The URL can be used to link to this page

Home My WebLink About95-05462 vltwl4MI'J q)~ 1I1I1W/11l& &- O'tw A rOO'WIONAl CO.POlAT.ON A1TORNEVS AND COUNSELLORS AT LAw TEN EAsT HIGH STREET CAAuSLE, PENNSYLVANIA 17013 WIl,\.IAM F. MAlnON DANllL K, D&AlIIOIII TtlOMAI J. W,LLIAMI 1\10 V. ann, III SnMiIN L. BU)(IM GIOllJl 8, FALLll. JI. WILLIAM D. rO'WlLL TtlOMAS G. COLLINS TIWHONI (717) 24).3)41 FACSIMlll (717) 24).1150 January 2, 1997 INTllNlT mdwol'mdwo.tom Donald R, Dorer RUBINATE. JACOBS" SABA 214 Senate Avenue. Suite S03 Camp HIli. PA 17013 Re: Tina R. Haul VS. Daniel W, Peters, Jr, Cumberland County: No, 9S.S462 CIvil Dear Don: George asked that 1 return these photos from the above referenced arbitration to you , Very truly yours, Marcia Compton Enclosure ,i (,,'I I TINA R. HAUS, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW v. NO, 95-5462 civil Term DANIEL W. PETERS, JR, Defendant ARBI'l'RATION PLAINTI'" S ARBITRATION NUORANDUM I, Facts On January 28, 1994, Plaintiff Tina R, Haus was driving her car on North Hanover Street in North Middleton Township, cumberland county, PA. The weather conditions that day were icy and foggy, and extreme caution was necessary in operating a motor vehiele. As Ms. Haus approached the Church of God Home on North Hanover Street, the car directly in front of Ms, Ilaus stopped suddenly, eausing Ms, Haus to apply her brakes and move to the shoulder of the road, bringing her car to a complete stop, Defendant Daniel W, Peters, Jr" was in the car direct ly behind Plaintiff Tina Haus, following the in the same lane of travel. Mr, Peters failed to bring his car to a stop, striking the rear of Ms. Haus's stationary vehicle, As a result of the collision, Plaintiff Tina Haus suffered personal injuries, l04l78/0MR .. II , Damaqes A. Accident Scene Upon impact, Plaintiff Tina Haus's car was knocked forward and spun somewhat, causing the vehicle to again collide with the Defendant's vehicle. Ms, Haus, though not losing consciousness, did feel strain in her neck and back, as well as her shoulders, with radiating pain in her left arm and neck. Ms. Haus attempted to alleviate the pain, hoping that it would go away, however, it did not, She initially saw Dr, James Wharton, a Chiropractor in Mechanicsburg, with complaints of neck pain, headaches, upper back pain, mid-back pain, lower back pain, and paresthesia in the left arm and hand. These symptoms were aggravated by any type of lifting and sleeping, and any other type of physical activity. B. Dr. Thomas A. Boch Plaintiff Tina Haus initially presented at the office of Dr. Boch on February 22, 1994, Ms. Haus had tenderness in the paravertebral muscles from C5 to T1 and L3 to L5 on initial examination. She had limited range of motion in the neck and low back during flexion extension and lateral bending. There was mild to moderate muscle spasms in C1 and C5, T7 and T9, and L3,4, and 5. Dr. Boch diagnosed vertical subluxation at C2-L3,4,5 and wedged disks at C5-6, T3-4, T5-6, Tll-12, L2-3, L5, and Sl, It was Dr. Boch's belief that all of these symptoms coincided with Me, Haus's 2 ~, complaints. Additionally, he found cervical kyphosis, which he believed to be a classic finding in cases of whiplash. The diagnosis was that of whiplash, cervical/thoracic/lumbar sprain/ strains, and vertebral subluxation, Plaintiff Tina Haus treated 53 times from February 22, 1994 through August 24, 1994, at which time, she was released as having reached maximum medical chiropractic improvement, However, at the time of the release, Ms, Haus was still experiencing neck and low back symptoms, Care under Dr, Boch continued from September 7, 1994 through October 16, 1994, treating for neck, low back pain approximately 38 more