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~ .s 0- ? :3 o c... p If) .- o ( "'" ~ d - ()o - ('f) o Z "j; .... , .. ~ ,I:. , · ,. ~ _ t. j LAW OFFICES JOHNSON, DUFFIE, STEW AI\ T (/ WEIDNER . I 301 Mork.. Sit... P. 0, BOI t09 Lcmofne, PenNftvlnll 11043.0109 .;.... t 5 1S9~1'" Tetephone (itt) 7611(54Q Teltcopt.. (717) 76M015 .. ,. #" -.... ". 'f-o~\ "' ,(11-':" , t~" '.'11 , ~;lu_; --- 'l,~t j-1 ;~,-l~ 41 IS, NJ ~. Z 91l/1lr " \ i i 006774.001271JlJIIll6,199&ICIIWISU'144311 . . 6. As a result of said motor vehicle eccident. Timothy S. Disbrow suffered mild headaches and lelt sided stiffness of the neck and sharp pain when trying to tlUn his head. 6. On September 15. 1994, Timothy S. Disbrow was soen for said complaints at the Dunham Army Hospital Clinic at the Carlislo Barracks and troated os reflocted In the chronological record 01 medical care, which is attached hereto, incorporated by reference heroin and marked as E~hlbit A. 7. Therealter, Timothy S. Disbrow did not require any further lormal medical cere or treatment. but treated for any symptoms by taking Motrin. 8. Any symptoms attributed to the September 14. 1994 accident abated by January or February of this year. 9. At the time of the accident, Martin E. POiper was insured undar a policy of automobila liability Insurance through Ponnland Insurance Company, 10. Pennland Insurance Company has agreod to settle any and ali claims arising out of any liability on the part of its insurad, which It has donied, by payment to Timothy S. Disbrow of the sum of $1,000,00. 11. Timothy S. Disbrow has not incurred any legal a~pensos as a rosult 01 this accident, his claim or its settlement. and tho e~ponso of this proceoding is being paid by Pennland Insurance Company, 12, Neither Timothy S. Disbrow, or his parents. have incurred any out of pockat e~panse. for medical care and the like as a result of this accident. his dalln or Its sattloment. 13. Douglas C. and Susan E. Disbrow believe that tho sattlemont JlroJlosod I. lair and ralSonable for Timothy S. Disbrow under tho circumstances. I - HIH,,~,.........tll , HEALTH RECORD DATE - . ~I - ,\ ~~ ) ,J) I ,,,,,,",,t' I CA I "'. '.''''''' c r . lIllO.l'lI ~ - CHRONOLOGICAL RECORD OF MEDICAL CARE SYMPTOMS DIAGNOSIS TREATMENT TREATING ORGANIZATION 1St' n IICh In! J J:d"'I!'l'C 1 It&> ;0. cut'( "".'ld.h.ll.....J""<..l..4.."z.J...)o APPOINi.\1EI!T ClINIC PI' ( t ').-_-H..$ k W.- ;~v('llXc ;0'\ I~\.\JA p~ S-\-".,ks <Cl sicLcl oC r"'LL~.'s -/-:+(:. ,..-, ( <ot,S- - ,- I c.. DAHC ~~. 'I ~ -",y- o ...... "....~ r ~ ~. ~ ~J ~J c.., /;'IA~ .:=<....:1 CuN. +t...J- ' -<-y- ;' . v /-Cc.. I . . G 6 ? L . . (,,..,~ fI. ~ z - /.I /) // ~-, ";,,/'f" . / jJl/.-tIS ,l,F& ')"'1) ".' ,1') toJ '_W J....-/ ~+ ~ ~-o ",,}-/i.... II) 0 ,nl "'v--' ,:; 13' '/ "",,-a .H... ~ / '/ d...~ r:, '" G jJ.' ,/'-0 ....,......... c J. ;-?( ~.... }r- 7!a' i' , I _ to vii I~ )Zt.tI 1- 0:1 Jd.:,... , \'. '^-"'1 ('- C<.--" 1,/, A<-z=. 6'[' oR'E(REQUA 00 573.Jr.2468 RICORDI ~ MAINTAINED AT. ATlE T' N (f. "', .u.. ""Hall SEX RELA IONSHI OS ON 0 H ANK/a A 0 OJ au 40 7740 C : ~ ~ :, J ,I, T: i'': T M Y S 1l7,::j::~ ~ t~ RET ~'~HC I'J'~! ').':L~~ ;':":"'r"'''' .....,"'.,.J'. 4. . . .I .. \ nc:" , . ., .'. ;4.... NOR'S N o " I' . : 1.. ~ 7 : : . _.' -:;.Cl'tRQN]:1t'OGICAl RECORD OF MEDICAL CARE STANDARD FORM 600 IAEV, "'" P,."crClI" 1:1 as... .IN' leMA flnJ,4fl '''1 CF=1 :')1-15 ~v5 )...J ,1.0 ~ 00\ TE S\\lI'Ti ',OI,\GNOSIS, TF1E,II~IENT, TREIITINGQ' VlIlAT10NIS'VnWh,nrry) -- _..--~- M'"~ "I'" "-', (\, II. .::1 ~ I ,...,~' . 0 :','.;" """.._ np _-!-l1'-1j C g~ (\ I (\ ., f\ \}-l..J <( t.rrO:. ~-::;nl:;'78 \\~V ~ . I ~ I _\ ' .L~-"'f~::::-"'-'-'-~ l\J T- _LIl. \~:' v.. LL\.U 'A -t-~~r' ,\\1\ _____. ,.' 5 19! : lY'\(\-\:' lL..I...o. ~Pc. ~ ~ )\Ltt\CJ\. I~ I --r- -----: (I'.l~'~ __J_,ht4.1I1...--1~'-'---I.Y-f.I~bL-_-... 0'14" L'~"~ P' 1-~1- .1j1 I ,\, 'J, ;,',", h ./L.~'".' 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Ie Mill I1E'.~ '~- . - ~ ': "lcaROI UAINTAINID AT' "AM f IOEC 0 "J '1;\~4 R U\ H' o iTA U5 ANK/GA " " 0, H OJ Ob? 40 7710 C:S:i?A, T1H.;TH( S J ns n02 1 C'I F.ET ~fHC -"l~CT :J:~Ll5 ': SOR'S M ,~ :..... .....:,.......:.:- -....... srM'OARD FORM 600 (REV, ...., p'"cr'te!l tv GSA 'r'l11 'CW", Flnl.l~ \~I CFFlI21)1~4~ !OS , : 1 : - J . I,'" -" '+ : ; : - e 7 I 5 CHRONOLOOICAL RECORD OF MEDICAL CARE DATE ~Y~IPlr ~,UIA(jNOSI:; TilE.