAVE
COMMENCED AN ACTION AGAINST YOU.
20O2
Prothonotary
Date: d/~- c~' °7~d'~- By: ~
( ) Check here if reverse is issued for additional information.
(De'puty)J
IN RE: KRISTA COOMBS, Individually
and as Parent and Natural
Guardian of KAYLA COOMBS,
a Minor
IN THE COURT OF COMMON
PLEAS CUMBERLAND COUNTY,
PENNSYLVANIA
NO. 02-4038 2002
PETITION FOR APPROVAL OF
MINOR'S SETTLEMENT
PETITION FOR APPROVAL OF COMPROMISE SETTLEMENT AND
DISTRIBUTION OF PROCEEDS FOR KAYLA COOMBS~ A MINOR
AND NOW, comes the Petitioner, Krista Coombs, Individually and as Parent
and Natural Guardian of Kayla Coombs, a minor, and respectfully set forth as follows:
1. Petitioner, Krista Coombs, Parent and Natural Guardian of Kayla
Coombs, is an adult individual residing at 607B Geneva Drive, Apt. 14,
Mechanicsburg, Pennsylvania 17055.
2. Kayla Coombs is a Minor, born on October 15, 1998, who currently
resides in the custody of the Petitioner, Krista Coombs.
3. Kayla Coombs, a Minor, suffered lead poisoning while residing in a lead-
contaminated apartment located at 116 South Third Street, First Floor, Lemoyne,
Cumberland County, Pennsylvania (~the apartment"). Kayla Coombs and Krista
Coombs resided at the apartment for one year and three months between June of
1999 and September 21, 2000.
4. Kayla Coombs was tested for lead poisoning and it was discovered that
she had a high level of lead in her blood (Please see Medical Records attached as
Exhibit "A.")
5. A lead inspection was performed on the apartment. The lead inspection
revealed that the apartment contained lead. {Please see Lead Inspection Records
attached as Exhibit "B.')
6. Kerry R. Saintz is the owner of the apartment.
7. The medical costs for Kayla Coombs' lead poisoning have been paid by
the Department of Public Welfare. {Please see copies of Medical Bills attached hereto
as Exhibit "C.')
8. It is most likely that Kayla Coombs will continue to incur future medical
expenses arising from the lead poisoning. (See physician's report attached hereto as
Exhibit "D'.)
9.
10.
The Defendant had a policy of insurance with CGU Insurance.
The policy contained a pollution exclusion provision, it specifically
excluded lead paint claims.
11. There was a fifty thousand dollar ($50,000.00) lead paint rider
purchased by the defendant. (See attached hereto as Exhibit "E'.)
12. The Petitioner has entered into an agreement to settle the case for Fifty
Thousand Dollars ($50,000), for settlement of Krista Coombs' claims.
13. Kayla Coombs' claims are not released and she may bring a claim in her
own right as an adult.
14. The Petitioner is satisfied that the offer of settlement is just and
reasonable and is willing to accept the said offer if approved by the Court.
15. In pursuing the claim against Kerry Saintz, the Petitioner engaged the
law firm of Schmidt, Ronca, & Kramer, P.C., under a contingency fee providing that
the said law firm should be paid 25% of any settlement obtained before the filing of
suit. (Please see copy of Contingent Fee Agreement attached hereto as Exhibit "F.")
16. Schmidt, Ronca, & Kramer, P.C., has incurred costs associated with the
investigation of this matter.
17. The Commonwealth of Pennsylvania Department of Public Welfare has a
lien of One Thousand Twenty-four Dollars and ninety cents ($1,024.90) against a
recovery or settlement.
18. The Petitioner requests that your Court distribute the present payment
of Fifty Thousand Dollars ($50,000) as follows:
Schmidt, Ronca, & Kramer, P.C.
Attorney fees (25%) ................... $ 12,500.00
Schmidt, Ronca, & Kramer, P.C.
Costs incurred to date ................. $
746.53
Commonwealth of Pennsylvania,
Department of Public Welfare
Lien .............................. $
(The lien is $1,024.90. A proportionate
share of attorneys' fees and costs is
$823.34)
823.34
Waypoint Bank, Camp Hill Mall, Camp
Hill, Pennsylvania 17011 to be
deposited in an account marked
as follows:
"Krista Coombs, as Parent
and Natural Guardian of
Kayla Coombs, a minor" ........... $ 35,930.13
TOTAL .............. $50,000.00
19. The Petitioner requests that this account be authorized without the
formal appointment of a guardian of estate of the minor or the entry of security,
with the Petitioner, Krista Coombs, being authorized and directed to invest funds
belonging to Kayla Coombs, a Minor, as follows:
A. to invest the funds in Certificates of Deposit to
the extent possible with Waypoint Bank, not to
exceed such sums as are fully insured by F.D.I.C.;
and
to invest the balance of said sums which cannot
be invested in Certificates of Deposit, if any,
in a Savings Account with Waypoint Bank, not
to exceed sums as are fully insured with F.D.I.C.
Each account shall be marked as follows:
"This money shall be held in trust not to be
redeemed, withdrawn, negotiated, or in any
way alienated except for the renewal in its
entirety before October 15, 2016, except by
Order of this Court."
WHEREFORE, Petitioner Krista Coombs requests that this Honorable Court
enter an Order approving the foregoing compromised settlement directing the
distribution of proceeds set herein.
Respectfully submitted,
DATED: 9/11/02
SCHMIDT, RONCA & KRAMER, P.C.
BY
amer
/Attorney at Law
/ Attorney I.D. No. 44715
209 State Street
Harrisburg, PA 17101
(717) (232-6300
Attorney for Plaintiffs
~ rN,dlRv ! AY, ER~
209 State Street
Harrisburg, Pennsylvama 17101
717 ~,~_ &300
Fax 717 232,e487
May l4,2001 ~G~6/~
Polyclinic Medical Center
2601 North Third Street
Attention'. Medical Records Department
Client : Kayla J. Coombs, a minor
Krlsta J. Coombs, parent
Address : 116 8outh Third Street, 1st Floor
l~resent.
Bills Requested : All bills from 10/05/00 to the prosent.
· Dear Sir or Madam:
Our office represents the above-named patient. Please forward to my attention
copies of the following:
Ix]
any and all hospital records, including but not limited to: discharge
summary, admitting notes, history, physical e~_,mmations, consultation
reports, x-ray or other diagnostic test reports, emergency room records,
patholot~' reports, operative rcport8, medical photographs, if any; ,1! doctors'
orders, notes, etc.; tissue committee report, ff any; employees' day sheet
showing names of nurses; physical therapy records; any and all outpaticnt
records for the dates Yeqtlested above.
any and all billings for services rendered for the dates requested above. On
your bill for hospital services, please do not show any amounts paid by
insurance, as we cannot use these m Court. Your bill should include your '
to~__~l char§es for services without showing the source of payment.
(Please bill us separately for your report or photocoPY chaz'l/e8).
PoIyclinic Medical Center
May 14, 2001
Page Two
Enclosed you will find a signed Medical Authorization authorizing the release of this
info,:marion to me. Thank you for your kind attention to this matter.
Very truly yours,
SCHMIDT, RONCA & KRAMER, P.C.
. Kramerc''~~~
atLaw
GCK/ det
Enclosure
cc: Billing Department
To~
POLYCLINIC MEDICAL CENTER
From: KRISTA COOMBS P/N/G of KRISTA COOMBS and GERARD C. KRAMER, HER
ATTORNEY
You are hereby authorized and clLrected to pen~lt ~he examination of, and ~he copying
ox reproduction in any manner, whether mechanical, photographic, or otherwise, by my
attorney or such other person as he may authorize, all or any portions desired by him
of the following:
(a) Hospital records, X-rays, X-ray readings and reports,
laborator~ racor~s and reports, all tests of any type,
character and reports thereof, statements cE charges, any and
all of n~ records pertaining to the hospita~ization, history,
condition, treatment, disgnos~s, prognosis, etiology or
expense;
(b} Medical records, including patient's record cards, X-rays, X-
ray readings and ~eports, laboratory records and reports, all
tests of any type and~ character and reports thereof,
ratste~nente o~ charges, and any and all o~ my records
pertaining to medical care, history, condition, treatment,
diagnosis, pro~uosis, etiology or expense.
You ara further authorized and directed to furnish oral and written reports to my
attorney, or has delegate, as requested by him for any of the foregoing matters.
By reasons of the £ac~ that such ~nformation that you have acquired as my phys~cian or
surgeon is con~ident~al to me, you are also requested to treat such info=marion as
confxdantial and requested not to ~urnieh an~ ouch information .in any Eom to anyone,
without writhe autho=iza=ion from me. I hereby r.e_.vo, ks an~ pre_viously dated medical
auth~rization.
Thxs Authorization does not prevent the ~ealth care provider from supplying billing
and other lnfozma~on to the first pa=tM carrier or medica~ insurer in order that the
bills are paid. It does, however, prevent the medical provider from supplying ~his
info~a~ion to a third party insurance adjuster or an adjuster for an adv.=se party.
I also authorize my et=orneys or their delegate to photograph my person while I am
present in any hospital.
I agree that a photosta~c copy of th/s authori~ation shall be considered as effective
and valid as ~he original.
Date= 5/14/01
o5/23/2OOl
11:05 James A.
Name: COOMBS,KAYLA
H~ : 180785446
ACCT: 429338851
PinnacleHeaith Hospitals
Piper, M.D., Medical D~£ector PAGE
Harrisburg, PA
Age/Sex: 31M F
LOC: UNLISTED
DR: VARMA,BMUPINDER
REC: 10/25/2000
W13589 COLL: 10/25/2000 09:30
INTERIM REPORT
1
10:23 PHYS: VARMA, BHUPINDER
COMP METABOLIC PANEL
SODIUM 140
POTASSIUM 4.8
CHLORIDE 101
CO2 26.0
ANION GAP 13
ALBUMIN 4.0
ALK PHOSPHATASE 305
UREA NITROGEN, BLOOD 5
CALCIUM 10.1
~CREATININE r 0.3
GLUCOSE *56
AST 38
ALT ,17
BILIRUBIN,TOTAL 0.5
TOTAL PROTEIN 6.1
AUTO DIFF
[137-147] MMOL/L
[3.6-5.1] MMOL/L
[97-108] MMOL/L
[20-30] MMOL/L
[6-78]
[3.5-4.8] GM/DL
[80-450] U/L
[0-20] MG/DL ·
[8.9-10.3] ' MG/DL
[0.3-0.8] MG/DL
[74-118] MG/DL
[o-4o] u/n
[24-65] U/L
[0.4-2.0] MG/DL
[6.1-7.9] GM/DL
REQUEST CREDITED
MANUAL DIFF ORDERED
CBCA
WBC COUNT 8.59
RBC COUNT *5.04
HEMOGLOBIN 11.7
HEMATOCRIT 35.0
MCV *69.4
MCH 23.2
'MCHC 33.4
PLATELET COUNT 322
RDW 14.0
MPV 9.0
WBC DIFF
NEUTROPHILS
BAND
LYMP}{OCYTES
EOS INOPHILS
MONOCYTES
RBC MORPHOLOGY
[5.5-15.5] K/ul
[3.70-4.90] M/ul
[11.o-14.o] G/DL
[31.0-44.0] %
[70.0-85.0] FL
[22.0-31.0] PG
[28.0-36.0] G/DL
[129-366] K/ul
[11.0-15.3] %
[6.5-12.2] FL
20.0 [16-60] %
1.0
66.0 [45-75] %
7.0 [0-8] %
6.0 [o-12] %
'ANISOCYTES +1
POLYCHROMAS IA +1
MICROCYTES -+1
COOMBS,KAYLA END OF REPORT PAGE
October 10, 2000
Schmidt, Ronca & Kramer PC
209 State Street
Harrisburg, Penns¥1vanta 17101
717 ! 232.6300 Fax 717 ! 232-6467
' ;~quost# -
'age~
~ cna cmt
Polyclin£c Medical_Center--.
Bm _ ~ mbs oomp
2601 North Third
Attentaon:
Medical Records Department
R~gU~S~FOR HOS~Z~AL~CO~D~
A~zess
ga~la ~. Coombs, a m:Luo=
Bough ~ha=d 8greeg~ ['~ Floo=
~emoEne~ ~ ~q043
Records l~quel~ed:"---~-~'~'~'2'~o=cls £=om 9/1/00 ~o ~e present.
Dear Sar or Madam:
Our office represents the above-named patient. Please forward to my
attention copies of the following:
Ix] an~ and &lL hospitm% =oeo=ds, including but not limited to:
discharge su~unary, admitting notes, history, physical
examinations, consultation reports, x-ray or other diagnostic
test reports, emergency room records, pathology reports,
operative reports, medical photographs, if any; all doctors'
orders, notes, etc.; t~ssue committee report, if any;
employees' day sheet showing names of nurses; physical therapy
records; any and ~11 outpatient records for the dates requested
above.
[x] a~x mad &ll bzllings for services rendered for the dates
requested above. On your b~ll for hospital services, please
do not show any amounts paad by insurance, as we cannot use
these an Court. You~ ball should include your total charges
for services w~thgUt showang the source of payment.
(Please bill us separately for your report or photocopy
charges).
polyclinic Medical Center
October 10, 2000
'Page Two
Enclosed you will find a slgned Medical Authorization authormzmng
the release of this mnformatlon to me. Thank you for your kmnd
attention to th~s matter.
Very truly yours,
SCHMIDT, RONCA & KRAMER,
Gerard C. Kramer
Attorney at Law
P.C.
GCK/det
Enclosuze
co: Billing Department
· Med=oal ~o~at~on
To:' pOLYCLiNiC ~t~DICAL
BE~ A~O~E~
~ou a~e he~M au~ho~lz~ and ~ec~ed ~o pe~ ~e ex~na~ion o~,
o~ zep~uction ~n ~ ~e~, whe~he~ ~chanl~l, pho2og~aphxc,
a~o~ey o~ su~ o~he~ pexson as he ~y authorize, all o~ an2 po~2ions
o~ ~e ~oll~ng3
(a) Hospital records, X-~ays~ X-ra~ ~ea~ngs and repo~s,
laboratory reese,s and repo=~S, all ~ests o~ any ~e,
all of ~ zeco~s pe~a=ning =o t~a hoapl=alizatio~,
~ion~ ~e~tr ~a~nosLs ~ p~o~osis ~ etiology o~
(b) ~1 reco=ds, in~u~g patient's re~ ~r~ X-rays~
ray =ead~ngs a~ re~s, l~ora=ory reco=ds and =e~r~s,
~ests o~ ~Y t~e ~ ~a=ac2er and re~rts thereoE,
stat~enks cE ~arges, and any and all o~ ~my reco=ds
pe=tainlng to ~ical ~re~ ~sto=y, ~ondi=ion~
~a~osi8, pro~os~s, et~ology o~ expense.
You are fur~er au=horized ~d directed =o fu=nish oral and w=itten
at=o~ey, or his delegate, as re~es2ed by ~ for any of the forego~g ~Cte=s.