times, Occasionally, Plaintiff Tina Haus continues to have acute episodes of neck pain, arm pain, and hand pain, Dr. Boch has advised Ms. Haus to avoid heavy lifting, repetitive bending, twisting of her torso, overhead work with her arms and hands, and prescribed the use of a home cervical traction unit, It is his opinion that she should follow these guidelines p.rIIUln.ntly. Dr. Boch has opined, with a reasonable degree of medical/ chiropractic certainty, the injuries for which he treated Ms. Haus were all the direct result of the automobile accident, which occurred on January 28, 1994, Dr, Boch believes that the mechanics of the accident, described by Ms, Haus, were consistent with the 3 findings of cervical, thoracic, and lumbar injury, in that the car was not only hit from the rear, but also spun around, creating a combination of whiplash and torque to the spine, Dr, Boch also opined that in the future, Plaintiff Tina Haus will be susceptible to exacerbations for an indefinite period of time. Dr, Boch's reports throughout his treatment of Ms. Haus are contained in Exhibit "B" of the arbitration exhibits, III, Witnesses A. Plaintiff Tina Haus - Ms. Haus will testify that the car in front of her applied its brakes. she brought her car to a complete stop toward the shoulder of Hanover Street, It is at that time that she was struck from the rear by Defendant Peters, causing her vehicle to slide and spine, effecting a second collision with the Defendant's vehicle, B. Mr, John Walker - Mr. Walker will testify as to the occurrence of the accident, IV. Conclusion Plaintiff Tina Haus contends that this is a case of clear liability in which Ms, Haus suffered significant personal injuries, including cervical/thoracic/lumbar strain/sprain injuries, for 4 II. Damaaes A, Accident Scene Upon impact, Plaintif( Tina Haus's car was knocked forward and spun somewhat, causing the vehicle to again collide with the Defendant's vehicle, Ms. HIIUB, thollgh not losing consciousness, did feel strain in her neck and back, as well as her shoulders, with radiating pain in hill- left arm and neck, Ms. Haus attempted to alleviate the pain, hoping that it would go away, however, it did not, She initially saw Dr, James Wharton, a Chiropractor in Mechanic.burg, with complaints of neck pain, headaches, upper back pain, mid-back pain, lower back pain, and paresthesia in the left arm and hand. These symptoms were aggravated by any type of lifting and sleeping, and any other type of physical activity. B. Dr. Thomas A. Boch Plaintiff Tina HauB initially presented at the office of Dr. Boch on February 22, 1994. Ms. Haus had tenderness in the paravertebral muscles from CS to T1 and LJ to L5 on initial examination, She had limited range of motion in the neck and low back during flexion extension and lateral bending, There was mild to moderate muscle spasms in C1 and CS, T7 and T9, and LJ,4, and 5, Dr. Boch diagnosed vertical subluxation at C2-L3,4,S and wedged disks at CS-6, T3.4. TS-6, T11.12, L2-3, LS, and 51. It was Dr, Boch's belief that all of these symptoms coincided with Ms, Haus's 2 complaints. Additionally, he found cervical kyphosis, which he believed to be a classic finding in cases of whiplash, The diagnosis was that of whiplash, cervical/thoracic/lumbar sprain/ strains, and vertebral subluxation. Plaintiff Tina Haus treated S3 times from February 22, 1994 through August 24, 1994, at which time, she was released as having reached maximum medical chiropractic improvement, However, at the time of the release, Ms. Haus was still experiencing neck and low back symptoms. Care under Dr. Boch continued from September 7, 1994 through October 16, 1994, treating for neck, low back pain approximately 38 more times, occasionally, Plaintiff