\!.\IE'.T rnloITlNG0' 1111ZATIl)f/lS'9nmh,ntry! _ d. 1I _ljll Ie '1wuut1-A_-_2i~CL1-=-~~~~- 7;=-~Z-...-- ---Mihlll' tII~elm --(..;, () '-I}J.I./l.~ _O!i01..L~_ _____ OAH_~~ws.PA 170~~_ n ,___________,_____________ _________ ..::2..-~_~ tV _~___J~t___ _.0/_.J&_ 4QrJ, Lc... bjt! ~f:Ll!d __P N.w_e./L_ -I@A"3'j:-{fJ-(d,~ Y:i-'_~"'r9. '-kJJue.;; -~ ~.._. -I- C-. - _______ax:.~_Ldl:.L~_S!.~~(-(.~ (~b'J~L_______, II ""1::../- I .--.--"-- --------------~.._-- hCl.J:j - t<-i_){u1Y~!)~ 0(7) I1p,!-;/tJ - /J.('t U,)10 ;(~ e(-euo.."k. ,uc::,7- __ ,. ~Zr.t-L5 -, Jt--L{ p/!- r .----., HDSrITAL AND CLINIC IDENTIFICATION TELEl'HOfIIE MEDICAL AOVIJ:ElCONSULTATlON II ECOIl 0 ... of form. _ AR .ao.u: pi ~.."t .. Ofr_ af The Su'llOft 0.,..1 OAOANIZATION OF PATIENrlSPOhSOR FMp 03 O"IA fOACE BENEFICIARY CAtEOOAY :J.. AD oOI.N.O Oft" U10E.N AEf OOTHI,. (SpwfJ, 'ATlENT STATUI DATI AND TIME OF CALL 0 ~ ", , e l1!IPtL 9 IN.'TlENT OUTPATIENT 0'1'-' fTT 0 NON,E"E OENey · "A~Y ""dUde ramplatlll, dYI"OfIl. ItUtnulioN to ""'.."11 ~, 1- rrJ...il.U'l- ';:.10 ~;-,u :.Ji1<LL~ . . " v:.t j ....... _I: ... ;, o OHN AEf/OEeo OI"EAOENey ~ 'J ;- dc', S'E. LlLdlv..l /I lLo~n ; OCHICK IF CONTINUED ON AEVIASI IIQNATUftE OF ....UICIANlCA... '..OVIO'.. A ~",:, 5008 \ VI.OG\IWM"IenI Pi'V',,~,&tli~ '"1_ ]!lCf! ~ 51 ANOARO FORM 100 BACt( jRI 'I. '.Hl L \DEe 0 6. . . . , I H rItOOG-62.....171 I HEAL T1f RECORD ( '-, , (, tJ CHRONOLOGICAL RECORD OF MEDICAL CARE ,';~ SPACE AVAILABLE ~. ~.' , APPOINlMOIT ell ,~ -,"; " I ~'R , 8 m~ DAHC, CBKS, PA 17013.50J3 rtlr....Jr_~~.,..r~,J I ,,~'Uf't~ I -tc:::.'1....F 0<13'- ,3 n'h I' ~""./.I!... "..- '/ 1~P> 7 " AGE I s A-'-. ALlERGIES: N \<..A ~ n, ',) c f..r'Cu !lANCY lESCH "b-SJJ8 " I 'm,"n" I I" lIu, 'PK' 0', _cA.,u". I;EC'D eel) J.A . ~"":'~.'r.. , I, '"r, IUCORO' MAIHTAINID AT' lItll1." Ote 0 6 ,qat. OJ ObO 40 77~'J . , , . . ) 1,.1,.. ~. TI~Grhl' S i17~:712 .t FIt ~r~ ~!HC ,/ o E~A 10 HI T o NKI VTC1Imii CHRONOLOGICAL RECORD OF "'IDICAL CARE .. I'J T : J ': L i j : STANOARO FORM 100 I"IV, ,.." Pf"l;rbltd ty aSA Ind leMA F,RI.4A l.l (FRI iOl-U!C!i . ~ ,': ~'~1 ~ e : : 5 -~+.._~......- 'O(}..IlJI ~L. .' H HIH "~-<r--A)..L...IU' HEALTH RECORD DATE .. 100-10\ CHRONOLOGICAL RECORD OF MEDICAL CARE SYMPTOMS DIAGNOSIS TREATMENT TREATING ORGANIZATION ISign Hch InIry! SPACE AVAILABLE G (-PP IV/< on APPOINTMEfH (;lINIC l(oj 0, / ,., - "114\(\'i ;1~ , , r ';:J l , ~ . ~r-rS'I'''ute. q,,~/a r/< [;- W1 c;- ,'" ... -rPR.. q .7- Z3 - SP rl)') 1(. ;e.> , ... ',vt ;'2. ,h..., c I I Imp""', DAHC. CIIIS. PA 17013.5003 --1- CP ~ ~(~c.>>T. Q.vJ\ J I'^--\ - r-J SA. t T~ ..,..-.,. / SP-ActAVAI APPOltmlENT ClINIC i . I 40("<;,'/ 5tZs7? c-ve... ~>!J""'ct: ~O ~t: ,J-l~ Y Del., (1.1. ._..____.._ ._.4 AHC, '- 188.28-48D8 PA.C ......... f .f I .p,", or .ehMlrf "ICaRD' MAINTAINID AT' DEe 0 6 1994 A NT'S NA'" ( I, ,,,,, d Ut'"",' , A L.A ONSHI 05 ON 0 ITA US 03 0&0 40 7740 " , . n, I) II T I HOT H Y 5 ~\;;1)70~ ~ Fn R[T USHC ..c'- -I)'JGL~S C '~'~I," "'I..r ~.l()-e7,1j . . 1 ~ .. f ." ~ .. -, lOR'S N '. VI " . --~ .....--. ~ ~ ~.-- CHRONOLOGICAL AECOADOF MEDICAL CARE STANOARD FORM 100 (REV, 1.10' pfltcnt.(J by OSA ,"d leMA ~IRI"'J1 ,~ I ;.':-D, 2f)1..4~ !11!J NBN 7540-00-13'-""8 " CHRONOLOGICAL RECORD OF MEDICAL CARE OATE SYMPTOMS, OIAGNOSIS, TREATMENT, TREATING ORGANIZAnON (Sign flch .ntryl Orthupedlo c~ :.:munltv Hu;pHlU O!lI'l1tt Army U"i~20ilQ__- Fort Bslvoh',. ' --MAL13 19 1 800.108 !k-. /tl,'1l ,1"1-tW t'? ~d? ~, ~ I~J.':.' , 'Je. c......... .~'. ~ ;,':1.1 R r-'-':!.u-...J ,..rr (~_...... -~- '" (2.1P\;.~f -~- -~~ ..uxt4.., .:t4J~~ kt..e. ~..u'~ ~__~ QV..U .1y ld. : ~.". ~'-.J 5' ~W- -;--~;t.1 ~ . , T~ ~. ~~ MlT' ~ a.N>'V\... Q:) c:./..;6.11\..e ..kL. ~ ~ -fn- -1~ c-l~ en.. L...tu..~ ~ ~ ~ ~ aJ..-€.. .:tu- 1~~~ ~ ~ ~vL d{-f ~ /1'b- J.wr-~ ~ II A {l,(IL 'I I /l~ '. 1.;1- . ' -, C1 I L__"'" . I.... ;.) 1;lS'/~ 3 I ?{-<jr-~J..:. I I I I .d1-cw- c: F" Ro 1--\ Q .villI I'~ c: ~~ ..t.dM1/4. ~ . ' A 8. IfJ1- J,.a:tzd k tv x. ALU @),ill'(j().,r C ~:dt.<it, B:: (' crtt4a.L-I I ~ GOO-;? #-6"0 -i-Po-rI'U e-_~ l( 1~ , f2Lv 2~ ~ c;.r 4A.d /~~ DR. LYNN A. CORNEUUS D.O. a:5D-JJ SEX tI! PATlENfS IOENflFICAnOt4 d.'u tAw .pau fur ,VItAIUIICIII Im",,,u AECORDB 'MAINTAINED AU P"'TIENTJS NAME ll.cu.. 1'11'1" .