By reasons of ~e fac~ ~a= su~ xnfo~2ion the= you have ac~xzed as
surgeon is con~idential ~o ~, you aze also re~ested to ~reat su~ infomtion as
con~iden~al and =e~ested no~ .~o ~u~sh any such zn~o~tion
~i~hou~ wzl~en au2ho=ization ~m ~. I hez~2 =e~ka an~
~s Au~oriza~on d~s not p=e~t ~e h~l~ ~ pro~r f=~ sullying b~ll~
bills a=e p~d. It does, h~=~ p=e~= the ~cal p~ov~r f~m ~ly~g thl~
I also au=ho=ize ~Y a=~o~neys or ~ ~elegate ~o phot~ra~
p~t in any hospital.
~ valid as the ozi~nal.
D~te: I0/10/00
,io o4/2ooo
00:28
Pt. Name:
Age/Sex: 23M( _~: 10/15/1998
Itosp. No.: 18~~
Account: #: 42
LOC.' ~Ii~ ...... ~ ~CTIC~ '
PinnaoleHealth Hospital-.
james A. Piper, M.D., Medical Dmrector
.. Ordering Physician
T72156 COLL: 10/03/2000 1~00 R~C: 10/03/2000 16:20 Dr. VARMA,BHUPINDER
COMP METABOLIC PANEL MMOL/L
SODIUM * 135 [137-147]
POTASSIUM 4.4 [3.6-5.1] MMOL~L
CHLORIDE 103 [97-108] MMOL~L
C02 24.0 [20-30] ~40L/L
ANION GAP ~ 8 ~ [6-18]
ALBUMIN 4.1 [3.5-4.8] GM/DL
ALK PHOSPHATASE 293 [80-450] U/L
UREA NITROGEN, BLOOD 14 [0-20] MG/DL
CALCIUM 10.0 [8.9-10.3]
CR~ATININE 0.3 [0.3-0.8] MG~DL
GLUCOSE 118 [74-118] MG/DL
AST * 43 [0-40] U/L
ALT * 18 [24-65] U/L
BILIRUBIN,TOTAL 0.4 [0.4-2.0] MG/DL
TOTAL PROTEIN 6.4 [6.1-7.9] ~M/DL
AUTO DIFF
REQUEST CREDITED
MANUAL DIFF ORDERED
CBCA K/ul
WBC COUNT 9.42 [5.5-15.5]
RBC COUNT * 5.20 [3.70-4.90] M~ul
H~MOGLOBIN 12.0 [11.0-14.0] G/DL
H~MATOCRIT 35.9 [31.0-44.0]
MCV * 69.0 [70.0-85.0] FL
MCH 23.1 [22.0-31.0] PG
MCHC 33.4 [28.0-36.0] G~DL
PLATELET COUNT 276 [129-366] K/ul
RDW 13.5 [11.0-15.3] %
MPV 9.2 [6.5-12,2] FL
WBC DIFF
NEUTROPHILS * 15.0 [16-60] %
LYMPHOCYTES * 81.0 [25-75] %
EOSINOPHILS 4.0 [0-8] %
RBC MORPHOLOGY MICROCYTES +2
WBC MORPHOLOGY ATYPICAL LYMPHS PRESENT
COOMBS, KAYLA
END OF P~PORT
PAGE.
o /28/2ooo
PinnacleHealth Hospita
James A. Piper, M.D., Medlcal Director
Pt Name: COOMBS,KAYLA
Age/Sex: 23M F DOB: 10/15/1998
Hosp No.: 180785446
Account #: 429903134
Loc.:-K~Y
W1588
COLL: 09/27/2000 UNK
Orderxng Physician
REC. 09/27/2000 16:08 Dr. VARFdk, BHUPINDER
CBC &M;UqUAL DIFF
WBC COUNT
RBC COUNT
HEMOGI~BIN ~
HEMA~CRIT
MCV
MCH
MCHC
PLAT~LET COUNT
RDW
MPV
N~UTROPHILS
LYMPHOCYTES
MONOCYT~S
EOSINOPHInS
RBC 'MORPHOLOGY
11.37
ANALYSIS REPF2%%~D
CONFIPd4ED
4.94
11.4 -
32.8
66.4
23.1
[5.5-15.5] K/ul
[3.70-4 90]
[11.0-14.01
[31.0-44.0]
[70.0-.85.0]
[22.0-31,0]
M/ul
G/DL
%
FL
34.8 [28.0-36.0] G/DL
[129-366] K/ul
PLATELET COUNT IS UNRELIABLE DUE TO
PLATBLET CLUMPING
SLIDE ESTIMATE OF PLATELETS APPEARS WI/"~IN
NORMAL LIMITS.
13.4
10.0
20.0
73.0
3.0
4.0
ANIS0~S +1
MICROCYTES +1
ROUnEAUX PRESENT
[11.0-15.3]
[6.5-12.2] FL
[16-60] %
[25-75] %
[0-121
[0-8]
COOMBS, KAYLA
END OF REPORT
p~le
0~/22/2000
',06':25
PinnacleHealth HOs~xtalu
James A. Piper, M.D., Medical D~rector
Pt. Name: COOMBS,KAYLA
ABe/Sex: 23M F~.DQB. 10/15/1998
Hosp No.' 1807~3
Account ~: 210083-;-&~
Loc.: KLINE PED CTR POLY
Orderin9 Physmcian
H61521 COLL: 09/21/2000 15:45 REC: 09/21/2000 19:33 Dr. VARMA, BHUPINDER
LIPID PANEL
CHOLESTEROL FOR LIPO
TRIGLYCERIDE
HDL CHOLESTEROL
LDL [CALC}
VERY LO DENSITY LIP
RISK FACTOR LIP (CAL
195
274
48
92.2
55
4.1
RISK
1/2 AVERAGE
AVERAGE
2X AVERAGE
3X AVERAG~
[0-200] MG/DL
[<200] MG/DL
[29-89] MG/DL
[0-130] MG/DL
FEMALE MALE
3.3 3.4
4.4 5.0
7.0 9.5
11.0 24.0
· Ordering Physzcian
H61520 COLL: 09/21/2000 15:42 REC: 09/21/2000 19:32 Dr. VARMA,BHUPINDER
RENAL FUNCTION PANEL
SODIUM 137 [137-147] MMOL/L
POTASSIUM 4.7 [3.6-5.1] MMOL/L
CHLORIDE 104 [97-108] MMOL/L
C02 21.0 [20-30] MMOL/L
ALBUMIN 4.4 [3.5-4 8] GM~DL-
UREA NITROGEN, BLOOD 10 [0-20] MG/DL
CALCIUM 10 0 [8.9-10.3] MG/DL
CREATININE 0,3 [0.3-0.8] MG/DL
GLUCOSE * 65 [74-118] M~DL
PHOSPHOROUS 5.6 [3.5-6.8] MG/DL
AUTO DIFF
REQUEST CREDITED
MANUAL DIFF ORDERED
WBC COUNT 10.43 [5.5-15.5] K/ul
. 4.,2 j0-4 90
OGLOB N' -..o-14.ol
HE~TOCRIT 33.1 [31.0-44.0] %
M~ , 6~.~ [70.0-85.0] FL
MCH 23.2 [22.0-31.0]~ PG
MCHC 34.4 [28.0-36.0]
P~TE~T CO~ * 369 [129-366] K/u1
~W, 13.3 [11.0-1~.3] %
MPV 9.6 [6.5-12.2] FL
WBC DIFF
COOMBS,KAYLA CONTINUED PAGE
0~/22/2000
'06~5
PinnacleHeal~h Hos~italb
James A.. Piper, M.D., Medical Director
Pt. Name: COOMBS,KAYLA
Age/Sex: 23M F DOB: 10/15/1998
Hosp. No ~ 180785446
Account ~: 210083732
Loc.: KLINE PED CTR POLY
H61520
Ordering PhysIcian
COLL. 09/21/2000 15:42 REC: 09/21/2000 19:32 Dr. VARMA,BHUPINDER
WBC DIFF ... (CONTINUED)
NEUTROPHILS 17.0 [16-60] %
BAND 1.0
LYMPHOCYTES * 76.0 [25-75] %
EOSINOPHILS 1.0 [0-8] %
MONOCYTES ' 5.0 [0-12] %
RBC MORPHOLOGY
NO DETECTABLW, RBC ABNORMALITIES
I~RRI TIN 33.6 [10-155]
NG/ML
COOMBS, ~AYLA
CLIENT REpoRT COMPLETED
END OF REPORT
. R~sult Gen Lab
COOMBS , KAYLA F .1 ICsL_..i: /-
Atn DrI WILLIAMS RONALD J
Adm Dr. 0~/21/00 OA
o /21/oo
CHEM- ROUT
SODIUM 137-147
POTASSIUM 3 . 6 - 5.
CHLORIDE 97
CO2 20-30
BUN 0-20
CREATININE 0 . 3 - 0.8
GLUCOSE 74 - 118
PHOSPHORUS 3 . 5 - 6.8
CALCIUM 8.9-10 . 3
ALBUMIN 3.5-4 . 8
HDL CHOL 29-89
~RIGLYCERIDE <200
L. DL CHOL 0-130
RISK FACTOR
15:45
48
274*
92.2
4.1
T
2,oo
12 .V-eo ' - '
15:42
~.7
21.0
10
0.3
65*
10.0
'/32
CHOLESTEROL 0- 200 195
09/21/00
LIPID EVALUA 15 '.45
HDL CHOL 29-89 48
TRIGLYCERIDE ¢200 274*
LDL CHOL 0-130 92.2
VLDL 55
RISK FACTOR 4.1 T
o9/21/oo
HEMOGRAM 15 ~ 42
WBC 5.5-15.5 10.43
RBC 3.70-4.90 4.92*
HEMOGLOBIN 11.0-14,0 11.4
HCT 31.0-44.0 33.1
MCV 70.0-85.0 67.3*
MCH 22. O- 31.0 23 · 2
MCHC 28.0'36.0 34.4
PLATELETS 129-366 369*
RDW 11.0-15.3 13.3
MPV 6.5-12.2 9.6
o /21/oo .
DIFFERENTIAL 15: 42
NW. UTROPHILS 16-60 17.0
LYMPHOCYTES 25-75 76.0*
MONOCYTES 0-12 5 · 0
EOSINOPHILS 0-8 1.0
BAND 1.0
o9/21/oo
RBC, WBC, PLT 15: 42
RBC MORPHOLO SEE TEXT
CKLB7286 ~ 11 ~17 09/22/00 FROM CKD1, ZRPRTGF1
Result Gen Lab
t COOMBS %KAYI~% F
Atn Dr: WILLIAMS RONALD J
,%
i / ~c
CLINIC
Adm Dt~ 09/21/00 OA Isol:
o~/2i/oo
IMMUNOASSAY 15:42
FERRITIN 10-155 33.6
.- IMf#:" 1807854-4~
agAIgOgU
CKL87286
I~,EFERRAL DATE AND VPb LEVEL,,
MOTHER'S NAME ~rt~tt0~ ~a~w~.
FATHER'S NAME _
ADDRESS
ALTERNATE CONTACT
ADDRESS
-SIBLINGS < 6 YRS OF AGE J
TESTED FOR Pb AND Pb LEVELS
HEALTH CARE PROVIDER '~.
ADDRESS ~
ENVIRONMENTAL INFORMATIO~I
DATE OF INSPECTION
· _ Pb SOURCE
Does the chdd spend more than 10 hours .a: week ~n another Ioo~on?
Doe~ any careg~ver work at an ocoup~o~ Immlvlng lead'~
Does any camg~ver have bobb,e~ that uee lead~
la the dwelhng Iooated near lead related indu~
Is li3e dwelling located nom' a heavy travele, d slreet?
Is there a wood burmng stove o~ furnace I,n the home?
Does the dwelling have a mung~pal water souroe9
How long has the fro.rely lived at this res~dence'~
REFERRAL SOU~..~ ~~
TELEPHONE
. TELEPHONE #
TELEPHONE #
TELEPHONE # ""1,-I z~ - ~ bO
./
DATE ..
PATIENT NAME.
DATE OF BIRTH
PHYSiCiAN
PINNACLE. HEALTH
Hospitals
LEAD POISONING CLINIC
EVALUATION SHEET
HISTORY
F~-I'AL ACTIVrI'Y NORMAL
COMPLICAI'IQN$ HYPERTENSION_
TOXEMIA (~ _UTI
NEWBORN HISTORY
DiABETE$.._(::~'.~PRE-ECLAMPSIA,(:~
.FLU/VIRUS_ (~ PREMATURE LABOR. ~
.OR TAKE NON-PRESCRIBED DRUGS?
INDUCED_ .C-SECTION~
CHILD'S
NUTRITION
STATUS
MEDICAL
HmTORY
PHYSICAL
DOES THE CHILD EAT A WELI~AL.ANCED DIET CONSISTING OF RED MEAT~ ANDJOR EGGS, DRIED BEANS,
PEANUT BUTTER, MILK AND/,..OR CHEESE, ENRICHED SREAD AND/OR CEREAL, FRUITS AND VE(3ETABLES?
DOES THE CHILD EAT A LARGE AMOUNT OF HIGH FAT FOODS?_. {~,'3 ...
DOES THE CHILD EAT MEALS AND SNACI<S REGULARLY SPACED DURING THE DAY?_ ?z' 5
ARE IMMUNIZATIONS UP TO DATE? ~{"~.-~
HosPrr~lZATIO~~
SURGERIES
. I ..... ~ - ~ F~CTURES
I~URIES STIT~ES~_~ ,
D~N~ OF H~D TRAUMA '
MINOR MALFORMATION~ HAIR WHORL
HYPERTELORISM ~J PALATE .
PALMS DPC ~ .SIMIAN
OTH~._.___.__J~
NEURO CNS
S3'RENGTH '~'~ MABS
PATIENT NAME . F~ [6. ~ Oa r,,,.~3 ~
...CLINODACTYLY
FACT SIMIAN
TONE
/kJ SyNDACTYLY_
DEVEEOPMENT MOTOR. SAT
CHILO'S
FAMILY
H~TORY
DRESSES ~/ ~ < ~ TI~ 8HO~ ~
~.au~E, vo~au~Y (~ o~ WORDS) ~' ¢ I ~ .. WORDS PER sE~CE. ~' 5 ~"r~ _ _
POI~8 TO ~DY P~8_ ~ ~.
~LORS ~ ~
USES PRONOUNS YES~ NO~ APPROPRIATELY
How o~ DoES T,E ~ A~T~ ~S T,E CH~D CLUMSY OR ~,O~,*TEm O..r~ ~
~MM~
ATTENTION DEFICIT DISORDER
LEARNING DISABILITY
FAILED OR HELD BACK A GRADE
BEHAVIOR PROBLEM~
SPECIAL Ol.~S IN SCHOOL
SPEECH THERAPY
SLOW/MENTAL RETARDATIO.N
TUTORED
TREATED WITH MEDS FOR BEHAVIOR
PSYCHIATRIC HtSTORY
COMMENTS
DATE
LEAD LEVEL
[ HGB/HOT
FERRmN
SMAC 20
Ronca &.Kxa_mer PC
20~ ~a~ Stmet
717 232 63(30
F-ax 7'17 232 8467
.ww~__s _~_aw.