Tina Haus continues to have acute episodes of neck pain, arm pain, and hand pain. Dr. Boch has advised Ms. Haus to avoid heavy lifting, repetitive bending, twisting of her torso, overhead work with her arms and hands, and prescribed the use of a home cervical traction unit, It is his opinion that she should follow these guidelines permanently, Dr. Boch has opined, with a reasonable degree of medical/ chiropractic certainty, the injuries for which he treated Ms. Haus were all the direct result of the automobile accident, which occurred on January 28, 1994, Dr, Boch believes that the mechanics of the accident, described by Me, Haus, were consistent with the 3 findings of cervical, thoracic, and lumbar injury, in that the car was not only hit from the rear, but also spun around, creating a combination of whiplash and torque to the spine. Dr, Boch also opined that in the future, Plaintiff Tina Haus will be susceptible to exacerbations for an indefinite period of time. Dr. Boch's reports throughout his treatment of Ms. Haus are contained in Exhibit "B" of the arbitration exhibits. III. Witnesses A. Plaintiff Tina Haus - Ms. Haus will testify that the car in front of her applied its brakes. She brought her car to a complete utop toward the shoulder of Hanover Street, It is at that time that she was struck from the rear by Defendant Peters, causing her vehicle to slide and spine, effecting a second collision with the Defendant'. vehicle. B. Mr. John Walker - Mr. Walker will testify as to the occurrence of the accident, IV. Conclusion Plaintiff Tina Haus contends that this is a case of clear liability in which Ms, Haus suffered significant personal injuries, including cervical/thoracic/lumbar strain/sprain injuries, for 4 which she has treated continuously for two years. Dr. Boch has opined unequivocally that this is a result of the automobile accident, ".- k'" rence F, Barone, I. D. No. 68921 4503 North Front Street Harrisburg, PA 17110-1799 (717) 238-6791 Dated: I~ bl-//9t, , f Counsel for Plaintiff LAw OmclS RUBINATE, JACOBS" SABA (NOfA'AIlnallllrl 114 SlNAn: A VIN1JI: S1JIn:503 CAMP HILL, PA 17011 TlLUHONlI (717) 731..,.. FAXI (717) 731..,.7 TDDI I..eetQ1.WI DoNALD R. Doua Scan A. haLAND IlIna TOI 95-099 December 26, 1996 VIA OVERNIGHT MAn. Geoqe B. Faller, Bsqulre 10 Bast High Street Carlllle, PA 17013 Andrea C. Jacobsen, Esquire 52 Bait High Slreet Carlllle, PA 17013 Stephen L. Bloom, Bsqulre 10 But High Street CarlIlle, PA 17013 RB: Tina R. HaUl VI. Daniel W. Peten, Jr. Cumberland Counly: No. 95-5462 Civil Dear Counsel, Bnclosed please find a copy of Defendant'l Hearlng Memorandum wllh l'CIard to the AItlltration hearing set for Monday, December 30, 1996 at 9:00 a.m. In the Old Courthouse, 2nd Floor Hearing Room In Carlllle. Thank you for your attention. /~r(,; \~tt- DRD:dek Bnclolurel c, Lawrence F. Barone, Bsqulre (w/encl.) 95-G99 LAW OmCES OF RUBINATE, JACOBS III SABA 214 Senate Avenue, Suite 503 Camp OW, PA 17011 Telephone Number: (717) 731-0988 Attorneys for Defendant, Daniel W. Peters, Jr. IN THE COURT OF COMMON PLEAs TINA R.llAus, PLAlN'lltT CUMBERLAND COUNTY, PENNSYLVANIA V8. No. 9.5-5462 CIVIL TERM DANIEL W. PETERS, JR., DEn:NDANT CIVIL ArnoN. LAW JURY TRIAL DEMANDED DEFENDANT'S HEARING MEMORANDUM 11I1s lawsuit arises out of an automobile accident occurrlnll on January 28, 1994. 11Ie Defendant, Daniel Pelcn, Jr., was opcratinll his 1989 Cheverlot Conlca In a llenerally noltherly direction on North Hanover Street In North Middleton Township, Cumberland County, Pennsylvania, In the vicinity of the Church of God Nunlnll Home, on which occasion the Plaintiff, Tina Haus opcratlnlla 1989 H)'Undal Sonata In a northerly direction on Nolth Hanover Street, lost control of the vehicle, and stopped up allalnst Ihe rillhllhouldcr, CUllin. dlqonally across the northbound lane of travel. Due to the Icy road conditions, the Defendanl was unable to avoid slrildnllthe rear of the Plaintiff's vehicle. Photollraphs will be presenled at the arbllratlon hear1n1l deplcUnIl the low speed nature of Ihls Impact. 