\faddu untl/lU (""~:-lr'l ., ~ I ,... '\ r';~~',. ""C'l1r 1'1'8 . .~ oS": r p ~',.1 r,. I ~ "0 AEL.4I'ONSHIP TO BPONSOR RANK/ORADE 5, SON t 02' SPONSOR S "'ME ORQANIZA TlON ~. -.. .- ,. . '. ~ J.. .... ~P'AT.5Ei1V1ci-16S"iiDEmmCAtlON NO ~ !'i... .__ CIiRONOLOOICAL RECORD OP MEDICAL CAR~ / S TANOAAD FORM BOO ,".. I,'" P'fttr:be<t tI~ OSA 1M tC"'R F!f\Mn /4' CFF~, :01 ~.S !~5 0.... TE OF BI'HH ~.' OF!' , , " ......J . ~.., I. ~&'... . ._~ . --_.._._.._..~~--------,_._-~ 111-101 ~ ~ NSN 7540.01.011.1116 EMERGENCY CARE AND TREATMENT (M.diell RfCordl l U "0) AAfHVAL ,.ur.tl'l ('lilY ,"'0101" .",," OATE n PllIVATE D AMBULANCE HI) ~ L!:..:J VEHICLE .J) --\ ci'.- 0'-..., DaH'ER".."", ....,.1, H U slAflON ,elt)', 51..., "". "del )(/';1- ,I, ~\, lIt' I-\:::." (i',\ "';', ''\ . .- r l:HIEF.... COMPLAlNT,SI f "rlwd'. .')'mpr:,"uI. iol"",'UJ'" 1",< .... ...... I '\', \\., \.1 ,... II .. CI I d."", u ).d H DpATlENT D~~H~ f~"ftl'''' C u . ""."101' IIn,""'" , llllllon lInd 0'"" d41.' \., ., , I i A" ..) H R5 H "C'. IIrYlI CO " -,' (;I \ " '. ,,," .' YES ONO PATIENT'S COpy tNOr/CE TO PA TIENT. PLEASE FOL LOW PHYSICIAN'S INSTRUCr/ONS AS STA TED BELOW) " I '. . PATIENT'S IOENTIfI'ICATION f,U,ch.rlll'" ImprllltJ liGNA U OF PROVIDER A 10 IT P 'OR WAr,TTEN ENTRIU alvEI N.'", .1." {I"" mll,rllli b . "N; DO . """leI ".'1.11, "11mI' '"1 rrf4l1q" 0Ijpn"'0'_9' "fd r I' I . A , .f"" ',IIP1IRT.\NT, LIITFAC LfTYHOLfJ,NOTRUT, ' "'ENT II!'COHOI ,," ,. ....' t IN U T aNI TO A IE t nctl.t , In, JI"" .' \).... pI "" " ".t;J /, ~ .". ~ / ~ ~ f - .)r.P -I Jf( I.~... I( ~ ../ c: /" (.,!' ./' ('. / /,(,.."/ PO""'r "r /"/" / In c. -!/'/< /.,;1 .;, / II ,,,. '11" Iim,t.lIo'" .11" fdUow~p PZ'J - t- ,_ I', I' '.' 114 -( I ,. ~.. .If -- .' J _ ), \ -... '\ ..., 1,"'" ~........v. ...' l "._ - \ ~, \ '1...(,1,. "/1, -, ", 'I, ., ); I -/.. I , , ,~, ~ I ok DEL 0 " EMERGU'CY CARE AND TREATMENT UANOARO FORM &Sa C.ov, ,,111 P"HIlt." Dy 115'" .nIlICMR FP~R 1"1 CFJ1110l.U.IOI" '- '-;':J OATE 'PTOMS, OIAGNOSIS. TREATMENT. TREATING C INIZATlON IS,gn ..Ch .nrry) . ~ LC.....t. " "'-- !.... . , . ' 17:" I:=- ...i:..b. '~. .... . ., ";-... ~. .t"o. '1:1 ~ ~ 1 11, "1, '~~C\D'CCO'~ ., t::.. .-- DEe ry ( ,,~~j . . . STANOARO FORM 100 eACK (REV, e.1l41 . ,HEAL lH RECORD OATE CHRONOLOGICAL RECOHD OF MEDICAL CARE SYMPTOMS, DIAGNOSIS, TREATMENT, TREATING ORGANIZATION (SiQn '~h .n,ryl ~OO.\CIJ NSN 1s.40-00-aJ.t....l 78 HO$PIT AL AND CLINIC IDENTIFICATION NAME IIMr. 'ln',"1I /1Jsbree-v; wno fIn" UN Of PATIENT/SPON TION OF 'ATlEtH. MEDICAL SOR Al ORD OCENTRAL FILEI AREA 03 ()6o-l(~ 1T't~THEAjS,,,,,,, ERVICE A'PtUATION OAA"Y ONAVY rx;AAINE COAI'S OAIA FOACE OOTHEA _,,1>1 P'...-.. ~ TlLEPtlONE MIDICAL ADVICE/CONSULTATION RECORD For ... of 'DIm. _ Aft _, _nom b om.. of Tho S_ 0....' ORO...NIZATION OF 'ATlENT/SPONSOR fM' DllTI AND TIME Of CALL BENEFI~~_~TEQORY AD ~N AD OAIT ODE.N AET OOTH.A ISP<</I't, 'ATIENT STATUS D'NPATlENT ~TPATIENT o NON,...EAO.NCY o D..N AET/D'CD O....AO.NCY L I L- .u......" Y f/Ml",," to,"p&oi,,'. d.."'O..... INtrVtfla'" '0 IN....." M~t /{p lu -z,1 "- SIONATUftE OF PHYSICIANJCARE pROVI OCHECK If CONTINUED ON REVEASE I'~-<" (o- DA FORIl OCT" 5008 PATlENrs IDENTIFICATION rL'" lhu 'pllt, for .ll,dlllflltlll RECORDS /r"P""U MAINT .INEO A' PATlENJS NAME fUu," fin," .\lWJl. lIuualJ S'X .&: C'PAATJSEAVlCE I SSNilCENTIFICA TIOH NO RANK/GRACE n':l nhn~o 11 ~O 78 I 74~1 GlseRQ.. TIMOTHY S. SOH 19'8 M AD u511t l 8 OOuG..'R'~-~'l..lD2' PEV. TI!JNSHIP TO SPONSOR ... \ ~ '- OPGAN.Z,.\liON SPON.S-9R 5 NAM' . .-" ... I O"'EOF eIRT'~-~ 'JE~ .) 6 :9Q4 CHRONOLOGICAL RECORD OF MEDICAL CARE STANDARD FOAM 600 'h ... p',w'ttd tv as" ..no leMA FIF\~A 141 CFj:!i lOl.,iI ~'$ NaN 1s.&O-OO.It~-.., fa ,.... HEALTH RECORD CATE - ~.- ----- --- N.....' / ~ I. MJ/ T.LEPHONE o. J.~ ~ ?r'/-7y~-.'J SSH OF 'ATIIHTI$PON LOCATION OF 'ATlENTS MEDICAL. SOft RECORD DCENTRAL. fiLES AREA V 3 0 _ _"'< - 77 "c OOTHEA /.p...17I (RVICI AFflLtATlOH a"A"Y ON"VY D....AIN. tOAI'S O..,A FOAtE OOTHIR ~fr' \ I , , , j I TE\.EPHONI MEDICA\. ,AllVlCEICllNS\lL T A nON IIIC1lIlD ,.. _ of _, _ All _...--' II Olfloo at T110 _ a.... "'.... ATION of rATIENTISI'ONlOR flU' L l 1 Hoar' TAL ,AND CLINIC IDINTlflCATION ~ r-J.'