May 14, ~001
Jerome Korinchak, M.D. ' '-'--
Greenhill Family Practice - , I .
503 Bridge Street ' , I~A~ Z 9 L~, ·
New Cumberland, PA 17070 . . ':~_.o. . / .
_
~ Krbt~ J. Coomb., parent - /~, [ I
Address : 116 JSouth Third Street, 1't Floor
LemOYne, PA 17043
Birthd~te ** 10/16198
8.8. Ho. : 180-78-S446
Records Requested : All mediod zeoords from 9/23/00 to.tho
BILls Requested : All bm, from 9/1/oo to the present.
- ' ent. Please forward co
Please be adwsed that I represent the above namea pati P
of ~ x~oord~ you have ~e c'b~ldit~on, treat~-mnt, and pro~ress of this
individual from 8epte~be~ 23, 2000 t~ the
· '
Please include copaes o/~~~'m ~ptember a, 2000 te the
to me. I am not at this time requesting any spemally prepared medical reports.
If you have tony questions, please fee! free to call or write.
Very truly yours,
C-CK/ det
Enclasure
non
!pat
~ TO:
From; KRISTA C00MBS P/N/G of KAYLA C00MBS AND GERARD C. KRAMER, HER
ATTORNEY
You are hereby authorized and chrected to ~e~ ~he ex~na~n of, a~ ~e copying
or repr~uctxon In any ~er, ~e2her ~chanlcal, pho~ograph~c, or othe~se, by my
a~=o=ney or su~ ocher pe=son as he ~y au=ho=ire, all or any portions desl=~
of the ~ollo~ng~
(al Hospital =e~r~, X-rays, X-ray =ea~gs ~d r~orts,
l~ora2o=~ records a~d =e~rts, all tes2s of any t~e,
~arac~eE and repor=s ~hereof~ 8~at~ts of c~=ges, ~y and
~1 of my reco=~ pe=ta~nlng =o the hospLtalLaatlon, history,
con~t~on, ~rea~t~ ~a~osLs~ pro~osLs, e~lology
(b) ~di~l Seco~, induing pa~aen='s =e~ ca=~, X-rays,. X-
ray ~adings a~ repo=~s, l~ora~o=y re~=~ a~ =eports, all
tests of ~y ~e and character a~ repo=ts
stat~ents of ~a=ges, and any and all of my
pertaining ~o ~cal car~, ~s~o=y, c~dit=on,
d~agnos~s, pro~os~s, etLology or expense.
You are ~urther authorized a~ dLLe~ed to Eu~sh o=al a~ ~itten reports to
stuckey, o= ~s delegate, as re~ested b~ ~ for any of ~he for~oLng
By reasons of ~ ~act ~a~ such ~nfomt~u ~hat you ~ve ~cq~r~ aa ~ phyai~ or
surgeon is confLdential ~o ~, ~u are also re~s~ to ~eat su~
~n~den~al a~ =e~es2ed not to furnish ~y such ~n~omt~oa ~n any fora to
wl~ut wz~=~en au=horiza=ion ~rom ~. ~ ,hereby re~ke any p=e~o~l~ ~ted ~1
authoziza~ion.
Th~s Au~ho=lzation does not p~n= the health ~re pro.de= f=~ su~lF~ blL~ng
~d o~r info~on to the first ~ carrier o~ ~ insurer ~ o~z that the
bills are pa=d. ~t ~es, h~e~z, p=ev~t ~e ~1 pro.de= f=~
· nfo~t~on ~o a third party ~u=~ce adJuste= or an adguste= fo~ an a~se pa~y,
I also auto.re my a~o~eys or theLr delegate to p~togzaph my[ pe=&on w~le
p=esen= 1n ~y hospitaL.
I agree that a pho~ostatic ~y o~ t~s ~utho~zation ~11 ~ conside~ a~ eff~c~l~
and ~d as ~e origi~l.
Date: 5t1¢/01
HOLY SPIRIT HOSPITAL
GREEN HILL FAMILY HEALTH CENTER
PREVIOUS MEDICAL HISTORY
MEDICAL HISTORY
ACUTE PROBLEMS DATES
FAMILY HISTORY
REM
Sf.,I~D¢ ~IB TESTS
Breast
Cholestrol
Mammo
PAP
Prostate
Rectal'
PEDIATRIC IMMUNIZATIONS
DPT OPV HIB
HEP B
. .OISER ~
NICO
ETOH
CAFF
OCCUP
DRUG ALLERGIES
CONSULTANT
TINE TESTS
DATE RESULTS
ADULT IMMUNIZATIONS
TYPE DATES,
C~,~,~S .:~YLA J
1 1'; 9~ 4IS&Z?
1~3 /6 5''.6 G~,ILL FH
GRH 105
8/93
' DATEi
PROB # I SOAP DATE/PROGRESS NOTES
03/19/01 KAYIA J, COOMBS
$ 'F~ ts a 2-ycar-oJd whig fe,~te who lruenis Mth fellow rdsal dischl~, cim~s~on and t~,*~: ~b ~ ~ ~ ~
days Shebodfe~erofl006ogasmoFrd%~ Sbef~Imn~tubesmlb~
A : I Am~tesmomtm
D M~ one-Ourd q4h pm, ~R~~~~bld ~
GRH 100
HOI~ SPIRIT HOSPITAL
GREEN HILL FAMILY HEALTH CENTER
PROGRESS NOTE~
I 1~ 9~ ~15~?
180 7~ 5446 GHt~L FH
pROB # I SOAP I DATE/PROQRES8 NOTE,~
T~..,J~.EIO.N E MESSAGE
1,3 15 98 415.427
180 78 5~-46 GH~LL Ftl
PROB # SOAP DATE/PROGRES~ NOTES ,.
A'
2
3
P 1
2
3 A4v~ q~
4
GREEN HILL FAMILY HEALTH (~EHTER
PROQRESS NOTES
100
DATE/PROGRE~O,S NOTe8
' .~...~' .. - ._~_J .... - - --I~-...
HOLY SPIRIT HOSPITAL
GREEN HILL FAMILY HEALTH CENTER
PROGRESS NOTES
GRH 100 ~'
F;t
V
'Sdimidt, Ronca & Kramer PC
209 State Street
Hamsburg, Pennsylvama 17 t01
717 / 232-6300 Fax 717 / 232-6467
October 10, 2000
Jerome Korlnchak, M.D.
Greenh~ll Family Practzce'.,
503 Bridge Street
New Cumberland, PA 17070
Attom~s and ?.~seLo~s at Lc~w %- ....
i~I. '
Client
S.S. No.
Records Re~umSted:
B~11s Re~Ues%ed :
: Kayl& J. Co~s, a m~no=
F~xsta ~. Coombs,
116 Sou~h Third S~xee~, 1"~ Floor
Lemo~rne, PA 17043
180-78-5446
All med~oal reoords fro~ 9/1/00 to the Present.
All bills from 9/1/00 to the p~elent.
Dear Dr. Kor&nak:
Please be advmsed that I represent the above named pat. tent.
Please forward copies of all records you have kept on the condmtxon,
treatment, and progress of thi~mndm~1dual from September. i, 2000
to the ~resent. ~/,/,,/&~ -- ,. '~
Please include cop~es of all bllllngs from Septeraber 1, 2000 to the
present. '..:..
I have enclosed an executed Medical Authorization for the release
of th~s ~nformat~on to me. I am not at thls tlme regu~t~ng any
specially prepared medical reports.
If you have any questions, please feel free to call or wr~te.
Very truly yours,
SCHMIDT, RONCA & KRAMER,
r/ard C. Kramer
ttorney at Law
GCK/det
Enclosure
'JEROME KO~INCHAK,
F~om: KI~ISTA J. C001~S P/N/G of KAYLA J. C001(BS, A MIROR Alii) ~ERARD C. KRAHER,
You are hereby authorized and d~rected to pe~ the ex~na~on of, and ~he copyin~
or repr~uc~on in any mnner, ~ether ~anlcal, photographic, or othe~Lse, b~ my
at~o~ey or su~ othe~ person as he ~y authorize, all or any po~t~ons des~ b~ hLm
of ~he foll~ng=
(a)
(b)
Hospital records, X-rays, X-ray reachngs and reports,
laboratory records and reports, all tests of any type,
character and ~eports thereof, statements of charges, any and
all o~ my records pertaining Co the hospltalizat~on, history,
c~ndition, treatment, ~liagnosls, prognosis, e~ology or
expense;
M~dical records, including patient's record cards, X-rays, X-
ray readings and reports, laboratoryrecords and reports, all
tests of any type and character a~d reports thereof,
star--nfs o~ charges, and any and all of my records
partain~ng =o medical care, history, condition, trea~mentt
d~sgnosis, prognosis, etiology or expense.
You are further authorized and directed Do [urnish oral and wr=~en reports ~o my
By reasons of the fact that such znformat~on that you have acquired aa my phys~cian or
surgeon ~s conf~dentLal to me, you are a~so requested co treat such informat~on es
confl~ent~al and r~quested not to ~urnlsh any such lnfo~matLon in any ~ozm to anyone,
authorLzation.
This Authorization doee not prevent the health care provider f~rc~ supplying b£11ing
and other ~n~o=mat~ion t:o the ~rst party carrier or mechcal ~nsurer ~n order that the
bills are paid. It does, however, prevent the m~dical provider Jzom supplying th~e
information to a third par~y =nsuranc~ adjusts= or an ed3uster for an adverse ~a=ty.
I also authozLze my attorneys or their delegate to photograph my person while I am
present in any hospital.
andl agrea~nal.that a_~otostatic copy o~ this authorization shall be on~de~ed as
Dat~~
PROB# SOAP
DATE/PROGRE88 NOTES
GREEN HILL FAMILY HEALTH CEHTER
PROGRE88 NOTES
.~33~y~'~ ~
10 15 98 ~15¢Z7
180 78 5~&& 6HZLL F~
ORH 100 ,~
HOLY SPIRIT HOSPITAL
GREEN HILL FAMILY HEALTH CENTER
PROQRES$ NOTE~
100
' .6 GI','..L FH
/ 9b?
Pt~: 429903147
LAB
10/03/00 0A Isol: ~r#.. ~8o7s$446
o~/~i/oo o~/21/oo
CI{EM-ROUTINB 15:45 15:42
SODIUM 137-147 137
POTASSIUM 3.6-5.1 4.7
CHLORIDE 97-108 104
CO2 20-30 21.0
BUN 0-20 10
CREATININE 0.3-0.8 0.3
GLUCOSE 74-118 65*
PHOSPHORUS 3.5-6.8 5.6
CALCIUM 8.9-10,3 10.0
AI.RUMIN 3.5-4.8 4 4
HDL CHOL 29-89 48
TRIG~YCERIDE (200 274*
LDL CHOL 0-130 92.2
RISK FACTOR ~ 4.1 T
CHOLESTEROL 0-200 195
o9/21/oo
LIPID EVALUA 15: 45
HDL CHOL 29-89 48
TRI~LYCERIDE <200 274*
LDL CHOL 0-130 92.2
VLDL 55
RISK FACTOR 4.1
o9/2i/oo
HEMOGRAM 15: 42
WBC 5.5-15,5 10.43
RBC 3.70'4.90 4.92'
HEMOGLOBIN 11 , 0 - 14.0 11.4
HCT 31.0-44.0 33.1
MCV 70.0-85.0 67.3*
MCH 22.0-31 0 23.2
MCHC 28.0-36.0 34.4
PLATE~ETS 129-366 369*
RDW 11 0-15.3 13.3
MPV 6.5-12.2 9.6
o9/2i/oo
I FFERENTIAL 15: 42
N~ROPHILS 16- 60 17.0
LYMPHOC~S 25'75 76 0*
MONOCY~S 0-12 5.0
EOSINOPHILS 0= 8 1 · 0
BAND ' 1.0
o9/21/oo
', WBC, PLT 15
BC MORPHOLO SEE TEXT
13:37 10/09/00 FROM CKDi,ZRPRTGF~
. ReSult Gen Lab
COgMBS , ~AYLA
Atn Dr. VARMA BHUPINDt~R
Adm Dr. 10/03/00 OA
LAB
Isol:
Pt#: 429903147
MrS. 180785446
o9/2i/oo
IMMUNOASSA¥ 15.'~
FERRITIN 10-155 33.6
13:37 10/09/00 FROM CKD1,ZRPRT~F1
CKL88899
Result Gen Lab
COO~S ,~Y~
Atn Dr. WILLIES RONALD J
Adm Dr: 09/21/00 OA
/
CLINIC
Isol:
KPC
Pt~: 210083732
Mr#: 180785446
CKL87286 ~ 11:17 09/22/00 FROM CKD1, ZRPRT(]F1
o /21/oo o9/21/oo
CHEM-ROUTINE 15'45 15:42
SODIUM 137-147 137
POTASSIUM 3 6-5.1 4.7
CHLORIDE 97-108 104
CO2 20-30 21 0
BUN 0-20 10
CREATININE 0 3-0.8 0.3
GLUCOSE 74-118 65*
PHOSPHORUS 3.5-6.8 5.6
CALCIUM 8.9-10.3 10.0
ALBUMIN 3.5-4.8 4 4
HDL CHOL 29-89 48
TRIGL¥CERIDE <200 274*
LDL CHOL 0~130 92.2
RISK FACTOR . 4.1 T
CHOLESTEROL 0-200 195
o /21/oo
LIPID EVALUA 15:45
IiDL CHOL 29-89 48
TRIGLYCERIDE <200 274*
LDL CHOL 0-130 92.2
VLDL 55
RISK FACTOR 4 1 T
09/21/00
HEMOGRAM 15.42
WBC 5.5-15.5 10.43
P~BC 3,70-4 90 4.92*
HEMOGLOBIN 11.0-14.0 11.4
HCT 31.0-44.0 33.1
MCV 70.0-85.0 67 3*
MCH 22.0-31.0 23.2
MCHC 28.0-36.0 34.4
PLATELETS 129-366 369*
RDW 11 0-15.3 13 3
MPV . 6 5-12.2 9~6
o9/21/oo
DIFFE~gNTIAL 15:42
NEUTROPHILS 16-60 17.0
LYMPHOCYTES 25-75 76.0*
MONOCYTES 0-12 5.0
EOSINOPHILS 0-8 i 0
BAND 1.0
o9/ 1/oo
RBC,WBC, PLT 15:42
RBC MORPHOLO SEE 'r~XT
.R~sult Gen Lab
COORBS ,KAYLA
Atn Dr: WILLIAMS RONALD J
Adm Dr: 09/21/00 OA
/
CLINIC
Isol'
P=~: 210083732
Mr$: 180785446
09/21/00
IMMUNOASSAY 15:42
FERRITIN 10-155 33.6
.............. ==~ ........ -~==~d of Report ..... ~=~.~.m=.~==.~=~..~=~
11.17 09/22/00 FROM CKDi,~RPRT~F1
CKL87286
u
October 10, 2000
Schmiclt, F & Kramer PC
209 State Street
Harrisburg, Pennsylvania 17101
717 / 232-6300 Fax 717 / 232-6467
Attorneys and Counselors at Lmo
Holy Spirit Hospital
North 21st Street
Camp Hill, PA 17011
Attention:
Client
A~ees
Birthdate :
S.S. No. :
Records Requested:
Bills Requested :
:3- :. : · '. -. -:, .~ '' : ' ----
Dear Sir or Madam:
Our office ~epresents th~.'ab0~-~med'patiefit''
attention copies of the following:
Ix]
Ix]
Medical Records Department ~'~;L:'..... ·
· ":""'~ ' ' - '~/
: Kayla J. Coombs, a minor
Krista J. Coomhs, parent
: 116 South ~ird Street, 1s~ ~loor
L~mo~ne, PA 17043
x0/xs/~s
180-78-5446
~1 medical records fr°m 9/1/00 to ~e present.