11Ie Plaintiff did not seek medical attention on the day of the accident, but presented henelf to 11I0mas A. Boeh, D,C. on or about February 22, 1994. Dr. Boch'streatment summary letter of Seplember 18, 1996 Is attached herelo as Bxhlblt "A". As noted by Dr. Boeh, the Plaintiff was seen on some fifty-three occasions between February 22, 1994 throullh Augusl 24, 1994, at which time the Plaintiff was"... released as having reached maximum medlcaVchlropractlc Improvement," Thereafter, the Plalntlfrs chiropractic care proceeded "under her group health Insurance" from September 7, 1994 to October 16, 1995, for an additional thlrty.elllht visits, As further noted by Dr. Boeh, the Plaintiff was seen In the SPrinll of 1996 for neck and left upper extremllles symptoms evidently related to some gardening activities on five occasions, Indeed, Dr. Boeh prepared a supplemental report referring to the appointment of August 24, 1994, attached hereto as Exhibit "B", during which Dr. Boch noted Improvement ranlles of 80-959(. with respect to the plalntlfrs neck, shoulder, ann, mld.back, upper back and headaches. 11Ie Plaintiff was described as being 659(. Improved with respect 10 her low back. 11Ie restriction percentage of range of motion for both cervical and lumbar spines was noted to be ,.. The Plaintiff was dlacharaed on August 24, 1994, and conllnued on "maintenance tl1lltment" . This "dlaclwJe. In tl1lltment allegedly related to the subject motor vehicle accident, coincided with a peer review report prepared by Larry A. Roth, D.C. on behalf of the fint- party Insurance company dated August I, 1994 and attached hereto.. Exhibit "C.. Therein, Dr. Roth concluded, In part, al follows: A course of chlropracllc as described In this report, and excluding all dlagnoltlc pluccdures except for Inlllal radiographs can be conlldered appropriate and necessary to address condlllons and complaints stemming from the 1/28/94 MV A for a period of up to 8 weeks durallon, and dating to 4/18/94. A maximum benefit from the care rendered should have been attained by that date. It was also noted that a stretchln. exercise was not Incorporated Into Ms. Haus' routine un11l4/1I94 by this practilloner. A home stretchlnglflexlblllty exercise prollram should have been Initiated Inlo Ms. Haus' dally activities lOOn after the Initiation of care from thll office, Further In-office treatment beyond the 4/18/94 date haa not been considered appropriate and or necelsary for the reported peralstent complalnls, without obJecllve findlnllslo wanant extended care. Additionally, the Plalnllff has been employed as a mall handler at the U.S. Anny War Colleae, and has not missed any substantial periods of employment relative to this accident. Additionally, the defendant II not on notice IS to any unpaid medical bills In connection with this accident, and any such bllUnlls should not be recoverable It the time of the arbltrallon bcarinll. For the foregolnlll1llsons, the Defendant respectfully requells that the AIbllrallon Panel enter an Ippropriate Iward In this matter based on the evidence presented. By: Donald R. Dorer, Esquire Attorney for Defendant Identlficallon No. 39126 Date: rw."l11ber 26, 1996 ElchIbIt A All "".'11114. ....,,,.... II'" .'''lln ('i) , "t. .,.... , <I . . '. BOCH CHIROPRAcnC QJNIC 323 YCIIIl Road c.w.. PA 17013 T~(7171243~ Fu:(7171243-6444 September 18,1996 Lawrence F. Barone, Esq, 4S03 