-'~ IENlflCIARY CATEGORY ..0 ISID.,N..D DAIT OOE'N A.T OOTHER fSporihl 'ATIENT nATUS D,H...TlENT DOVll'..nEHT o NO......IAOEHCY o DE.H AET/DEtO OUOEAOEHCY ;-.. 1 .~_c'-' I i t T 1 r j T ! "\ I ~f' L, -r.~L..... /' J ,L..J:.-~/' J ..J - .,...., - ~ ,~', c~ -da~HG.~1 l.:';. __t~'..-.t' , . .::: /:'-1 d~''''p...'L'--^, , /: .d..~t..:_, "..,-f"\ ~ OCHICK I' co SIGNAN". Of PHYSICIAN/CARE '''OVIDtA N AE.VE.... OA ~, 5008 flAtlENrs IOlNftf'IC....TlON It'" tAli .pdt' lor .lltrJhllUcd ...COADI ,,",,,,"11 MAIHTAIHID PA fliNTS NAME tl..ul., Fi"'" .UuUl. ,"LlwUJ BtX 1I1L-'110H&H'P TO SPONSOR AANKlGAAOE REC'l'l,",i"1') ,.4 SPONIORI NA..I ORQAHIZA nON OEe 0 6 19q4 OI.AM/SlAVICE pSNJiQiNriFiCAllOH HO CHRONOLOGICAL RECORO OF MEDICAL CARE lOATH OF BIATH BTANOARO FORM SOO ,Of' ,-,,, P'UCI'DU bv alA 11'10 ICMR FIAMA III CF~1201.U 105 (M.dl(" Rf(OtdJ ., ......yUIN, VA, A 0". .105"'1 L CU . j _ " ("'"oe" co,.. ."fOwt, ,hull IllIfhHt ond ulh,' d.'., ~~~~~ 0 AMf1ULANCE OTHER fS,Jfrlf,' "'""'"11''' ... I OPATlENT tu ....1 5 ((A (,I"" O",O(lJ'l 11/- t(~) .cz AAFl/VAL OA TE 1M N H V , 8'1 11 '-I ~ .5 N 'S HQM A H S 0 DU 5 .,"~. :)'.1' ,,"Ii .. ;).~S(.. -J) f.-I~r.b (2,fti1)0r\ . CHIEF COMPLAINTtSlll"tl14,J, H",phII't1U', ""rdIUMII a fu :"s. U a~ VITAL 'IGfl$ l.lJiJ" ... TIME UP PUL.SE RESP, TEMP" Wf.(CIulIJ CA TEGOR Y is.. ".un" I EMERGENT AGEP"n NON,URGENT o YES 0 NO DESCRIBE 11. "'wu'u", dl110 ,r"M_"r 1I1"UrYI,12' O~Jun&lf d.,o TIME SEEN BY PR~DE" ,rtlll't1,"otlOR' j,.rlud_ ""611" o( I,,,, "nil. IOn;, Ill.6"'''''''''' (010'"0' ~ "U. '4' !I.II (Trwatrn,""l'rQr,dll"" I"dud' m,dlt.rld" ,,"" o"d (ollow-uPI c;/ C .. /3; 1l1, tJ . h.cJ}.. CLL-ir {J~ )("2: ~S'~ a.-t t~ ~~ 'i~ ~ e eSa<3 eClllv e ~~~. Ot. Lvi) ( ~)Cl~ OUARTERS U Hrt, a, HI'\. 1'2 Hr\. MODIFIED DUTY UNTIL D!\Y ON H V r ~ IV'A-f) &K - ~ J.... ~ 7vL ~ fJ.."f{3 fvo ~ '[. VCv~ , ~ C1r>r . B1.-G- TOD'"'Y ROUTI....E ,u I I VI :PUc~ ~~~ PRovED DETERIORATED TIME OF RELEASEI PATIENT'S IDENTIFICATION I,\IttflQI'lltolll"P"Mt/ FOR WRITTEN ENTRIES GIVE; SO""" f4Jr, "'It, m,dJI,; Sl"':' DOB. ,,,""1ft .tauu "H'Y o'l'it1!fdlllJ,IIN ~S'u~",.r " .h., tI."PORTrt.'"r LlSW("HP""OUO.1 Tu,.\r .\ E.,'r It!CORDJ , l.l (",} P-"L D,'s6zow) II""'" .H.t D;J-O!..O-4,:,-?-9<{v c,(u1-. J:61 ~,) :D.s I 1M) f1F:.~.e; ,,'f '\v~ U,< t1 ',T I .."iDEC 0 :.=....'!F'.,-\ UI":l--.,Jh l'! v ''',I ~ &n~~ ~ EMERGENCY CARE AND TREATMENT STANDARD FORM 5581REv" fpill P,,,o,CelJ b~ GSA ,""leMR F,nW~j"CFFll:01.4' !~ ""'.tu....t "~Q,d CdP~ . .. . . 1. -'" .. bu..nlll\"1 .-.,,,,, aut oU.I,CIIO:I__. CLINICAL RECORD Report ~n' j'JJ6brCJtU,' ~11~CJr;j,? conllnuatl~~ 01 s. F. \ .L)"sff" 's".,. oul 0"" ',n_1 (Splel/, ",0. 01 ,uminll.on 0' ch'.. , cc: ,,~'.. '"..:,; '., -': (Si,nandd"') '. 37: /I'f Iv mak.. (J)tlq waft2/U11.j MV/6,l.D-n ..tadUl f,t!U;; ~ ClIncl .tY(JUU."/let'C/ a. 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A'~ ~c~ 141 loti II /' r q'Y3D,~"r' 4.~ c2 O,l:, 1)(" .)'Ul1t;,JOL..J.O()~ (}XI<. - /1.O(.,ma.J' ~9 Okm4 ni.C L6 (J J I EAG. /(a:/z, 1 S- PI( - Ii./ /Ill aJ{.'.J Pve' i I'lttlid "-M11t.l 'tr,pId, (ll1d .1./ Ill-l- / pre!" ~~. ~./11 M1 6- c{) (cllf.fflr~l?'n rdl'.lfi'r'~9n ~/"np "ATI.....'. UJItNrlf'CAfION I or IrP.llI 0' .."".n .nlI'f" .... ,".lfn, i,lI. tltll. mIrto/I,. ,ud.; dill', 110'1""'0' ""Il,uf "",,,,) , AlGIITI." NO. I WARD NO , " or CONIINUATlON Of , , ." ....,..~!:'~ I . urORl ON AEC'D ac,") 01': /~) ,---~j ttllllltJnrd .'orrn aM U.IU~ ,""en ,..."1111."..... l'IIUU"C'O-.'fllIP' _"'CU'IUII' ".""dlU'-' =:",.1' "II '.~.\)Il DEe Q ,:J ':J! . . '. . . ,}-& ~ xif>>k! z /2..' S1fu' tulw Idt V-ILR dJe! 41~dcl & ()tLuwed t7fX( /lLjIL! r JI/W a.-(.J~~mIM. e./ ,ata-lid (}<tt c?mlt.C<.-n ty' ~ ./LmuL/.a./ Mc,J bL1:,-0 .. Va WU1 jJa-c.eILG tu-k cUdl rllJ..f tuaJt.f ;tIlL c!ltifJd IIdnu...tbLI . I '-(AU; ~{lJ Al.taiid Yo /h, $u.~' tuk .&I&Fc/ ~i1 i t,0Q.f.&. It?..id /Jed {1lc/~YoJY' 12t, /.{ r -4 . tu,ad t!~'?!.kt!.Iic/ tVJtCL (3/(e; /<XU de<U.1.d-ec-1. M.J11 acU1U.J.<Ub7V tLJa..() 1Ut-/ tlh<~Lddy'-- m!U<JC2l't kl 144aJ VA; vutd ,,&ul<dd i:u. Ale,] ,en f2c1ttzJice (la,cb.o!ol/ M1 M<TJ1C:lay. /}..u IU,-w. ,-eua.li,1 )It? JIll.' fJa~?J.d) tuA~ fI!J- ~a..f Wlt$! tk~!(lc/ IUd Ittk jL(/JUI # 1<7JJ? U/1/t-k. JIb ~ r-o IJ)R/}fL/{!, Iky tlYu J:-~'Y;11 a t!tmaLdI ~ PeeL; tULL- ct/1cf r;tliC aI~l..l.d' lUll! 6~ ~ ~ laiA, a a&1U1 a/ flu! &-I<G COlli fu .di-?tl Yi:J tt.Jj2.