~l.bills from 9/1/00 to ~e present~
Please"forward to my
any and all hospital records, including but not limited to:
discharge summary, admitting notes, history, physical
examinations, consultation reports, x-ray or other diagnostic
test reports, emergency room records, pathology reports,
operative reports, medical photographs, if any; all doctors'
orders, notes, etc.; tissue committee report, if any;
employees' day sheet showing names of nurses; physical therapy
records; any and all outpatient records for the dates requested
above.
an~ and all billings for services rendered for the~ates
requested above. On'your bill for hospital services, please
do not show any amounts paid by insurance, as we cannot use
these in Court. Your bill should include your total charges
-for services without showing the source of payment.
"(Please'bill us separately for your report or photocopy
cha{~es).
..~Holy Spirit Hospital
October 10, 2000
Page Two
Enclosed you will find a signed Medical Authorization authorizing
the release of this information to me. Thank you for your kind
attention to this mattes.
Very truly yours,
SCHMIDT, RONCA & KRAMER, P.C.
e~rard C. Kramer
Attorney at Law
GCK/det
Enclosur~
cc: ~illing Department
HOLY SPIRIT H, .'ITAL
Me~io-- 1 Autho. rization (
..~rom: KI{IS~A J;. COOM3S ~/N~G of KAYLAJ. C001~3S, A ~INOHAlqD GERARD
'HEK A~TORIqEY
You are hereby authorized, and directed to permit the examination of, and the copying
or reproduction in any .manner, whether mechanical', photographic, or otherwise, by ny
attorney or such other person as he may authorize, all or any portions desired by him
of the following:.
(a) Hospital records,. X-rays,. X-ray readings and reports,
-laboratory records and reports, ali tests of any type,
character and reports thereof, statements of charges, any and
all of my records pertaining to the hospitalization, history,
condition, treatment, diagnosis, prognosis, etiology or
expense;
(b) Medical records, including patient's ~ecord cards, X-rays, X-
ray readings and reports, laboratory records and reports, all
tests of any typ. e and character and reports .thereof,
state~ents of charges, and 'any and all of 'my records
pertaining to medical care, history, conditioN, t~eatment,
diagnosis, prognosis, etiology or expense.
You are further authorized and directed to furnish oral and written reports tO my
attorney, or his delegate, as requested by him for any of the foregoing matters.
By reason~ of the fact that Such information that you have acquired as my physician or
surgeon is confidential to me, you are also requested to treat such informatio~ as
confidential and requested not to furnish' any..such inf6rmation in any .form to anyone,
without written authorization from me. I hereby .revoke any previously dated medical
authorizstion.
This Authorization does not prevent the heal{h care p~vider from supplying billing
and other information' to the first party carrier or medical insurer in order that the
hills are .paid. It does, hoWeVer, prevent the medical provider from supplying this
inf0m~ation to a third party insurance.a~Juster or an' adjuster for an adverse party.
i also authorize ny attorneys or their delegate to photograph my person while I a~
pre~ent in any hospitai.
I agree that a photostatic oopy ok this authorization shall be ~o~sidere~ as effective
and valid as the original.
· 101~O'lOO
Test Results ("" f · rage
F '[-'- SPECIALTY LABORATORIES
Il'--' S~ta M~ioa, ~ 90404-3900 Fax 310'828'~4
Holy Spirit Hospital
ATTN: Laboratory
503 N. 21st Street
Camp Hills,PA 17011
I'el / Fax:717 763-2941 / 717 763 2947
iAge-DOB: 111-10/'5/'998
Patient ID: {[415427
'{[M.D. Jerome L.
Physician: ][Korinchak
Date:Collection II9/15/00 6:31:00 pM
Accession #
0915K27-OUTll 098-5197029
{)ate:
Result Status: ][Complete I
Date: Reported 119/20/00 l:l,:00 AM pST
Comments:
LEAD WHOLE BLOOD
Analyte Il Result II
Specimen Ilyen°us Il
Lead Whole Blood 1149.5' Il
Reference Range
< 10.0 mcg/dL
REFERENCE RANGES for Lead Whole Blood:
Age Reference Range Alert
< 15 years old < 10.0 mcg/dL > 20 mcg/dL
15 years and older < 10.0 mc~dL > 30 mcg/dI
OSHA Industrial Alert -- > 40 mcg/dL
Lead Whole Blood: Confirmed by repeat analysis,
This test result or one or more of its components was developed
and its performance characteristics determined by Specialty
Laboratories. It has not been cleared or approved by the U.S.
Food and Drug Administration. The FDA has determined that such
clearance or approval is not necessary.
James 8. Pelec M.D.. Ph.D,
Page 1 of 1
....... ,~ ,-.,,~n~o/~ *,*~;qa1447.htm 9121/2000
SPECIAL'I'Y [.ABO TORIES
2211 Michigan Avenue Phone 800~421 ~7110
Santa Monico, CA90404-3900 Fax 310 828 6634
Holy Spirit Hospital
ATTN: Laboratory
503 N. 21st Street
Camp Hills,PA 17011
Tel / Fax:717 763-2941 / 717 763 2947
Patient: ][COOMBS,KAYLA J
Patient ID: ][415427 __
]IM.D. Jerome L.
Physician: ][Korinchak
Date:C°llecti°n ][9m004:49:00?M
CncntII Specialty Accession #
Accession #
II
090?ras,0trrlt 098-5130644
Received
Da~: ~D~00 3:57:00 ~M PST
Result Status: JJComplete
Reported ] 9/11/00 2:47:00 AM
Date: ] PST
Report
Comments: ] J
LEAD WHOLE BLOOD
Analyte II Resu. IIRefe,'eneeRa,,ge
Specimen IlVenous II
Lead Whole Blood l142a. · Il < lo.o mcg/dL
REFERENCE RANGES for Lead Whole Blood:
Age Reference Range Alert
< 15 years old < 10.0 mcg/dL > 20 mcg/dL
15 years and older < I0.0 mcg/dL > 30 mcg/dL
OSHA Industrial Alert .... > 40 meg/dL
Lead Whole Blood: Confirmed by repeat analysis.
This test result or one or more of its components was developed
and its performance characteristics determined by Specialty
Laboratories. It has not been cleared or approved by the U.S.
Food and Drug Administration. The FDA has determined that such
clearance or approval is not necessary.
James B. Peter, M,D.. Ph.D.
Page 1 of 1
http://ww~v.datapassportmd.com/Files/17r25541615.htm 9/11/2000
UN DATE~
UN TIME: -1229
I~.~ ,~RTMEN'[ OF LABORATORY MEDIC'[NE{'."
~ENSON S.P. SNAMIDOBB N.D.., OIF T0R
~**~*DISCHARGE
'ATIENT: COOMBS~KAYLA d ACCT ~: 0000156472?0 LOC~ OP R~8 U #: 415427
AGE/SX: 1Y llM/F NOON: EEO: 09/15/00
:ES DR: KORZNCHAK~JEROME L MD STATUS: RES CLI BED: DIS:
REFERENCE LAB TESTINE~
LEAD,BLOOD
~a te T I me
)9/15/00 lB3? (a)
~OTES.' (a) SEE SEPARATE REPORT
* denotes PANIC val~e
Patient: COOMBS,KAYLA d Age/Sex~ 1Y llM/F Acct#O00015647290 Unit~41~427
~U~ DALE: lg/1,~/uk~ ......
gUN TIME: 1229
B. .~RTMENT DF LABOR~T8R¥ MEDICINE(','
ST' ENSON S.P. SNAMIDOSS M.D., DIRi OR
*****DISCHARGE
~TIENT= COOMBS,KAYLA J ACCT $: 000015603962 l. OC: OP REG U ~: 415427
AGE/SX: 1Y iOM/F ROOM= REG: 09/07/00
DR: KORINCHAI(,dEROME L MD STATUS: REG CLI BED: DIS:
REFERENCE LAB TESTING
LEAD,BLOOD
)ate Time
)9/07/00 1649 (a)
~OTES: (a) SEE SEPARATE REPORT
* denotes PANIC value
~a~ient: COOMBB,~AYLA d Age/Se~: tY IOM/F Ac,:~000015603962 Uni~415427
PINNACLE HEALTH
POLYCLINIC HOSPITAL
CHILDHOOD LEAD POISONING PREVENTION CENTER
2601 NORTH THIRD STREET
HARRISBURG, PENNSYLVANIA 17110
(717) 782-2884 or 1-800-374-7114
TO:
FROM:
DATE:
RE:
Krista Coombs
~(Karen Orlando, RN
Public Health Nurse
September 22, 2000
Environmental inspection for lead-based paint
Enclosed is a copy of the environmental inspection for your child, Kayla Coombs.
If you have any questions regarding this inspection please do not hesitate to call me.
Thank you. ' '
Enclosures (3)
This program is partially funded through a contract with the Pennsylvania Department of Health.
LEAD PAINT INSPECTION REPORT
REPORT NUMBER:
INSPECTION FOR:
09121100 1t :27
Kayla Coombs
pERFORMED AT:
116 S. 3rd Street
Apt #1
Lemoyne, PA 17043
INSPECTION DATE:
INSTRUMENT TYPE:
09121100
RMD
MODEL LPA-t
XRF TYPE ANALYZE
Serial Number:. - 1528
ACTION LEVEL: 1.0 mglcm=..
OPERATOR LICENSE: 000510
PINNACLE HEALTH
POLYCLINIC HOSPITAL
CHILDHOOD LEAD POISONING PREVENTION CENTER
2601 NORTH THIRD STREET
HARRISBURG, PENNSYLVANIA 17110
(717) 782-284 or 1-800-374-7114
Date:
Owner:.
Address:
Re:
September 22, 2000
Kerry Saintz
· 731 Harrisburg Pike
Dillsburg, PA 17019
Lead-based paint inspection at 11'6 South 3rd Street, Apartment 1
Lemoyne PA 17043
Dear Mr. Saintz:
As owner of the above named property, you ara hereby advised that a child who
lives 'at or 'frequently visits the above named address is being followed for an
unacceptab!y high blood lead level. An environmental investigation was conducted at
the above named addrass and ravealed the' presence of lead-based paint hazards..
EnClosed is the raport of the inspection. The detailed report has the' r~iings
segregated first by room number and then' by type of structure with the exterio[ ro0ms.
appearing first.* This*rep°rt is for your reference and shows all araas tested.. A P (poor)
under paint condition designated a defective surface (chipping, peeling, cracked). An I
(Intact) indicated the surface is not a hazard at the present time. The areas positive
and intact are not an immediate hazard, but would be hazardous if the surface should
fall into disrapair or if the surface is disturbed during renovation Work.
· The summary rePort is organized exactly like the detailed rap0rt, however, only
readings or averaged sets that have a lead value that is equal or greater than the action
leVel are listed. A lead hazard constitutes painted surfaces that contain lead greater
than or equal to 1.0 izg/crn2 and are in disrepair,. (chipping, peeling, cracked or
blistering), even if the leaded layer(s) does nol constitute the top layer(s) of paint. The
areas listed in this summary raport with a paint condition of (P) must be corrected.
As painted surface's age, lead-based paint becomes brittle and produces, chips
and fine dust particles that ara easily picked up on childran's fingers. Due to the normal
hand to mouth activity' of small children, this leaded dust is ingested. Exposure of young
children to lead can result in developmental delays, attention deficit disorder, learning
disabilities, mental retardation and in extreme cases death. The only way to prevent
and treat lead poisoning is to eliminate the child's intake of lead by reducing the lead
hazard in his/her environment.
Prior to undertaking any actions to achieve a lead safe environment it is
necessary to read the enclosure "LEAD BASED PAINT: HAZARD REDUCTION
GUIDELINES".
Our goal is to assist families of children with lead poisoning in their efforts to
reduce the lead hazards in their environment. Through our education efforts and your
cooperation in correcting the lead hazards in the child's home environment we can
reduce the risks of lead poisoning for these children. If you have any questions or
concerns please call the Childhood Lead Poisoning Prevention Center at (717) 782-
2884 or 1-800-374-7114.
Sincerely,
Karen Orlando, RN
Public Health Nurse
Cumberland County Housing Authority
kemoyne'C°des Enforcement officer
Child's Physician
Cumberland County State Health Center
Family
Enclosures: (6)
This program is partially funded through a contract with the Pennsylvania Department of Health.
DETAILED REPORT OF LEAD PAINT INSPECTION FOR: Kayla Coombs
I~spection Date:*
Report Date:
Aba, t~ement Level:
Rep(Srt
Total Readings:
Job Started:
Job Finished:
09/21/0~
9122/2000
1.0
09/21/00 11:27
135
09/21100 11:27
09/21/00 12:56
Reading
No. Wall Structure
Location Member
116 S, 3rd Street
Apt #1
Lemoyne, PA 17043
Paint Lead
Cond Substrate Color (mglcm=) Mode
Exterior Room 001 Front Porch
005 C Door ' L£t
004 C Door
006 C Door
008 C Door Rgt
009 C Door Rgt
010 C Door Rgt
007 C Threshold
011 C Threshold Rgt
Con~mnt: Readingl's 8-11 are
that she and the child do sit on the £ront steps, and the
access to tho dogr. The front porch overheng~is noted as
and peeling white paint. Unable to test viththeXRFdue
Rgt
Rgt easing
U Cfr
L£t casing
U Ctr
the entrance to house #
Wood White 1.8 QM
Wood White 2.0 QM
Wood Green 1.2 QM
Wood White. 1.6 Q~f
wood ~nite 3.5 QM
Wood ~hite 1.4 'QM
Wood Green 3.7 QM
Wood Green 0.1 QM
114. Mom states
~hild does have
having chipping
to the height.