North Front Street Harrisburg, P A 17110 RE: Tina Haus D,O,A. 01/29/94 T'ma Haus presented herself to my office on 02122194, She related during her intake consultation 'thalshe had bun involved in an automobUe accident on 01/28/94 and had been seen by another cb1ropractor, Dr, James Wharton oCMechaniclburs. prior to being seen in our office, Her entrance complaints were neck pain, headachcs. upper back pain, mid back pain, lower back pain and paresthesia in the left ann and hand, Thcse symptoms were worse in the momlngsand were aaaravalod by lifting. s1eep!na and any type oC physical activity, " ' " "." ",,,..,' ,-,~'~-':"" TInA ~ ~II, at that time;. weJi-n.6~rilhed. wbl~e female ofno~ weight and aye;qe'b~t'~, ~' . :_ Sbe"ij'peiied to imderitiiid.:ill ofo\!i'cO'iIiU1tatlon' questions regarding tier condition and l.had po ..:, ~ ,- ,,; '~!'_~~.~vo ~t)ho,,,:~ exasi~tina her ~ptoms or wio.Il"ier:in& b~ OD ~y P~~~~~:~J:", ' , yeara ~ence in deaUns \VlthJqJwy wes " , " ",' ,', ':.", ',:.,..,.' '::'_~"!"'.'-1\"':''''',"''' ~.~ :\:'!":~;:A;r-':':.: ~":,<: :.. . ':,.,.;;:::,.:"\;~~: ::,/~:, ;':::'~:::Z:'.~ '::,", " :):;,::',<~:,~! (::"::'.~:' :~.':~-:;.2i;~~:;,!;!ggt; : '. Her previOUl trauma history Included a broken ailkIe In 1973 and a car/molOrcycle IccIdent In..., ' 1987."siitjpcal blstory'was ~ted to two c-sectlorii whlc1l were Perfonned in 1984 ,an~ i9Bi5:"';'.~' " . On liItake; wheii'aslCed Ihho wason any prescription drugs, her respo~ was ~ the n.~v.~L ,.~{ ; . Our ex.ml~.t1on ofMs, Haus Included x-rays and a physical exam, There wu 'tenderness t~' palpation in the paravertebral muscle at the following levels: C-S to T -land 1,.3 to 1,.S. There was limited range of motion in the neck and low back during flexion, extension and lateral bending, Cervical foraminal compression test wu positive in hyperilexion and hyperextension, The muscles palpated were and judged to be In mUd to moderate spum at the following locations: C-I,S T-7,9and L-3,4.S, Spinal x-rays revealed vertebral subluxation at: C-2, 1,.3,4.5, and wedged discs at: C-S,6 T-3,4 T- S,6 T-11,12 1,.2.3 1,.5 S-l, These areas correlated to the patient's symptomatic complalnls, Also present on the patient's static lateral cervical x-ray was cervical kyphosis, which II a classic finding in casel oCwhiplash. Some arthritic changes were seen at C-4.5,6, The left laleral bending x-raY revealed a loss ofnonnal motion blo-mechanics in the lower lumbar spine, which along with cervical kyphosis were objective signs oftrauma and ver1ebralsubluxation, Our diagnosis at that time was whiplash, cervical, thoracic and lumbar sprain/strain and vertebral lIP II 11 " " ..... " .... IUbluxation. MI Haul wu treated In thll office from 02122/94 to 08/24/94 approximately fifty- three times before being releued u having reached maximum medlcaVchlropractlc Improvement Her treatmentln our omce conalated of chiropractic Ip\naladjultmentl. Interferrentlal electrical therapy, hot paclca and intersegmental traction. At the time ofber release, ahe wu ItllI experiencioa neck and low back I)'llIptolDl, We contlnued her care under ber poup beallh iDlurance from 09107194,to 10116195, trea.tlng her for neck and low back pain for approximately thIrty-elaht more vlalll. . . . Moll recenlly, I was consulted by Ma, HaUl around May 23rd ofthla year for treatment for 1D0lher acute episode of neck pain and left ann and band pain wblch resulted from lome prdcolna activities. IIIW her I total of 5 times, Wb1Ie MI. Haul wu being treated for ber accident of 01/28194, I advised her to avoid heavy lifting. repeated bending, twiatlnS of her torso and overhead work with her U1lIIand handl, I allo prescribed a home cervical traction unit for her to ule outside the office