-fl-;t./{!.' I( r:T 11-/' {!adka<l tuA-klflllJ1ICL f<-t.;9/;('(,,t.f.; j?//C!- Clu,d jJcujv - ~~ &xv'ottlumdta/ en ~a..I;d . fo a..-t.J'f Yh In /CL- . pI a.:J al'-t"t.I.{:' ~<7 {)Ji,~ RE"t' -,', "", . .loJ ~~~r~t(.li.~~~l H,~c IDEe 05 I ::'ll ~ . . 8LMnllnnl t'urm '01 . t. ~ . . , .U..,o.o:t____ . - , CLINICAL RECORD R.pGfI.m l)j"~);rc)I.l). 71.1"nOtJ..),? /g-- co"t1nuatl:~ 01 S, F. :-'lS IS".., 0'" flit' I,,,., ISpfC,l, lIP' 01 ft.lm,"",.," 01 d.,., ....- _ (Si," And dar.) p /1'1 Iv /1'uJL (JXLJ IlICI Ie;/u,i'f ./dttl/5Urn, ,/tU..lu.l /fit!.,) we)'~ CIII? d .J-Y(JtLU'fli!.1JC/ tl ,dl> a,~. :J ~'rJ fJtlttl wAt-tA tl-'tItJ a.wtVf j.Ll.idd.j i 'f1iJ.n #1 If IJu"'tp 1/t.1i'~ jJai?l, /;W/:t' ~d ~h <=L Me! ~'f'<z:1 and dutJ.-6c/ n~l. 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ILl AI.J aM fJvc'~ /'l(),td "-<J~.l1le I-rll.>b.tJ t1"J "IIIi'- j pt/~' ,4/1-"~up, Ale:. I) ,(,.-11 (. r:{) cebhll,{,h'~" ,.>4I''t'~17J :s I--r , p .....TlIN' 1101.,..TI'II;" rlON I'Q' 'r/"~ Dr ..,'U,". ,"".., ;... .""m'-Ie... lUll, muldl'. ".d.. ...,. II.,,,,t.,., ""..IoUllu",fY>> 1 "IOIITI... NO. I W.....ONO urORl ON II CONTlHUllION OF AEI' ~....O al.4 Ifl!lull ",,' fu,", ,or 'I'I",U"""".".IIIII.O_'" '.'fUII'e' ct"UIU H _1t,cnIICO'O, "."".1'"" OC'''I''II' 1:"7.!,)!l DEe 0 6 199~ . , . .. '-0..;; M.' - . . . xf;~l" c .0. , -S~~l ' IU/W !dl- ,/-,fp eIt de.! 4lW(.Jd b, i...t'-./.L.lv!?d fWe..1o'u./(,j /en Ilk a.t..~fhmlt'l4. J ,ala.iid {#f.1 &''7lftIAl tt/ s<<, -UIlLU.LIa/ APed bed:;; ~() (L/:.t jJa-ttn:6 (ul..{J dUll /W.I {04AV fJ..J.L diPd ddnt~1iTd, '!i~u tt-C(J dl.Iaticl ;J~ ,:21 $~u to4-0 ,.dL'rfjcd;c1 ~J'1 t()c.t.li:1..- IJ~d /~c,I (0..{c!i/o . /4, ,I..;'; r 4- u,<&.1 tZ.nJaIlEd 0'he! E I::G <<.JCU c4.:,,:,~,tJt.,?r l/~ ../d.I OcLnu.4..LI.&Tl..J tL-'c,l() IW-/ a..61i<}-,!t.dtIy2 /LC~./..Jau. 4J tMcd ~ ~ulcI filu.<U!d bf .dff.ll ,(./) l:rc!ttf..t0... &.clw/~f/ 01~ 1?b,c/cu-::/. /Au kt...J- ,altUid >0 #U' ;PW..uLtJ tljJ~.idr 1lAcu' WU:y Jtw c/ ;uJ kJ&. 1/ /)l/ 'If /-C?-rJ u0-:./(. ;0 j;-O fa ()/~ f) II-Ie /~I tOCu 'i,.~'f;1/7 a f!g?Z0.2LLef *, ~ci:J , I ~. M<.L- an::! Cl41' dtJd IVil1 b .4h.n rd.I)' ~, (j Mio..V g/ ;/ltl' C I<G CUll! 1.1.1' ~rll ~1 f/-i"C:!t/L/{!, /i/ ~tud( at! . t'uJI/IUl'I',c<. jJA-cP/;c<-t-1.; /'t/(! cl.;:1.-I ;XUIL- - J1~r)iL~ &'ll106It,v-;1dla..1 07 ~cJ;d n', a/..i...4yJ/AmICL ;?/ 0) _ /..........' .. I t{. u..,'.' ..,.. ~ .;/;J,v&l ()lJ,I/.! REI"1l oeo .-11 DEe 0 6 1994 .. 1 6el( - l(.rt /' I ()'{ r . . ., . MEDICAL RECORD CONSULTATION SHEET ftEOUIIT FROM; 'Jrlf~'IIlIl"'~"'''''.''~'''''~ '11 0"1 c' ll(~UU' ~:; cf! /" ~ IJ- Iv - Ji) /,'17 ", -- C"""o'''/v..r~''r 70 C'--1- r C'" I <:' @ ".. ~:- .., 10 4c:,,/ /"ccf Jive /r.'~", ..c '1'<.'/0 ..k/A~.r..J"" +- /~7 - 2 o<:'~vll 1"+- y<l ~ rr::cc:;r,rcr-/ Aottrd }... ~ t'd Ie:' / ./f1 t. -;, -r- ...-/~f''''<:''- '!"'t-/;;:'" re- - p~I()~Al OIAOMJ5.5 \l9 ~"rI ~"f"E""" , " f t}c.c.. /.,c /-...... c:'/C1 /'>1 C ,P "'kit d DOCTOA5SIQ,....'Ufl.E APPRG..EO frl-<241'.tYf:'O PLA":E ':;' CCI6l..rl.UI,(,)~' lJACu".E a '':C'''' :J8E:SoCE CC"lC~L. C'~ J.OOu C El,IEll;G[~C' 11/ ("'l:" /! CONSUllA liON REPORT 56 ~ r'-tP /?F ~.~ s~r~ ~ 00;0 :;;~ ~~( R~'O oco.w ICltlllllll,,4!111 ,,"',.... Ildt' DAfI . ,1""'011 2 ~ \S~3'\ .IOE""TI'CAfIO,.,....O ~M"'~II"'I.cN r. Illol01$fE"'t" ,"""Ot.lQ , "!!.t.,,f S ,ct,...I,'''...'IC.. ,~" I". , .f', ..... -. ",... 1" \1.,' - 6;" "'1/ _.~,' ",."J'# ,..t4r.~~":"'f"'~' ~. _~',--:l ,r, ': '., '''''fC:~?:'; ~l'l. .,'~ ,. ...~.~.. ~ ..,. V -:, n ~ n.-.nlfO "( ',~) '8' '.~l ',itO OI\IjQI'.. f'.OIH' S. SON 'Q'8" AD USMC f 8 O'J;. A\ 101' CONSUL T A liON SHEET STANDAAD FORM 513 IP" . "1 P'..,:.' tlU r. C;1A. tCl.lA ""VA IO~ IIICI I il] '0' OrthOpodla C~~~~ltY H"e,l'~ po~l\\ ArmY VA 22060 . l\el-nlr. lor- . . e . MEDICAL RECORD REQUEST FOR ADMINISTRATION OF ANESTHESIA AND FOR PERFORMANCE OF OPERATIONS AND OTHER PROCEDURES A, IDENTIfiCATION I OPERA liON OR pR::EtUJ ~41\.....Q 11- 8, STATEMENT Of REQUEST 4LY<- ~..,~ @ ~ /I.l I, C<.AA.. 1. Th. ".IItUfI Ind pur POll of th, OPI'lllo" or prw:edure, pOUlbl. allernlll'1' method' of trutm,n" the "I"'S lnvoh/fld. oInd tn. POU' blllty 01 complications have bun 'uUy upUl"ed to m. I acknowledge Ihll no IU,Jr,nl,n hv. bltn mId. to me conelt"'"llh' '''ullS 01 the operation or procedure. I und."tand thl nalur. of the operation or praclduI. to b. lOirlml-.,...."'