Exterior Roma 002 Side Porch
069 B Door Cfr ~t easing I Wood
070 B Door Ctr U Cfr P Wood
071 B Threshold Ctr P Wood
072 D Window Lft Rgt easing Z Wood
white 1.3 ~4
white 1.4 ~
Grey 2.7 QM
white >9.9 QM
Interior Room 001 Liv~ngP~
030 A Window Ct= ~t ~..h P Wood
031 A Window Ctr Rgt ~..h P Wood
024 A Window Ctr Rgt casing P Wood
026 A Window Cfr Sash Z Wood
027 A Window Ctr Well P Wood
White 1.3 QM
White 1.4 QM
Beige -0.1' ..QM
Beige 0.0 QM
White 1.'0 QM
028 A Window Ctr Well P Wood
029 A Window Cfr Well P' Wood
White 1.0 QM
White 0.2
A~erage - 0.6 ' '
025 A Window Cfr Sill
032 A Window Ctr Part. bead
013 A Door Rgt Rgb easing
012 A Door Rgt Lft oes4ng
014 A Door Rgt U Cfr
016 C Door Lft Rgb ~h .
015 C Door Lft Rgt c&s~ng
017 C Door L~t U Ctr
018 C Door Cfr Lft oas~ng
019 C Door Cfr U
021 C Door Rgt
020 C Door- ~ ~t ~s~ng
022 C Door ~t U C~
03~ D Wall U Cfr
023 D Balo~d C~
034 D ~or Lft ~t ~sing
C~nt: ha~ngs f 34 ~d 35 are for ~ ontr~ce
~o
Wood Beige -0.1 QM
Wood White 0.6 ~
Wood Beige -0.1 ~M
Wood Beige ~0.1 ~M
Wood Green 0.1 QM
Wood Beige -0.2 ~M
Wood Beige -0.1 ~M
Wood Be/ge -0.1 ~M
Wood Beige -0.1' ~
Wood Beige -0.1 ~M
Wood Beige 1.3 9H
Wood Beige -0.1 QM
Wood Beige 0.2 QM
Plaster Beige 0.3 QM
Wood Beige 0.1 ~M
Wood Beige 0.2 ~M'
wood Beige 0.0 QM
to the dining roma.
DETAILED REPORT OF LEAD PAtti INSPECTION FOR: Kayla Coombs " Paint
Reading
No. 'Wall Structure Location Member Cond Substrata
recommended treatment for the front window is stablization with paint and
-- Lead
Color' (mglcm2) Mode
then the well area covered with aluminum coil stock and then the edges
sealed with caulking.
Interior Room 002 Dining Bm Beige
036 A Window Cfr Beige
038 A Window Ctr White
039 A Window Ctr Beige
037 A Window. Ctr White
043 C Window Ctr
044 C Window Ctr
045 C Window Ctr
Rgt casing I Wood
Bash I Wood
Well I Wood
sill I wood
Rgt ~amb I Wood
Bgt ~.h I Wood
Rgt ~h I Wood
0.0 QM
-0.2 QM
1.o ~M
0.2 ~M
1.0 QM
White 1.0 GM
White 0.4 GM
Average = 0.7
040 C Window Ctr W~11 p Wood White.
041 C Window Ctr well p wood White
Average
0.7
1.0
0.9
042 r C Window Ctr Well p wood White
053 D Baseboard Ctr I Wood Beige
052 D Window Ct= Rgt ~amb p Wood White
048 D Window Cfr sash I Wood Beige
049 O Window
050 D Window
QM
1.0 GM
-0.1 GM
1.4 GM
1.0 GM
Ctr Sash I Wood Beige 1.0 GM
Ct= Bash I Wood Beige 1.0 GM
Average m 1.0
White >9.9 GM
Beige -0.1 QM
Beige -0.1 GM
the [iving
051 D Window Ctr Well p Wood
047 D Window Ctr Bill X Wood
Wood
046 D Window Cfr Lft oas~ng X
C~m~ent: The side windowneeds to receive the-same treatment as
roumwindow.
Interior Room 003 Kitchen -0.1 GM
054 A Dqor Lft Lft ~asing I Wood Beige
055 C Window L~t ~t casing p Wood .Beige -0.1 GM.
056' C Window Lft Bash P Wood Beige 0.0 GM~
057 C Window Lft Bill P Wood Beige -0.2 Qt, f
058 C DOor Rgt Lft casing p Wood Beige -0.1 QM
059 C Door Rgt U Ct~ [ Wood . Beige 0.1 QM
065 D Baseboard Ctr Z WOod Beige -0.1 GM
060 D Door Rgt Lft ~aeing I Wood Beige 0.2 QM
061 D Door l%gt Lft ~''h p Wood Beige 1.0 GM
062 D 'Door Rgt Lft ~amb ~ Wood Beige 1.0 QM
063 D Door Rgt Lft ~mm~ p Wood Beige 1.0 QM
Average - 1.0
064 D Door Rgt U Cfr P Wood Beige >9.9 QM
066 D Cabnt oasg Ct= I Wood Beige 0.0 GM..
067 D cabinet Door Ctr I Wood Beige 0.2 GM'
068 D Cabnt ehlvg Ctr I Wood . Beige -0.1 GM
Co~mnt: Bead~ngs ~55-57 are for them/trot/window above the sink.
Interior Room 004 Ballwa~
073 A DOor Ctr P~t casing I WOod Beige
2
DETAILED REPORT OF LEAD PAINT INSPECTION FOR: Kayla Coombs
Reading - Paint
No. Wall Structure Location Member Cond Suba~ate
074 A Door .Ctr U Ctr P Wood
086 B Door Rgt Rgt ~ P Wood
085 B Door Rgt Lft casing I Wood
087 B Door Rgt U Cfr P Wood
083 C Door Lft Rgt casing I Wood
084 C Door '. L£t U Ctr I Wood
080 C Door Rgt Rgt casing P Wood
081 C Door Rgt L£t ~m~ P Wood
082 C Door Rgt O Ctr I Wood
078 D Door Lft Rgt ~amb P Wood
077 D Door Lft Rgt casing I Wood
079 D Door Lft U Cfr P Wood
075 D Door Rgt Rgt casing I Wood
076 D Door Rgt U Ctr I Wood
Lead
Color' (mglcm=) Mode
Beige -0.1 QM
Beige 0.0 QM
Beige 0.0 QM
Beige 0.1 QM
Beige 0.1 QM
Beige 0.2 QM
Beige 0.2 QM
Beige 0.0 QM
Beige 0.0 QM
Beige 0.1 QM
Beige 0.0 QM
Beige -0.1 QM
Beige 0.2 QM
Beige 0.1 QM
Co~ent: Readings 73-74 are for the door to the Living room. %5-76 are for
the side closet door, 77-79 are for the door to the Master Bedroom, 80-82
are for the door to the bath,83-84 are for the rear closet door, and 85-87
are for the door to Keglers room.
Interior
110 A
093 A
094 A
091 A
090 A
092 A
106 C
Room 00~Bedroom
Baseboard
Door
Door
Closet
Closet
Closet
Window
107 C Window
108 C WindOW
109' C window
102 C' Window
104 C Window
105 C Window.'
103 ' C Window.L
099 C Window
100 C Window
101 - C Window
Ctr p WOod
Rgt ! Wood
Rgt I Wood
Lft P Wood
Lf2 I Wood
Lft Wood
Lft Wood
Lft Wood
Lft Wood
Lft
Lft
Lft
Lft
Lft
Rgt casing
U Ctr·
Door
Door Casing
Door J~m~ I
Rgt casing · 'Z
.Sash
Wall
Si11
Wood
Wood
Wood
P Wood
- I Wood
'p . WOod
p "WOod
P Wood
Beige -0.1 QM
Beige 0.0 QM
Beige -0.1 QM
Beige -0.1 QM
Beige 0.1 QM
Beige 0.1 QM
White ' 1.0 QM
White 1.0 QM
White 1.0 ~M
Average = 1.0
Beige -0.1
Beige -0.1
Beige 0.2
White >9.9
Beig~ -0.2
White 1.0
White 1.0
White 1.0
Average - 1.0
GM.
097 ' C windOW
098 C WindOW'
096 C Window
095 C Window
088 ~D Door·
Rgt Sash
P~t Well
Rgt Sill
Rgt Lft casing
Rgt LEt casing
.Wood
Wood
Wood
Wood
Wood
Beige 0.1 QM
White >9.g GM
'Beige ;0.2 GM '
Beige ' -0.1 GM ;':
:Beige 0.2 GM '
QM ' '
089 D Door Rgt U Cfr .. F Wood Beige -0.1
Comment: Ka~la'e room. Both window tracks and wells need to be atablised
with'paint, the~thewella need to be ooverod with aluminumcoils~ockand
the edges aealed~' ' .
Zntertor Room 006 Bathroom '-
112 A Door Lft Rgt l--h P Wood BaiB~ 0.1 GM
111 A Door Lft Rgt casing I Wood Beige 0.2 QM
.113 A DOOr Lft U Ct= I Wood Beige -0.1 QM
DETAILED REPORT OF LEAD PAINT INSPECTION FOR: Kayla Coombs
Paint Lead
Reading- ' (mglcm=) Mode
No.~ Well Structure Looation Member Cond. Substrata Color ,
115 C w~ndow .Cfr ~t casing I wood Beige 0.0 QM
117 C Window Ctr Sash p Wood Beige 0.1 QM
118 C Windo~ Ctr Well P Wood White 1.6 QM
116 C Window Ctr Sill p Wood Beige 0.0 QM
119 C Window Ctr Part. bead I wood White 2.0 QM
120 C Window . Ctr Lft ~amb p Wood ' White 1.3 QM
114 D Wall O Ctr I Plaster Beige ;0.1 QM
Interior Room 007 Bedroom
124 A Close~ Lft Door I Wood Beige -0.2
123 A Closet Lft Door Casing I Wood Brown 0.2
122 A Closet Rgt Door I wood Beige 0.2
121 A CLoset Rgt Door Casing I Wood Brown 0.2
127 B Baseboard Ctr -I Wood Brown -0.2
125' B Door Lft l%gt casing p Wood Brown 0.2
126 B -Door Lft U Cfr I Wood Beige 0.0
132 C window Ctr Rgt ~m.~ I Wood White 0.8
128 C Window Ctr Rgt casing I Wood Brown 0.0
130 C Window Ctr Sash I Wood Brown -0.2
13~ C Window Ctr Well p Wood White 7.6
129 C Window Cfr Sill P Wood Brow~ 0.2
Calibration
001
002
003
133
134
135
Readings
.... End o£~'eactinga ....
0.8 Std
1.0 std
0.8 Std
0.9 Std
0.6 Std
0.8 Std
4
SUMMARY REPORT OF LEAD PAI~IT INSPECTION FOR: Kayla CoOmbs
Inspection Date:'
Report Date:
' Abatement Level:
Report No.
Total Readings:
Job Started:
Job Finished:
09/21100
9122/2000
1.0
09121/00 11:27
135 Actionable: 35
09/21/00 11:27
09/21100 12:56
Reading
No. Wall Structure Location Member
116 S. 3rd Street
Apt #1
Lemoyne, PA 17043
Paint Lead
Cond Substrata Color (mglcm') Mode
Exterior Room 001 Front Porch
005 C Door Lft Rgt ~,mh p Wood White 1.8 QM
004 C Door L£t Rgt oasing Z wood White 2.0 QM
006 C Door Lft U Cfr' I wood Green 1.2 QM
008 C Door Rgt Rgt jamb P Wood White 1.6 QM
009 C Door Rgt -~ft casing p Wood White 3.5 QM
010 C Door Rgt U Cfr ~ wood White 1.4 QM
007 C Threshold L£t P Wood Green 3.7 O_M
Comment: Readingt~s 8-11 are for the entranoe to house # 114. Mom states
that she and the ohild do sit on the front steps~ and the ohiid does have
aocess to the door. ~he front porch overhang ia noted aa having oh£pping
and peeltng white paint. Unable to test withthexI~due to the height.
Exterior Room 002 Side ~oroh
069 B Door Ctr Rgt oasing ! Wood White 1.3 QM
070 B Door Cfr U Cfr p Wood White 1.4 QM
071 B T'n=eshold Ctr p Wood Gray 2.7 QM
072 D Window Lft Rgt o&sing I Wood White >9.9 QM
Interior p~om 001 Living Rm
030 A Window Cfr Rgt ~*~h p wood White
031 A Window Ctr Rgt fl~m~ p Wood ~nit e
027 A Window Ctr Well p Wood White
021 - C Door - Rgt Rgt ~.m~ p Wood Beige
C~ent: Readings 9 34' and 35 ere for the entranoe .to the dining room.
recommended treatment for ~he front window ia s~lizet£0n with paint and
then the well area covered with aluminum ooil stock and than the edges
sealed with ~aulking.
1.4 QM. . .
1.0 ~
1.3 QM
Interior Room 002 DiningBm
039 A Window ' Ctr Well I Wood White 1.0 .QM
043 C Window Ctr ~t ~=-~ I Wood ~hite 1.0 Q~
042 C Window Cfr Well P Wood White 1.0 QM
052 D Window Ctr Rgt ~mh p Wood White 1.4 QM
048 D Window Ctr Sash I Wood Beige 1:.0 QM
049 D Window Ctr Sash I Wood Beige 1.0 QM
050 D Window Ctr sash I Wood Beige 1.0 QM
Average ~ 1.0
051 D Window Cfr 'Well p Wood White >9.9
Comment: The side window needs to reoeive the same treatment as the living
room window.
Interior Room 003 Kitchen
061 'D Door Itgt Lft. ~-~ P Wood Beige 1.0
062 D Door Rgt Lft jamb P Wood Beige 1.0
063 D Door Rgt Lft ~ P Wood Beige 1.0
SUMMARY REPORT OF LEAD PAINT INSPECTION FOR: Kayla Coombs
Reading · Paint
No., Wall Structure Location Member Cond Substrats
Lead
Color' (mg/cm=) Mode
Average = 1.0 '
064 D Door Rgt U Cfr P Wood Beige >9.9
Comment: Readings ~55-57 are for the mirror/window above the sink.
Interior Room 005 Bedroom
106 C Window Lft Rgt ~amb P Wood White '1.0 QM
107 C Window. Lft Rgt ~em~ p Wood White 1.0 QM
108 C Window Lft Rgt ~m~ P Wood White 1.0 QM
Average = 1.0
105 C Window Lft Well P Wood . White >9.9
099 C Window Rgt Rgt ~amb p Wood White 1.0
100 C Window Rgt Rgt jamb P Wood White 1.0
101 C Window Rgt Rgt ~"~ p Wood White 1.0
Average ~ 1.0
098. C Window ~ Rgt Well 'p Wood White >9.9
Con~aent: Re~la,s room. Both window traok8 a~d wells need to b~ stablized
with paint, then the'wells need to be ooveredwith aluminum coil stock and
the edges se&led.
Interior Room 006 Bathroom
118 C Window Cfr Well P Wood White 1.6 QM
119 C Window Ctr Part. bead I Wood White 2.0 QM
120 C Window Ctr Lft ~m~ P Wood White 1.3 QM
Interior Room O07.Beci~oom :
131 C Window Ctr Well p Wood White 7.6 ~M
Calibration Readings .... g~d of Readings ~2--
~i~,J~ca & Kramer rc Harrisburg, Pennsylvania 17101 Fax 717.232.646 www. srkl~a..w..corn_,
Address : 116 South Thud Street, Ist Floor /
. ~ Lemoyne, pA 17043~
· H~cords Requested : ~ ~~ t~e p,~ese~t.
B~s Requested : ~s from 9I 1/oo ~o ~ne p~=a~. //
De~.Dr. Kor~ch~:
Please be.ad--seal ~at I repre~'bove n~~ease fo~ard copies
of aH records you have kept on ~e conm~on, ~ea~ent, '~d progress of ~is
~di~duE from September 23, 2000 to the present.
Please include copies of all billings from September 1, 2000 to the present.
I have enclosed an executed Medical Authorization for the release of this info[ frzation
to me. I am not at this time requesting any ~pecially prepared medical reports.
If'you have any questions, ple~e i.f.~e!:free to gall-or write.
Very truly yours,
SCHMIDT~ RONCA 8~ KRAMER~-P.C. '
// Attorney at Law., ,': '. ..... . . . ,
GCK/ det
Enclosure
SPIRIT PHYSICIAN S~ 7ICES, INC.
205 GRAND¥1E 'NENUE
SUITE 210
GU 000000594879 CA 5~4870016
COV/AMT SCHM 1
D21 1 GUR 8
-90.00 .00
LINE# DOS SVC CD DESC
TYPE DOE PV DX BPO
21 10/02/00 3501 MEDICAID C/A
10/02/00 077107
BD SUP #RESP PTY 0
22 10/02/00 1501 MEDICAID PAYMENT
10/02/00 077107
o771o7 ~
BD N SUP #RESP PTY 1
24 01/04/01 3501 MEDICAID C/A
01/05/01 077107
BD SUP #RESP PTY 0
KAYLA J 05/24/01 0751
GHILL OFFICE VISIT TOTAL -90.00
BL PV GHILL IQ PV
BATCH# DTL# POS TOT AMT
QTY INV# RESP RESP-TO RESP AMT
87591 30 -25.00
23000470 D21 -25.00
87591 31 -25.00
23000470 D21 -25.00
1397 23 11
30000539 D21 .00
PF1 INQ MENU PF4 RESP PRTY PF7 CS LVL DTLS PF13 PT INV LST PF16 BDEBT TRAN
PF2 GU CA LST PF5 CHGE DTLS PF8 GU LVL PRPY PF14 PAGE BACK *LN#:
PF3 CA PV LST PF6 PYMT DTLS PF9 ADDL FIELD PF15 RETURN *ENTER NXT LN 25
NPARDL00
14679 32 -5.00
30000539 D21 -5.00
DT~'~UMMARY PT: 000000594879
GU 000000594879 CA 594870016
COV/AMT SCHM 1
D21 I GUR 8
-90.00 .00
LINE# DOS SVC CD DESC
TYPE DOE PV DX
COOMBS KAYLA J 05/24/01 0751
GHILL OFFICE VISIT TOTAL -90.00
BL PV GHILL IQ PV
BATCH# DTL#
BPO QTY IN'V# RESP
25 01/04/01 1501 MEDICAID PAYMENT 14679
01/05/01 077107 30000539
BD SUP #RES~ PTY 0
26 01/23/01 99213 EP LEVEL 3 18506
~7237q~ 077107 466.0 I 102600517
BD N SUP #RESP PTY 1
27 03/09/01 3501 MEDICAID C/A 28240
03/09/01 077107 102600517
BD SUP #RESP PTY 0
28 03/09/01 1501 MEDICAID PAYMENT 28240
03/09/01 077107 102600517
BD SUP #RESP PTY 0
POS TOT AMT
RESP-TO RESP AMT
33 -65.00
24 11 ,57,00
D21 .00
34 .-32.00
D21 -32.00
35 -25.00
D21 -25.00
PF1 INQ MENU PF4 RESP PRTY PF7 CS LVL DTLS PF13 PT INV LST PF16 BDEBT TRAN
PF2 GU CA LST PF5 CHGE DTLS PF8 GU LVL PRPY PF14 PAGE BACK *LN#:
PF3 CA PV LST PF6 PYMT DTLS PF9 ADDL FIELD PF15 RETURN *ENTER NXT LN 29
NPARDL00
,'~' DTL,~UMMARY PT: 000000594879
GU 000000594879 CA 594870016
COV/AMT SCriM 1
D21 1 GUR 8
-90.00 .00
LINE~ DOS SVC CD DESC BATCH~ DTL#
TYPE DOE PV DX BPO QTY INV# RESP
29 ./L~L~ 99213 EP LEVE~ 3 'k 30050 1
03/19/01 077107 ~6.~ 1\ 108100692 D21
30 05/09/01 3~0~ MEDiCAiD c/~~ 40947 36
05/10/01 077107'% 1~00692
BD SU~ #RESP PTY 0
3~ 05/09/0~ . 150~'~CA~ ~,~NT ~0947 37
05/10/01 0771o7 -~, lO8~6~2
BD SUP ~P ~Y 0
BD SUP ~RES~PTY ' ''
COOMBS KAYLA J 05/24/01 0751
GHILL OFFICE VISIT TOTAL -90.00
BL PV GHILL IQ PV
POS TOT AMT
RESP-TO11 RESP~
-32,00
-32.00
-25.00
"~25.00
PF1 INQ MENU PF4 RESP PRTY PF7 CS LVL DTLS PF13 PT INV LST ~ PF16 BDEBT TRAN
PF2 GU CA LST PF5 CHGE DTLS PF8 GU LVL PRPY PF14 PAGE BACK *LN#:
PF3 CA PV LST PF6 PYMT DTLS PF9 ADDL FIELD PF15 RETURN *ENTER NXT LN 1
NPARDL00
COOMBS , KAYLA
DETA.~ L OF CURRENT CHARGES, PAY]{ENTS ANI ADJUSTME qTS
.0/25 0264006 001 15.00- 15.00-
CBC & AUTO DIFFERENTIA85025 ~
.0/25 0264006 001 15.00 15.00
CBC & AUTO DIFFERENTIA85025
L0/25 0265107 001 49.00 49.00
CBC & MANUAL DIFF 85023
[0/25 0265394 001 54.00 54.00
COMi REHENSIVE METABOLI80053
BALA~ CE FORWARD 0.00.
SUMMJ/~Y OF CURRENT CHARGES
86 LABORATORY 103.00 103.00
SUB-~'OTAL OF CURR. CHARGES 103.00 103.00
GUD/ RELATIONSHIP: P SEX: F ;UAR NO: 18078544 5
ACC DATE: TYPE: TI~ E: PI~ LCE: ~MPL REL
DIA( NOSIS: 984.9
PINNACLE HLTH HOSP
HARRISBURG, PA
"r~ HILL, PA · 17011BIRTH_DATE ~
,47 763-2141
FEI # 23-1S12747 10/1S/98 ~
RAT,ENT NUMD~R, s, o3e.a SE×/AGEF~aM I AOM'SS'ON O^TE t D'SC"~GE O^TE [ DAYS [ o~o7~o o
GUARANTOR
NAME
AND
ADDRESS
KAYLA E COOMB$
116 S 3RD STREET
LEMOYNE~PA 17043
C.O.B.
1
MED ASSIST OP D~81 014~8188
KORINCHAK~3EROME
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT. PAYMENT $
DATE DESCRIPTION OF I SERVICE TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE EST. COV~GE PAT,
POSTED HOSPITAL SERVICES~ CODE CHARGES INS. CO. NO.1 INS. CO. NO.2 INS. CO. NO.3 INS. CO. NO.4 AMOt
DETA:ZL OF' CURRENT CHARGES~ PAYMENTS AND AD3USTME~ITS
09/07 LEAD LEVEL,BL,G01~510~369 6~.00 62.00
09/0T SPEC COLLECT FE01~:5101031 7.00
BALAI~CE FORUARD 0.00
SUMM.aRY OF CURRENT CHARGES
LABORATORY 300 69. O0 6~. O0
SUB-IOTAL OF CURR. CHARGES 69.00 6:;:'.00 ';
DIAGNOSIS: TgO. 6
. PAYMENT [S DUE UPON RECEIPT OF THIS STATEMENT.
YOU MAY SUBMIT THIS FCRM
TO YOUR INSURANCE CARF ~ER
FOR REIMBURSEMENT.
FEDERAL IDENF. NO? 23-1512747
T 0 T A L S 69.00 6~.00
PATIENT NUMBER I REFER ALL QUESTIONS TO THE PLEASE SEND PAYMENT TO:
~ BUSINESS OFFICE
(717) 763-2138. HOLY SPIRIT HOSPITAL PAY THIS AMOUNT ';
I
HOLY SPIRIT HOSPITAL
CAMP HILL., PA
503 NORTH 21ST STREET
CAMP HILL, PA. 17011-2288
ADDITIONAJ
CHARGES NOT POSTED
OR IF IN~IJRANCE CARRIERS CO
THE AMOUNTS SHOWN UNDER
COVERN3E.
TYPE OF . DATE OF BILL I DATE OF
BILL .. I PREV. SILL
I
A R PATIENT NAME
CO0~BS ,KAYLA 3
''~., HZLL, PA
..7 763-~141
FEZ # ~3-1~1~747
I PATIENT NUMBER SEXI AGE I ADMISBION DATEI
15&47~90 F~3M 09/15/00
1701 !
' BZRTH-DATE
10/15/98
DISCHARGE DATE
GUARANTOR
NAME
AND
ADDRESS
KRZSTA COOMBS
_116 S 3RD STREET
LEMOYNE,PA 17043
INSURANCE COMPANY NAME I GROUP NUMSER I~1~ POLICY NUMBER J
MHD ASSIST OPogsI. 10142:8188
KOR[NCHAK,3ERONE
PLEASE RETURN THIS PORTION WITH YOUR PAYMENT. PAYMENT
DATE DESCRIPTION OF I SERVICE TOTAL EST. COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE PATIE
POSTED HOSPITAL SERVICES CODE CHARGES INS. CO. NO.1 INS.,CO. HO,2 INS. CO. NO.3 INS. CO. NO.4 AMOU
DETA:~L OF CURRENT CHARGES, PAYMENTS ANE AD3USTME~TS
9/1S; LEAD LEVEL,BL,QOI~'SlOP'36g 62.00 62.00
9/15 SPEC COLLECT FE0125101031 T.O0 T
BALAI~CE FORt,JARD O. O0
SUMMARY OF CURRENT CHARGES
LABORATORY 300 69. O0 62. O0 7
SUB-'[OTAL OF CURR. CHARGES 69.00 6p'.O0 7
DZAGNOSIS; V15.86
PAYMENT. ZS DUE UPON RECEIPT OF THIS STAqEMENT.
YOU MAY SUSMZT THZS FCRN
TO YOUR ZNSURANCE CARF ZER
FOR RETMBURSEMENT .
FEDERAL IDENT. NO. ~'~-1512747
T 0 T A L S 69.00 6~..00 '~
PATIENT NUMBERIBUSINESS REFER ALL QUESTIONS TO THE OFFICE PLEASE SEND PAYMENT TO: I
IS&47~90 (717)763-2138. HOLY SPIRIT HOSPITAL PAY THIS AMOUNT ..... .;T
HOLY SPIRIT HOSPITAL
CAMP HZLL, PA
503 NORTH 21ST STREET
CAMP HILL. PA. 17011-2288
ADDITIONAL PATIENT BILLING MAY
CHARGES NOT POSTED WHEN THI~
OR IF INSURANCE CARRIERS DO
THE AMOUNTS SHOWN UNDER
COVERAGE.
8AUDD
CO
GUARANTOR KRISTA COOMBS
NAME 116 S 3RD ST
A,D LEMOYNE PA 17043
ADDRESS
· \
TOTAL
,OSp~=ALSERVICES
D OF CURRENT CHARGES, ENTS
43,00-
D9/21 115071 001
CBC AUTO DiFFERENTIA85025 43.00
09/21 )115071.001
CBC AUTO DIFFERENTIA85025 ?6.00
09/21 115130 001 82728
TIN 55.00
09/21 t116023 001
CBC ·MANUAL DIFF 85023 26.00
09/21 17043 001
LIP: PANEL 80061 68.00
09/21 117060 001
RENI FUNCTION PANEL 80069' 15.00
09/21 266420 001
EXP~ iDED VISIT ' EST T99213 43.00
09/21 266421 001
)ED VISIT ' EST P99213
55.00
09/27 16023 001
CBC l MANUAL DIFF 85023
09/29 t037499 001 262.
SYS( tN MEDICAL ASSIST CONTR
FORWARD
OF CURRENT pAY/ADJ
ADMISSION DATE DISCHARGE DATE
INSURANCE COMPANY NAME
APA
WILLIAMS RONALD
EST. cOVERAGE
INS. CO. NO. ~.
Ar.
43.00
76.00
55.00
26.00
68.00
15.00
43.00
55.00
262
EST. COVERAGE
~3. co~ NO. 2
Ts -
0.00
2 262.00
J
EST. cOVERAGE
POLICY NUMBER
~1428188
EST. COVERAGE pATIENT
SUMMI
~IN~
~R!
OF CURRENT'CHARGES
86 LABORATORY
60 OUTPATZENT VST
OF CURR. CHARGES
;soONDENCE.
PINNACLE HLTH HOSP
280.00 280.00
58.00 58.00
338.00 338.00
MAY BE NECESSARY
FOR ANY CHARGES NOT I?OSTED WHEN THIS BILl.
WAS PREPARED OR IF iNSURANCE CARRIERS DO
NO'r PAY ANY PART OF THE AMOUNTS SHO'NN
UNDER ESTIMATED' INSuR.ANCE COVERAGE.