....,..,...,.,'....'-.I6f"(W(" L\.l~ ;) .w (,.n \M-'~ ' whiCh I' to te performed bf or under the dUfctlon of 0, 2. I rlquelt the PlnOlmanc. or the Ibov.""am'd OptrJtlon or procedure Ind or luch additional O~I'Jtlon, or proceduru II ate found Ie b. nfcnury or dn.UDle, In thl JUdam."1 01 Ihl p(l)luslonal siaN allhe below n.med mldlul loIclilly, durlni the COUIU of Ihe abo....e n.med ooer,Hlon or procedure. J I reQuell the .Jdmu111lr,llon of luch innlhula as may t:e conlidered necnury or .ld~luble In Ih'ludgment of Ih. profeUIOn.l1 IUH 01 thl tllOW "amed medlc,,1 f.lCdlly. 4. [,c,pllon, to luriery or antslhui,. if .ny, ire: U ~t -'//_./1'''111 I 5. I nquul tne dlspaul by iuthontln of the below.n.med medical 'aclllly 0' .ny tlilun or Pill1S 'Which II ma)' be n'Cllury 1(\ "mov, 6, I underSUnd th.1t photogr.Jphl Ind movln m.ay be taken 0' lhll oper.tlon. Ind th.1 they m.y b. viewed by ,;,arlouI perlonnellsnder 1010& tUlnlng or Indcetnn.llon .1 Ih., or other 'Ielhliu. I canunt 10 the Ukln. 0' such pu;tures .lnd obSlf'\o,Jtlcn 0' Ihe operation by .lU l~o"lId person".I. lutlllet to Ihe lotlowu1. conditions: I. The n.aml of the ~ahent Ind hls/her '.mll)' IS nol used to Identify IIld pieturn. b, Said pictures be used only lor purpos" of medlc.1l/d"nUI Itudy or rUUfch. C, SIONATURES IC",q.., .., pe.u.t.w ....... _.... ."..,....111 If,,......wllll/OlU .. ""U.t .OW , _IU'. ,..,vw kf_ IIf"U"fI 1. COUNSELING PUVSICIAtHOENTlST I h.J';'~ counseled th.I patl.nt tlI to Ihe n.lture of the proposed p'ccedu,,,{sl, .lttend,nl tllks Invol.....ed. and ..p~cted IflullS, n described o1l)O>J' .:.:J.L.t.-{ /! fI""IA~,- () ~ 15'1".IU'. 01 COU"'.""I Potr'.c.,"lo.",,", 2. P~T1ENT' I u"de"t.anlj the n.aturt of the proDOSM prccedure(s), .allend.ant 111"-1 In,;,olved. and e.petted rflulh, n described abo~". Ind h,rew! ' I lueh p,oeedun(I) be plrfolm.d t/,,/ .:l-f~ fjl( I ~:. r to,'. ,"c! T..".. 3.' SPONSOR OR GUA8.CJ,AN: (W n PI lInt I a mln r or unabl. to 1'\/' conllnU I. Iponlor/lu,ard"n of I \ "'-0 ~I #-'" ~ und.r1l1nd thl nature of the plopoud proce"1u'IU), allendlnl fllk, Invol,;,ed. and II peeled rnulll, I dtlCtlbed above. .nd heftby request luch procedur.'I) b. performed, .J ~'hh""". ",1-f,JlI Ir,'J 10.1. '"" T,m, OW.I".,. .,~!u4"1 m,,.,tI,,, 0' oPu.I,", '..ml <<., 'Arlr.~T:J.. t.'Ir....lIO,., ''''t.,,.,........,IrII"''''''..'., ,...,-..UI.'~'II . ~.foJ b 0 40 /7 +"}l" r-"" "'~I~ __.u/Vtll'" ~t&::SE~H. T:M0THY S I ') 7' ) ~ : ~ j . " RE T ~'S II C I WA 0' - , " ' .: I '}- B 7 15 IUNDUD 'O"M IU 1"" '''-''I a,"".lh"',CII 1o'''''"''IIII,on l 1"""Unc.,CO"'''' Il"Vu,rll..co'd. '"l"''' 1.11 e'''1 201.'" let 112.110 'I.. S GO_rwNrl P,ru'iC"'U ~~l_ ~Ilii:!.r.]~~ :1 ') ~ 7 . ,,o, ,t' J . ,I.. ~ J u. ~ ".-. ..~. -''': .~.:. 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".-!.. --~ rtE'C'D ceo .u nfe 0 6 19qi ---------.---..-.--..--...--.....-.......-.--.---...-.......--... . --.---..--..... ~~!~~~~($i..!.. _:~~~~!!!~..~fi..~_~n \h. foiiGltl',; ~'i'I'11 , '-".,..... ,--------------.--.--------- -----------------,--------------------------_._---- "c:t1I' _ &ou"~ If....f 'h~,rl C6l1 I n_l, fi!':--- C-I'," l .~,.... -'.L-U! "" t D!UAGll\lIl'Dl, It Fi~"" ;,; . ., I 1..,/.1 ., 1'1 JI .: . ; ~ ~.' ~':.: .."i7-t - ',~'l' ._u__.__ 11t-401 . r !)(AMINATlONI5l REQUESTED ..!"'- RADIOLOGIC CONSULTATION REQUEST/REPORT IRId/olo /N.d", M"H,in,lUlr1'llovndlComp.rrd To..., phr E.""inltio.,) $E.)( SSN IS"..",..,., WARO/CUNIC 6 " It- AC U1HC PREGNANT DYES, TELEPHONE,.. DE NU. .. "....CIt..,...rD4 C'r V-I REGISTER NO. I, " REQUESTED BY fPn~ y(. ,', \. ,. ')'- .. '.' . SIGNATURE OF REQUESTPR . , .::. .......> ~ .' OATE-REQUilliO <j-p / pelF e REASONIS, FOR RE~UE5A vI;- Md flndln,; j; 'I ;;cf -(wY'-;- .....: ~a- W- ~ ....u>......- - DATE 0 E)(AMINA~)'..' RADIOL-OOIC REPORT DATE OF REPORT (MQnth. dQ', 'I"" ANSCRIPTION, on'''. ,.,.." @) REC'D DCO ~ DEe 0 61991 "'\..: r.::',':( .' ":: ION I or f'tp,d gr..nU,,,,n N.tM - I, "",, "dddu. M,4Ice' FullltyJ ! , "lIf' L.OCATIO 0 R a OJ O~O 40 1140 D! S~,O\l. T I ~OTlir S Iq7~07C2 ~ F~ ~ET USMC ~~'ji SJ:CL.'~ C I':'/I-i :.',1: ,~lq-9715 _ -_7,"'~'~_-r':.":"'-""DIOlOatC CONSULTATION REOUEST/REPORT t - MIOICAL RICO"D LDCA o RADI LOG SiiiNAfURE --,' STANDARD fORM 11". I.,UI P'ucrtlMQ bY o.AIICM"k FPMR 14l C'RlllJHl.la'.1 . . .,"101 ..... ,J<IO-4,.,....,2t4 RADIOLOGIC CONSUL TAllON REQUEST/REPORT (Rldipfp INucl'" M,dicin,lulrmpundlCpmPUlfd Tp",p "phv Eum/n.rlanr) AO sue. $~ ,.5po",o'l W~f).~t-INIC REGIUER NO. ElCAMINAflON(SI REQUESTED (\-r -' l.f\~4 toe r) (.\,........-..D I RECUESTE'iJOY (Pn"rJ PAEGNAN T o YES 0 NO TEl.EPHONE/PAGE NU. FIL.M NO. . _eo SIONATURE OF REQUESTOR .If'S ~4--<>' ,?.v PEelFle R[AlaNIS) FOA REQUEST .CompkllnU 0,,.1 'Indln," (\Jt~ \,_,..a-~ p"'........- I Af>n . _ '1 '( ~,\.....rr.,- Lj (~Ir'( oS fl/o f"Mc......~ DIJ r" '- n'4"'~ ~@ S'r-<, I ..... ') " " '\ lID H .~a "" 1"',,1\ ,,..L.~<1' . cr- 0;- I '\ ~ '1 I' DATE OF REPORT f,lon'''. d07. 7ft DATE OF TRANSCRIPTION f.\lonl", dO)', Jlar, DATE OF EXAMINATION 1.\'0'''''' du. rI"" AAUlOl.OGIC REPORT REC"J DCe o1ll OE.e 0 6 ,qq. _, . _.-.,.,f."*:,..rr,rr" '-.1 L.OC ONC'~ ole R 0 ATlE. . 10 _ It)NI ~'){f'dO''''"fI'"'"h'II''U''; Nom. -loUr. (Int. mlddl,. .\I,di,,1 FOfllt11 L.OCATION OF R~OIO~OGIC FACH..ITY OJ OhO 40 7740 CI~e1,);J. TI~OTHT S 1~73070, K F1 ~[T UtHC ~~CT :J :r,L.\$ ~ I ' '. ' _ I . \ 'I ' I 11- 3...5 , . , ".' ~ _ ,__~._~~'.. ~IAO LOOIC CONSUL T .' ,r..: f....Il... ,.,.... REOUEST/REPORt I __ MI:OIC.-I... AlcoAt 5'li1NA TuAE &TANOARO FORM 5 P,"U tU oy alA/Ie FPI,lf.t t.U CFRII01. r.e::. RADIOLOGIC CONSULTATION REQUEST/REPORT (Rltfio'o tWue'", M,d/dn,tlll_undICDmputrd romo rlphy (nm;n,rio..) EKAMINATlONIS) REQUESTED SDC UN 13'Mlorl WAnO/CLINIC REalSTER NO. /!r' q/ L~0,r.',V.D PREGNANT ~ DYES lAl NO , TELEPHO"'E/~AClE H~:- SPECIFIC REASON(S) FOR REQ~EST ICo ...,"""": ~nd'",., .', ' tt.4!.h...t;(;rt:-.;r,.<=>-+//Jk~"-'~'~ l) 0/ ~~,_:...s (j~ ~7 ,~ ~ \ u--S ~"'- ....'7-" ,,-~w..-:::J, .~~G<~~... ~ _ . '~~~ cJ.~ /~ 5~{t'~ ~~. ,,-,-?-{, ,~ Fy:.. DATE OF EXAMINATION t. on'", d4)/, )If.} DATE OF REPORT (JI..HI. do,., )/..rJ DATE 0 TRANSCRIPT N (Monti'. cU)I, )I.dr} RADIOLOGIC REPORT 13. Disbrow. Timoth}" 4/05/94 Right hand RIGHT HAND - 3 VIEWS COt1l1!iNT: shaft of rule out intact. There is a possible hairline buckle fracture \l1thin the dhtal the right 5th metacarpal. Reimaging ill 7 to 10 da~'s is suggest"d to a fracture in this area. The remaining osseous struct\~es are Il1PRESSION: Possible hairline fracture. distal shaft. 5th riiht metac.'U'pal. Dictated by: O~:cll\ ,,~C'O tjC C Q b \qql Garry B. Maln.'U'. D.O. "I- April~. 1994 , ." ,., . " ATIE 4T'S IOENTlFIC'\T10~4 Iro" tlP'1I or wnU'" '"En" In.: Nom. - to.t. "I'It, mlddl" .U,dlul FarlhtyJ loCATION OF MEDICAL RE~O OS , L.OCATlON OF RADIOI-OolC FACI\"ITV 01 0&0 40 770 r;S(l~OW, TlilOruT S 11710702 ~ F~ ~ET US~C H S G r ~ 1 ': ~ USe ""1_' S,'.'tC :11-6715 " , ~;.~ IT ANDARD fORM II.. ,'III IhuCftbfll by U'A/leMR FP'-4H tU CF". 101-"101.' Z'U-' ..... nfO-oO'-II..,n4 . U ~ aOVER~~MENT'PRtNTlNt1 OFFICE: IOU-.!O 3J1 RADIOLOGIC CONSULTATION REQUEST/REPORT fRJdlologYINuclll' MtdicinllUJtflfound/Computld romo9f1phr [xdmination.J AGE SEX 55N ,SPlJ'''O'' WARO/CL.INIC It m-o(.O -l.{cJ- &. yl,w;. FILM NO. "")0' REGISTER NO. lXAMINATlONISI RElJuUTEO I PREGNANT B o YES NO TELEPHONE/PAGE NO. -N1i DATE R[QUESTED r )\- ~ L ttJ C'/..{l. REQUESTED ~ 'PM II f:5,f to'1U"/ SIGNATURE O~4EQ~ESTOR .,J). ~ PEelFle REA ONIS) FOA R u! T I o",p...n".n "dill'" ~<;r p~ ATE 0 EXAMINATION I. ~ U) ca CD u:l ~ QATE 0 RAN5CRIPTION ,. on' . "')'.I,On AOIOLOUIC REPORT fAM C~v ~ ~r~rP~ a-~ay -- z:- u:l t.. l.: I:~ ~ lfJ fa ~ ~",w-6.L.i~C.2 tJ r"~ ?-.'C.C';c;)'> I) b \QG~ ~t\., ~~ 2. 11.<..l 7'{: AL. , ATIUl 'S It) 1'1 I I~ ION I 'II' I)P'4111' um,.II .11"." ,j~, N~m. IluI. flu', mldJI... ."..d,cal flJtlllf'1J L.OC )), 5 cf-~w OJ- {)(,o J.)~I rnq ~6(ft;1;tOIOLOQ1C 'ACllITY j.,' 410 ~ !fa - 7') I/o n-iJ SIGNATURE r h...l:t k~I"~ -;"',-7':') ~ RADIOLOOIC CONSUL TATION . REOUEST/REPORT t - MIOICAL RICOAD STANDARD fORM 511.8 .llIJl PI'", tltq c:v G''',I~'.O~ FP"IR (H CFRII~I.l1-IOI' " noL ~;'.~': ", .' ,,- I " ,lIIrvlOUI lea Ou. 000 -l.'LINICAL RECORD ELECTROCARDIOGRAPHIC RECORD CLlhICAlIM,liUSS10,. MIOICAT10N OIMIIIIGINCY ORoutlN. 01101101 o AM.ULAN' OAt( ;J~ ~1,O'f3"A7~C9~ A~II cr.-IAnON IOfllla, ~ 'tUn AU"IC. "INT. I11I1YTt-lM INfElII".&U 'WAIfU .. ORS CCM'LL,n 0.' or illS.' 