10/15/00i
8rAUDD
COOMBS ,,KAYLA
PATIENT NUMBER JSE~ AGE J ADMISSION DATE DISCHARGE DA-E DAYS J
429903147 J F! 2 10/03/
POLICY HUMBER
l
GU~,RANTOR KAYLA COOMBS MAP^
NAME 116 S 3RD ST
A,D LEMOYNE PA 1704~
ADDRESS
101428188
VARMA BHUPINDR
j CATE DESCP, IPTION OF SERVICE TOTAL
J EST, COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE PATIENT
HOSPITAL
SERVICES
CODE CHA~GES iNS. CO. NO. I INS. CO. NO. 2 INS. CO. NO. 3 INS. CO. NO. 4 AMOUNT
i0/03 ~116025 001. 55.00
CBCI~,~ MANUAL DIFF 85023
!0/03 ~117041 001 87.00 87.00
COMPREHENSIVE METABOLIC PANE
10/11 ~037499 001 124.00- 124.00- -
SYSG'EN MEDICAL ASSIST CONTR
BALA~.'E FORWARD 0.00
SUMM~Y OF CURRENT PAY/ADJ 124.00- 124.00-
SUMM~Y OF CURRENT CHARGES
86 LABORATORY 142.00 142.00
SUB-3)TAL OF CUER. CHARGES 142.00 142.00
GUA~ RELATIONSHIP P SEX F ,GUAE NO 180785446
ACC ~)ATE TYPE TIME PLACE EMPL RE[
DIAgnOSIS 780.6
;; ~[~ :~'~:':"::;:;~'::.:~::~'..: PLEAS" EFER TO PATIENT ADDTONAL PATIENT BILLING MAY BE NECESSARY J
.... ': :'~.: · .:~-.': .~ ':'.,¥"~:"':?J NUMB~ ~N ALL ~QUI~rES FOR ANY CHARGES NOT POSTED WHEN ~;S 8ILL
AND CORRESPONDENC_. WAS PREPARED OR IF ~NSUR~CE CARRIERS DO
I
~Z9903147
J ............................... PAY THIS AMOUNT 0.l
PINNACLE HLTH HOSP
HARRISBURG, PA
PAY
UNDER ESTIMATED INSURANCE COVERAGE.
POLYCLINIC HOSPITAL
2601 N. 3rd Street
, HarrisbL~g, PA 17110-2098
April 30, 2002
Gerard C. Kramer
Schmidt, Ronca & Kramer PC
209 State Street
Harrisburg, Pennsylvania 17101
PINNACLEHEALTH
RE: Kayla Coombs
Dear Mr. Kramer,
I apologize for the delay in sending you my report regarding Kayla Coombs. Kayla
was referred to the Lead Poisoning Prevention Clinic on September 21,2000. She was 23
months old and had a blood lead level of 42 p.g/dL (micrograms per deciliter). While there is
no threshold for elevated blood lead level, the Centers for Disease Control and Prevention
(CDC) recommends that a venous blood lead level of 10 p.g/dL is abnormal and there are
associated adverse effects.
CDC guidelines recommend that a child with a venous blood level > 20 p.g/dL should
have a complete medical evaluation along with identification and the elimination of
environmental lead sources.
I performed a medical examination of Kayla on September 21, 2000, at the Lead
Clinic located at the Kline Children's and Teen Center. Her physical examination was
unremarkable. Her weight, height, and head circumference were all within normal limits.
Her developmental evaluation also was considered to be within normal limits.
I recommended, based on CDC guidelines, due to her significantly high venous
blood lead level (done on 9/21/00) of 42 p.g/dL she be treated with a recommended oral
chelating agent called Succimer (Chemet) to lower her elevated blood lead level. She was
prescribed vitamins with iron and her mother was provided with nutritional and
environmental counseling.
She was referred to the Infant Development Program for a detailed developmental
evaluation. Rita M. Shell, Ph.D, evaluated Kayla on October 13, 2000 at the age of 24
months. Dr. Shell found no develoPmental delays and no recommendations were made for
intervention services.
Our program instituted a complete environmental evaluation. A copy of that report
may be obtained on request. Follow-up studies revealed that after treatment her venous
blood lead level decreased to 18 ~g/dL (1/1//01). She will be followed every 3-4 months to
maintain non-toxic levels of lead in her blood.
Generally, elevated venous blood lead levels as Iow as 10 p.g/dL have the potential
of causing harmful effects especially to infants and children during the preschool years.
Most investigators report lower IQ scores in lead poisoned children along with poor school
performance and poor job related performance later in life. Maximum detrimental effects of
lead poisoning are associated with elevated blood lead levels in the first 2-3 years of life.
Kayla, however, is performing satisfactorily at the present time. It is recommended
that she have a developmental evaluation done again at school entry to monitor the effects
of the lead poisoning on her learning ability.
If you have any questions please do not hesitate to call me at 717-231- 8494.
Sincerely,
~.K. Varma, M.D.
Director and Chairman of Pediatrics
Medical Director
Childhood Lead Poisoning Prevention Program
?igure 2-1. Lowest observed effect levels of inorganic lead in children*
Death
Encephalopathy
Nephropathy
Frank Anemia
Colic
Hemoglobin Synthesis
Vitamin D Metabolismt-~
Nerve Conduction Velocity~-~,-
Erythrocyte
Vitamin D Metabolism(l)
Developmental Toxicity
iQ
· - .ea~ins.t
Growth ~
Transplacental Transfer
' ~ Increased function ~ Decreased function
:Note: The levels in this diagram do not necessarily indicate the lowest levels at which lead exert~ an effect: These
are the levels at which studies have adequately demonstrated an effect.
~ource: ATSDR, 1990.
Victoria Price
617.725.7051
vprice@onebeacon.com
One Beacon
INSURANCE
December 4, 2001
B Overni ht Mail
Gerard C. Kramer, Esq.
Schmidt, Ronca & Kramer
209 State Street
Harrisburg, PA 17101
Re: Kayla Coombs v. Kerry Saintz
Dear Mr. Kramer:
Pursuant to your request, enclosed please find a copy of policy no. FPLQ 793956,
effective 12/18/99-12/18/00 issued to Kerry 1~ Saintz. As you can see, 116 Third Street
in LeMoyne, Pennsylvania is listed as an insured location. On the second page of the
declarations is a list of the forms which are included on the policy.
Form Gl4011 08 95 is entitled Exclusion - Lead Commination- Pennsylvania.
This form excludes coverage for an "occurrence" at any insured premises which results
in: "bodily injury" arising out of the ingestion of lead in any form. The policy also
contains a limited "buy back" for liabilities arising fxom lead exposure as follows:
G14012 08 95
ADDITIONAL COVERAGE- LEAD CONTAMINATION LIABILITY -
PENNSYLVANIA
This endorsemem modifies the insurance iaovided under the following:
BUSlWESSOWWI. JIS LIABILITY COVERAGE FORM COMI~RCIAL
GENERAL LIABILrFY COVERAGE PART
The following COVERAGE is ~
LEAl) CONTAMINATION
1. Insuring Agreement.
a) We will pay those Suing that the insured becomes legally oblJ~L~l_ to pay as
damages because of '~oodily injmy" arising out of the ingestion, inlm~ion or
absollXion of Icad in any form. We have the fight and duty to defend any "suit"
seekingthese damages. We may at our disc~etiun investigate any-occummce- and
OneBea~on lmurance Group
Boston, MA 02110-2103 P.O. Box 9546
f 617.725.6155 www.onebeacon.com
100 Summer Street, 17th FI. Boston, MA 02205-9546
Gerard C. Kramer, Esq.
December 4, 2001
Page 2
1) The amount we pay for damages is limited as descnq:~:l in item iL LIMITS OF
INSURANCE below; and
2) Our right and duty end when we have used up the applicable limit of insurance
in the payment of judgments, setllements or defense costs incurred by us.
No other obligation or liability to pay sums or perform acts or services is covered
b) This insurance applies to "bodily injury" only if:
1) The "bodily injury" is causedbyan "occurrence" th~_t takes place inthe
"coverage t~tfiiov/"; and
2) The "bodily injmy,, occurs doring the poliey period.
2. Exclusions.
This iusumnce does not apply to:
a) "Bodily injmy" expected or intended from the standpoint of the insured.
b) "Bodily injuof' for which the insured is oblig~__,xl to pay damages by reason of
assumption of liability in a conWaet or agreement.
¢) Anyobligaflonoftheinsoredunderawork~rs~ co~npensahon, disability benefits or
unemploymeut compennvajon law or any ,~imilar law.
d) "Bodily injury" to:
1) An employee of the insured arising out of and in the course of employment by
the insured; or
2) The spouse, child, parent, brother or sist~ of that employee as a consequence of
1) above.
This exclusion applies:
1) Whether the insured may be liable as an employer or in any other Calagity;, and
2) ' '
To any obliganon to share damages with or repay someone else who must gay
e) Any loss, cost or expense arisin4 out of any:
I) Request, demand or order that any in-Ired or others test for, monitor, clean up,
remove, contain, treat, detoxffy or neutralize, or in any way respond to, or
the effects of lead; or
2) Claim °r snit by or on behaff of a governmental authority for damages beeauso
of testing for, monitoring, cleaning up, iemoving oontalning, treat~
B. LIMITSOlVlNSURANCE. The following provisions are addeck
1. The most we will pay for any one "occurrence- for "bodily injuff' resulting from the
mgesaon, mhalst,on, or absorlmon of lead m any form under the coverage provided by
thi.~ endorsement is $50,000. ' ' ' '
you. Legal This hm~ ~S reduced by the legal costs neees:nary to deftgi~d
costs, c°sts are defined as attorney's fees, expensos for nivesO?tlon and court
2. The most we will pay for all "ocourrences" daring the policy period for "bodily injurf'
resulting from the ingestion, inlmlotJon, or ~rl~on ofl~d in any form undgr the
coverage provided by this endorsement is $50,000.
It is this language which limits OneBeaeon's obligation to Mr. Saintz to
$50,000 for defense and indemnity in connection with this claim.
Gerard C. Kramer, Esq.
December 4, 2001
Page 3
If you have any additional questions, please feel bee to call.
Very truly yours,
Victoria S. Price, Esq.
km
enclosure
CONTINGENT FEE AGREEMENT
THIS AGRt~EMENT entered into the 2kt day of (~'~:~.~ ,20 0 \, by
and between SCHMIDT, RONCA & KRAMER, P.C. and KRISTA J. COOMBS
p/n/g of Kayla J. Coombs, of 250 Pleasant View Drive, Etters, Pennsylvania
17319, hereinafter referred to as "Client."
WITNESSETH:
The law fimx of SCHMIDT, RONCA ~ KRAMER, P.C., will act as Client's
attorney [r~ negotiating for a settlement, and in bringing ~ claim against
KERRY SAINTZ and/or anyone else with respect to a potential medical
malpractice claim for complications relating to lead paint incident whiCh
occurred on or about September 1, 2000, in Lemoyne, Cumberland County,
'Pennsylvania. ·
In return, the Client will:
1. Promptly supply accurate infOrmation, as requested by SCHMIDT,
RONCA & KRAMER, P.C., and cooperate fully, including making herself
available for meetings with attorneys and for legal proceedings. Client
promises all information supplied will be truthful and accurate.
2. (a) In any claim brought on Client's behalf, to pay to SCHMIDT,
RONCA & KRAMER, P.C., for its services an amount equal to twenty-five (25%)
of all funds or property accruing to Client as a result of SCHMIDT, RONCA &
KRAMER, P.C.'s services in securing a settlement of these claims without
litigation; an amount equal to thirty-three-and-one-third percent (33-1 ! 3%) of
all funds or property accruing to Client as a result of SCHMIDT, RONCA &
"KRAMER, P.C.'s services in securing a settlement of these claims after a suit
has been filed; and an amount equal to forty percent (40%) if such funds or
property are secured after start of trial or as a result a verdict or judgment.
Trial begins at jury selection. In any matter submitted to arbitration, suit is
filed when the arbitrators are appointed or when a Petition to Appoint
Arbitrators is filed, whichever first occurs. In any matter submitted to
arbitration, trial starts the first day the arbitrators have convened to hear
~ testimony. -
(b) Client agrees not to settle or negotiate the above claim or any
proceedings based thereon.
(c) If Client renominates this Agreement before recovery, Client agrees
that SCHMIDT, RONCA & KRAMER, P.C., shall be entitled to a fee based upon
work done 'and benefit conferred.
{d) Client agrees to read and follow SCHMIDT, RONCA &
KRAMER, P.C.'s "Instructions to Our Clients."
3. Client agrees to reimburse SCHMIDT, RONCA & KRAMER, P.C.,
out of any recovery, in addition to attorneys' fees, all costs and expenses
incurred on Client's behalf in order to make thc claim. All such costs and
expenses will be advanced by SCHMIDT, RONCA & KRAMER, P.C. as they are
incurred. Such costs and expenses include, but are not limited to, filing fees,
cost of medical records, copying costs, fax costs, long distance telephone costs,
expert witness fees and sheriffs service costs. In the event there is no
recovery, the Client will not be responsible for any costs or interest charges.
Costs will be repaid to SCHMIDT, RONCA & KRAMER, P.C., out of any
funds or property collected either by settlement or judgment.
The Client has read and does understand this Agreement.
Signed the day and year set forth above.
WITNESS: Client:
i~TA CO0i~S p/n/g of -~'
· KAYLA COOMBS
Approved:
SCHMIDT, RONCA & KRAMER, P.O.
I have received a copy of this Contingent Fee Agreement.
Initials
VERIFICATION BP-R~:D UPON PERSONAL KNOWLEDGE
AND INFORM~,TION OBTAINED THROUGH COUNSEL
I, KRISTA COOMBS, Individually and as Parent and Natural Guardian of
Kayla Coombs, a minor, verify that I am the Petitioner in the foregoing action and
that the attached Petition is based upon information which has been gathered by
my counsel in the preparation of this lawsuit. The language of the Petition to the
extent that it is based upon information which I have given to my counsel is true
and correct to the best of my knowledge, information and belief. To the extent that
the contents of the Petition is that of counsel, I relied upon counsel making this
Verification.
I understand that intentional false statements herein are subject to the
penalties of 18 Pa.C.S.A. § 4904 relating to unsworn falsifications to authorities.
Date:
KI~STA COOMBS, Individually
and as Parent and Natural
Guardian of Kayla Coombs,
a minor
CERTIFICATE OF SERVICE
ANDNOW, this //.~dayof ~D/~ ,2002, I, Gerard
C. Kramer, Esquire, hereby certify that I have, this day, served a copy of the
PETITION FOR APPROVAL OF COMPROMISE SETTLEMENT AND
DISTRIBUTION OF PROCEEDS FOR KAYLA COOMBS, A MINOR by serving
a copy of the same in the United States mail, postage prepaid, at Harrisburg,
Pennsylvania, addressed to:
Kerry A. Saintz
731 Harrisburg Pike
Dillsburg, PA 17019
Defendant
Victoria S. Price, Esquire
One Beacon Insurance Group
P. O. Box 9546
Boston, MA 02205-9546
Respectfully submitted,
SCHMIDT, RONCA/is KRAMER, P.C.
/6erard C. Kramer
Attorney at Law
Attorney I.D. No. 44715
209 State Street
Harrisburg, PA 17101
(717) 232-6300
Attorney for Plaintiff
IN RE:
KRISTA COOMBS, Individually
and as Parent and Natural
Guardian of KAYLA COOMBS,
a Minor
IN THE COURT OF COMMON
PLEAS CUMBERLAND COUNTY,
PENNSYLVANIA
NO. Oa- 't0%
PETITION FOR APPROVAL OF
MINOR'S SETTLEMENT
HEARING ORDER
ANDNOW, this,/~- dayof .~l~X~ ,2002, IT18
HEREBY ORDERED AND DECREED that a Hearing will be held on the Petition
for ~of Minor's Settlement for Kayla Coombs, a minor, in Courtroom
NopSI ]_.~ef~he Cumberland County Courthouse, One Courthouse Square,
Carlisle, Pennsylvania 1~13 on the ~%ay of ¢/~ J//) '~~
at ~[ ~ o'clock, 4 .m.
IN RE: KRISTA COOMBS,
Individually and as parent and natural
guardian of KAYLA COOMBS, a minor
IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
: 02-4038 CIVIL TERM
ORDER OF COURT
AND NOW, this ~ day of October, 2002, following a hearing, IT IS
ORDERED:
(1) The settlement terms as set forth in the foregoing petition on behalf of
KAYLA COOMBS, a minor, born October 15, 1998, in the lump sum of Fifty
Thousand and no/100 Dollars ($50,000), IS APPROVED.
(2) The funds shall be distributed as follows:
SCHMIDT, RONCA & KRAMER, P.C.
Attorneys fees (25%)
$12,500.00
SCHMIDT, RONCA & KRAMER, P.C.
Costs incurred to date
$ 746.53
COMMONWEALTH OF PENNSYLVANIA,
DEPARTMENT OF PUBLIC WELFARE
Lien
(The lien is $1,024.90. A proportionate
share of attorneys' fees and costs is $823.34)
$ 823.34
VVAYPOINT BANK, Camp Hill Mall, Camp Hill
Pennsylvania 17011 to be deposited
in the name of "Kayla Coombs, a minor, born
October 15, t998":
(a) in certificates of deposit not to exceed
such sums as are fully insured by F.D.I.C.; and
(b) the balance, if any, in a savings account
not to exceed sums as are fully insured with
F.D.I.C.
$35,930.13
TOTAL $50,000.00
Each account shall be marked as follows:
No withdrawals shall be made until the
minor reaches the age of majority except
by an order of a court of competent jurisdiction.
(3) The petitioner may execute a release regarding the $50,000 settlement as
indicated in the petition.
(4) Counsel shall filed proof of compliance with this order on the doc~J~et.
By t ourt,
Edgar B. Baying, J.
Gerard C. Kramer, Esquire
For Petitioner
:sal (~ '
SHERIFF'S RETURN
CASE NO: 2002-04038 p
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
COOMBS KRISTA ET AL
VS
SAINTZ KERRY A
- OUT OF COUNTY
R. Thomas Kline Sheriff or Deputy Sheriff who being
duly sworn according to law, says, that he made a diligent search and
and inquiry for the within named DEFENDANT , to wit:
SAINTZ KERRY A
but was unable to locate Him
deputized the sheriff of YORK
serve the within WRIT OF SUMMONS
in his bailiwick.
County,
He therefore
Pennsylvania,
to
On Se t~ 10th , 2002
attached return from YORK
Sheriff,s Costs:
Docketing 18.00
Out of County 9.00
Surcharge 10.00
Dep York County 37.52
.00
-74.52
SO answers~
~. Thomas Kline
Sheriff of Cumberland County
this 2~ ~ day of
~-L~ A.D.
Prothonotar~
this office was in receipt of the
09/10/2002
SCHMIDT RONCA KARMER
Sworn and subscribed to before me
COUNTY OF YORK
OFFICE OF THE SHERIFF SE.V,C CALL
(717) 771-9601
28 EAST MARKET ST., YORK, PA 17401
SHERIFF SERVICE I INSTRUCTIONS
PROCESS RECEIPT and AFFIDAVIT OF RETURN I PLEASE TYPE ONLY LINE I THRU 12
DO NOT DETACH ANY GOPIE$
1 pLAiNTIFF/S/ /2 COURT NUMBER 02--6038 Z:~iVt.1
Krista Coombs parent & natural guardian of ~ ~
3. DEFENDANT/S/ Ka~ ~¢~V~T~ OR COMPLAINT
Kerry A. Saintz I Writ of SLr~nons
SERVE 5 NAME OF INDIVIDUAL, COMPANY~ CORPORATION, ETC. TO SERVE OR DESCRIPTION OF PROPERTY TO BE LEVIED, A~FACHED, OR SOLD.
Kerry A. Saintz
6 ADDRESS (STREET OR RFO WITH BOX NUMBER, APT. NO, ClT~, BORO,/WR, STATE AND ZIP CODE)
AT 731 Harrisbur9 Pike Dillsburq, PA 17019
7 INDICATE SERVICE: ~ PERSONAL Q PERSON iN CHARGE ~ DEPUTIZE ~¢~¢~T.~.~.L~.~ Q 1ST CLASS MAIL L~ POSTED 'J OTHER
NOW August 26 ,20 02 I, SHERIFF Q-F'%iii~O-UNTY, PA, do hereby deputize the sheriff of
York COUNTY to execute thi%.Wd~nd~'~ake return tJ;ic~ccording
to law. This deputization being made at the request and r sk of the plaintiff.
ADVANCED FEE PAID BY ATTY.,
OUT g}: COUNTY
CUMBERLAND
NOTE: ONLY APPLICAeLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN Any depu[7 sheriff levying upon or attaching any properfy under within writ may leave same
without a watchman, in custody of whomever is found in possession, after notifying person of levy or attachment, without liability on the part of such deputy or the sheriff to any plaintiff
herein for any loss, destruction, or removal of any property before sheriffs sale thereof
9 TYPE NAME and ADDRESS of A~FORNEY / ORIGINATOR and SIGNATURE 10. TELEPHONE NUMBER 11. DATE FILED
SCHMIDT, RONCA & KRAMER 209 STATE ST. HARRISBURG,PA 17101 232-6300 8-26-02
12. SEND NOTICE OF SERVICE COPY TO NAME AND ADDRESS BELOW: (This area must be completed if notice is to be mailed).
CUMBERLAND CO. SHERIFF
SPACE BELOW FOR USE OF THE SHERIFF -- DO NOT WRITE BELOW THIS LINE
13. lacknowledgereceiptonhewdt R~ AHRBNS
or o~mplaint as indicated above /
16. HOW SERVED: PERSONAL (~ RESIDENCE ( )
/ 14 8 D 2AT_~ _R~)C2EIVED 159-25-02Expirati°n/Hearing Date
POSTED( ) POE(~)/ SHERIFF'SOFFICE( ) OTHER( ) SEE REMARKS BELOW
17. LJ I hereby certify and return a NOT FOUND because I am unable to locate the individual, company, etc. name above. (See remarks below.)
.18,~NAME AND TITLE O.~.[NDIVlDUAJ.~RV~E.P L ST AJ3~IR~,~HERE IF NOT~HOWr~-r~VE (Relations~l~ to Defendant) 19. &ti of S~ioe120 T~me of Service.
2J. A~S ~me~ Date ~m~iles Int [Date '~me Miles Int. ~ ~me Miles Int. Date ~me ~ I,, [D'te ~me' Miles Iht
/
/
22 REMARKS:
23. Adva.ce Costs 18.00 17.52
24. Service Costs 25 N/F 26. Mileage
100.00
34. Foreign County Costs
1 35. Advance Co~s I 3B. Ser~'~ Cesta
41. AFFIRMED and subscribed to before me this 4
42. day of SFPTFNIRFI~
28 Sub Total 30. Notary 31. Surchg 32 Tot. Costs
35.52 2.00 37.52
Mileage/Posted/Not Found I 39 Total Costs
47t DATE
Foreign J 49 DATE
County Sheriff
51 DATE RECEIVED
1. WHITE - Issuing Authority 2. PINK - Attorney 3. CANARY - Sheriffs O~ce 4 BLUE Sheriffs Office
COUNTY OF YORK
OFFICE OF THE SHERIFF s .v,cEc,LL
(717) 771-9601
28 EAST MARKET ST., YORK, PA 17401
SHERIFF SERVICE INSTRUCTIONS
PROCESS RECEIPT and AFFIDAVIT OF RETURN PLEASE TYPE ONLY LINE 1 THRU 12
DO NOT DETACH ANY COPIES
Krist:a Coombs parent & natuz:a.I guar,4~ar~ cf "~
Ke'~y A. SaJntz Writ (:f
SERVE ~ 5 NAME OF INDIVIDUAL, COMPANY, CORPO~TION, ETC. TO SERVE OR DESCRIPTION OF PROPERTY TO BE LEVIED, A~ACHED, OR SOLD
t
Kerry A. S~tz
6 ADDRESS (STREET OR RFC WITH BOX NUMBE~ APT NO., CIIM BORO, ~P., STATE AND ZIP CODE)
AT 731 H~%~i,sburg Pike DJllsb~.]r~r PA 17019
7. iNDICATE SERVICE: LJ PERSONAL LJ PERSON IN CHARGE X~J DEPUTIZE ~..C~.[~.~,I~L,.~d 'J 1ST CLASS MAIL 'J POSTED LJ OTHER
NOW Auqus! 25 ,20 02 I, SHERIFF~OF'J ~UNTY, PA, dco.,hereby deputize the sheriff of
~'~ r L'~ ~ COUNTY~to e~ecute this V',Jr-[t,ar¢ ~al~e.return the~ceC-~cording
to law. This deputization being made at the request and r sk of the plaintiff. '¢;'~ ..'::/;:~'~'"~.~*~
SHERIFF
8 SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE: ~'}~}_~% ] ~.rfd
ODI OF COUNTY
CUMBERLAND
ADVANCED FEE PAiD ~B ATTY,,
NOTE: ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN - Any deputy sheriff levying upon or attaching any broperty under within writ may leave same
without a watchman, in custody of whomever is found in possession, aEer notifying person of levy or attachment, without liability on the part of such deputy er the sheriff to any plaintiff
herein for any loss, destruction~ or removal of any property befoFe sheriffs sale thereof
9 TYPE NAME aDdADDRESSofATrORNEY/OR~GINATORandSIGNATURE 10 TELEPHONE NUMBER 11.o_,Lb_t)~DATE FILED
SCHMIDT, RONCA & KRAMER 209 STATE ST. tiARRISBURG,PA 17101 232-5300 "' °- '
12 SEND NOTICE OF SERVICE COPY TO NAME AND ADDRESS BELOW: (This area must be completed if notice is to be mailed)
CUMBERLAND CO. SHERIFF
SPACE BELOW FOR USE OF THE SHERIFF -- DO NOT WRITE BELOW THIS LINE
13 lacknowledgereceiptofthewdt ~, A~S ' / i4 DATE RECEIVED 15 Expiration/HearingDate
or complaint as indicated above ~/ 8- 27- fl 2 9 ~ ~ 6- 0 Z
/
16. HOWSERVED: PERSONAL(~.~ RESIDENCE( ) POSTED( ) POE(~,,)~ SHERIFF'SOFFICE( ) OTHER( ) SEE REMARKS BELOW
17. LI I hereby certi~ and return a NOT FOUND because I am una~)le to locate the individual, company, etc name above (See remarks below.)
~18~NAMEANDTITLEOF~INDIVIDUALSI~ RVED/blSTA[;~R~:S~HEREIFNOT.~iHOW~'BOVE(Relations~:)toDefendant) I 19 .~teofS~rvice I 20. TimeofService
2~ ATTEMPTS Da~e ]~}~ef~f~l I.t Date Tim~-Mil& Int. [Date '~me Mil~s Int/D¢ ~me Miles Int Date ~me ~es%l~t.~D~te ~e' Miles Int
25 Adva~ce~ 00 o 0~C°s~s 24. l~00Service Costs gS. N/E 2~.].~ · ~Mileage
I3 Advahce C°sts I 36' Service C°sts
34. Foreign County Cgsts 5.
41. AFFIRMED and~§ubscdbed to before me this ,~
28 Sub Total 30. Notary
38 Mileage/Posted/Not Found
31. Surchg 32 Tot Costs 33 Costs Due or Refund Check NO
37.52 g2.4g
39 Total Costs [ 40 Costs Dueor R~fund
County Sheriff
49 DATE
51. DATE RECEIVED
3 CANARY - Sheriffs Office* 4 BLUE - Sheriffs Office
, ~. 1.WHITE Issuing Authori~ 2. PINK- Attorney
IN RE: KRISTA COOMBS, Individually
and as Parent and Natural
Guardian of KAYLA COOMBS,
a Minor
IN THE COURT OF COMMON
PLEAS CUMBERLAND COUNTY~
PENNSYLVANIA
NO. 02-4038 2002
Pi~ITITION FOR APPROVAL OF
MINOR'S SETTLEMENT
PROOF OF COMPLIANCE WITH COURT ORDER
ANDNOW, this~/~-- dayof /~-/~CE//~/~,---~,2002, attached for filing
is a copy of a letter dated November 29, 2002, from Barbara M. Conklin, Branch
Sales Manager of Waypoint Bank verifying that the restricted account has been
opened for Kayla Coombs, a minor, in accordance with the Order signed by Judge
Edgar B. Bayley on October 1, 2002.
Also attached for filing is a copy of a letter dated November 20, 2002, from
Margaret L. Sohn, Claims Investigation Agent, Department of Public Welfare
acknowledging payment of the lien in full.
Respectfully submitted,
SCHMIDT~ RONCA/k KRAMER~ P.C.
BY //'/ ~
,~A,~,trard C. Kramer
orney at Law
Attorney ll.D. No. 44715
209 State Street
Harrisburg, PA 17101
(717) 232-6300
SCHMIDT RONCA & KRAMER
GEP~ARD C KRAMER ESQUIRE
209 STATE STREET
HARRISBURG PA 17101
PC
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
TPL SECTION CASUALTY UNIT
PO BOX 8486
HARRISBURG, PA 17105-8486
November 20, 2002
Re: KAYLA COOMBS (minor)
CIS #: 710142818
Incident Date: 09/01/2000
Dear Attorney Kramer:
This is to acknowledge receipt of payment in the amount of $823.$4
regarding the above-referenced individual.
Your cooperation in this matter is appreciated..
Sincerely,
Margaret L. Sohn
Claims Investigation Agent
717-772-6609
717-705-8150 FAX
LOOK FOR US. WE'LL GET YOU THERE.
November 29, 2002
Gerard C. Kramer, Esq.
Schmidt, Rouca & Kramer PC
209 State Street
Harrisburg, PA 17101
Dear Mr. Kramer,
Thank you for bringing the Kayla Coombs account to our attention. Per our conversation, we
contacted Connie lntrieri, Kayla's grandmother, received your check from her in the amount of
$35,930.13, and delivered the Certificate of Deposit to Connie in the name of: Krista J. Coombs
Trustee for Kayla J. Coombs. We asked to ascertain that Krista understands that no monies
should be withdrawn until Kayla's 18th birthday, according to your instruction.
We have placed a note on the account stating that "Funds are no~I to be released until Kayla
reaches age 18 (10/l 5/I 6) per court order."
We at Waypoint Bank appreciate the opportunitY to handle this arrangement for your client. If
you have any questions, do not hesitate to contact me.
Regards,
~bara M. Conklin
Brancb Sales Manager/Waypoint Bank
RO. Box 171 I, HARRISBURG. PENNSYLVANIA 17~05-1711
Toll FrEe 1-866-WAYPOINT (I-866-929-7646) · ww~:wagpointbank.com