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'! ~ ::---- _j I --=-- j"'~ ... -=--~ :.r::.~:~ ,. -:~:::t,.':i~=i:;j . l.~..:' . :.t,._ .-.,..- i~;;~;J"lf!~ ;g~~1;;': .~~ _ ,~:':-:;i,' ;.n._l :,~:,:.;I~.'"J :C'I,I:;-'R " ... -1",1":1 _",_...;;... :_~j '_;n ',:;: ..:::;::..1 .-.: .:! u.'., ( .(YY/7.7/J ,/,..( .u~ AUTHORIZATION A~D CONIENT TO OBTAIN MEDICAL AND DlPLOYMENT INFORMATION I hereby consent and request that the bearer be permitted to examine and obtain copies of all hospital and medical records of every sort and kind, Interview all doctors and other IIIIIIndants and all employers and former employees regarding all Inaners relaling to examination, diagnosis, care and treatment of myself, earnings and loss of earnings. I am willing that a photostat of this authorizalion be accepted willi the same authority as the original. PA: Any person who knowingly and with intent to Injure or defraud any Insurer files an appllcaUon or claim containing any false, Incomplete or miSleading informalion shall, upon conviction, be subject to Imprisonment for up to seven years and payment 01 a fine of up to $15,000. NJ; Any person who knowingly tiles a statement of claim containing any falsa, or misleading Information Is subject to criminal and civil penallies. OH: Any person who Wlltl Imen! 10 defraud or I<nowll1g !nat he ,. Iacliitabng a lraud against an Insurer, submits an apptlcation or lUes a claim containing a false or deceptive statement Is guilty of Insurance fraud. tT.f: ()-. 199'1 Slgned.....---:::::h'\ (~I'..'V'" J Address ~,' \1; (:'0" '0', (\ r: r-' 0/'" Date ,. .,,- \ , " \ ~ '" ,~, \-'L'\~, c..~o lEd, 3.g1) @(.cz..,:,(:.. , "eL'lL'lZ[r:...t: ./?'"lL"--' ~ 0c-r>L.) ,a..,v 'Z1~.Li.U.~...' (j17L.~L \-.iK...t..~1- ...?_,(",,~-, ~...a..U:-,--- , ~ ';>U:-J',-.>a..f.\~ " ,jt4.-;:- ~,-<.... ",. ;l-ll.-t... Y _?J.. ,.I1-ti.l. (. ~~l ~0-Y O.L'-I-c,- ,.."v..~ q . ..... (I ~ . ~ (I - ,<'_.l, C,.'- !LC.!-,,_ I .;1- "T:~ /Ci...C['-<.~7-~ .4~t' j:-.. Lt/ HJ '../' J . Ztf...L~) ~. . J (' J -1..."'1.1'1d ,d-./r-!-.d"t.. e" \ " " :.r," ......,; . .".' ,. I,.I~ Ii t ,'1", ~1.~a..,..0. ....; ,',..,',;.", ......',,, .'~ ,':." . .' " ''", ," ... .'.. I .. .. '~'. ,. ....1 . '? ... ..? ('1- ).I/q, 'j'1/ ~ .... . R~C'O Ct"'" , """''':: ~nv f) 719?,/ GENERAL RELEASE (PLEASE READ CAREFULLY) WOW ALL MEN IlY THESE PRESEIll'S, THAT l/WE, Douglas C. Disbrow and Susan Disbrow as parents and natural guardians of Timothy S. Disbrow and Timothy S Disbrow in his own right FOR TilE SOLE CONSIDERATION OF One Thousand Dollars (~ 1,OOO.OO)lawful money of the United States to me/us in hand paid by Mar- tin E Peiper and Reba E Peiper the receipt thereof is hereby acknowledged have remised, released and forever discharged Martin E , Reba E Peiper and his/her/their heirs, executors and administrators, their successors and assigns and any and all other persons and entities (whetheJ: herein named or not) of and from all claims, demands, damages, actions, causes of action, or suits at law or in equity, or whatsoever kind of nature, for or because of any matter or thing done, omitted or suffered to be done by the said Martin E. , Reba E. Peiper prior to and including the date hereof, and particularly on account of all injuries both to person or property resulting or to re- sult, from an accident which occurred on or about the 14th day of September, 1994, at or near Carlisle, PA. It is underetood and agreed that this settlement is not to be construed as an admission of liability on the part of Martin E. or Reba E. Peiper and that this release contains the entire agreement between the parties hereto, and the terms of this release are contractual and not a mere recital. I/We further statL that I/We have carefully read the foregoing release and know the contents thereof, and I/We sign the same as my/our own free act and deed. HI WITNESS WHEREOF, I/WE have hereunto set my/our hand and seal this day of , A.D., IDCB) IS D) (TSD) In the Presence Ofl County of On the day of , A.D., , BEFORE ME, THE SUB- SCRIBER, PERSONALLY APPEARED THE ABOVE NAMED WHO IN DUE FORM OF LAW ACKNOWLEDGED THE FORE- GOING RELEASE TO BE AN ACT AND DEED AND DESIRED THE SAME BE RECORDED AS SUCH. IN TESTIMONY WIlEREOF, I HAVE HEREUNTO SET MY HAND AND SEAL THE DAY AND YEAR AFORESAID.