to help restore her nonnal 'lordotic cervical curve, In my opinion, Ihe should follow Ihese SUidelines pennanenlly. ~ my opinion, to a reasonable desree ofmedicaVcblropractlc certainty, Ihe iqjuries for which I treated MI, Haul were Ihe dlrcct rCIIIlt of her automobUe accident of 01/29194, The mechanics of . the accident deac:nDed to me by Ma, Haul were consistent wilh our finding of cervical, Ihoraclc . aDillwDbar lqJwy in that her car Was not only hit from tbe rear but was Ipun around; ~ a ., combl~t1on ofwblpluh and torque to the .plne. ' , ' , "/ ,~:~:~:~:~.~?~~;~;{:'~~~~~I~:'~;:-:Vl:~:l':;;;:r.~~::' ...;:: '.:: ~ :~...::,,' :-:",~..t!::.,. ~..;;,'.:'.:. :"':':. ;/<, ',~.. .~. ..~. '.~:. :.~! '~::.'..:.-~:~'::~ :::":. ..;:-:. '::Tbil:illecliC4i Utnture that I hive 'read, special ectucationalll.emlnan thiU have Ittend,~ IJ!ll my ',,~:': " . . ~Dif.~ence In,~ Jqjwy ~ fo~ ~ost~ee .d~ei; 11ioWa'1hal duo to'thci ~,''''''': ": ':. ~~ ~~foriN, as puf of the b~ '" ~ese. typO)f.Pfalnl~~lrUUri~,#pto,ii1~t1~,:~;'; ;",' .:: ..,.., ..'., recwreoce can continue for an indellnite penod of time. . '. , , "I ,,' ,,' ...~..._,.:~.:'_..:..;. .' ......... .~. ': .~. .-..... ..t~.:..~T'~ '".. _'" :1.' .:' '. 'It .. my ~r opinion, to a ~nable ~e~ ofmedicaVclUiopraCtlo cert~ty,i1iat ,the.' , prognolla In thll cue II that there will be exacCrbatloni' fot an indefinite penod of time, ThIs opinion II bued on the fact that thll patient hu continued to experience the iqjwy related I)'IIIptOIDl following almost 100 treatment vialtl to our office, Sincerely, ~j.~~ j)~C. Thomas A. Boch, D.C. Exhlbll B .."h">'I'.., ""'il"'" t'" '"""'11 <.t) Elchlblt 0 r \ , - " LARRY A. R~TH, D.C. JS4S RYAN AVE. PHILADELPHIA, PA Augult1, 1994 KATHLEEN YABLONSKI, R.N, CLAIMS REVIEW ASSOCIATES 660 AMERICAN AVE, SUITE 103 KING OF PRUSSIA, PA 19406 RE: Tina Rae HaUl Claim: 46N0385212027 CRA': 988,760-1 001: 1128/94 Dear NIl, Yablonlkl: In reference to your requelt of July 20,1994 I have reviewed the following recordl and docu- mentl relating to the above mentioned claimant. , 1. Thomal Boch, DC SOAP Note 317194 Treatment Notel 2/22194-7/1194 Examination of Travel Card NID Supplemental Report 3/11194,4/15/94, , 5/18/94, 6122194 Conlultatlon 2/22194 Roentgenological Report 2122/94, 4/4194 MUlcle Telt312194, 317194 ROM Worklheet 2128194-616/94 Chiropractic/Orthopedic/Neurological Examination 2/22/94 , Letter of Explanation NID Billing Statementl 2122194-5/18194 2, Application for Benefitl/Authorizatlon 4/8/94 3, Notice of LOlli NID The record I lubmltted for rovlew Indicate that Tina HaUl, a 35 year old female, ellegedly IUS- talned Injurlel In a motor vehicle accident dated January 28, 1994. MI, Haulltated on the Application for Benefitl thatlhe walltruck by another vehicle on an lca covered rOld, There II no indication MI, HaUl sought or received Immediate or emergency care following this Incident. The first Indication of any care sought or received by Ms, Haus was not until February 22, 1994, when she presented to the office of Thomas Boch, DC, A report dated 317/94 reported entrance complaints of neck pain, headaches, upper back pain, mid back pain, lower back pain, pain and paresthesia In the left arm and hand, Examination flndlngllllted on the lame report noted palpatory, limited range of motion In the cervlcel and lumbar spines, and IIveral orthopedic test findings, Radiographic studlel appear to be taken on IIveral dates, noting subluxatlons/mlsallgnments, and a cervical kyphosis, as well al narrowed disc spaces in the thoracic spine and canalltenosls In several regions, A diagnosis was subsequently listed as RE: Tina Rae Haus Page 2 motor vehicle sccldent, radicular neuralgia, vertebral subluKatlon compleK C2,5,6; T3,IIl,S,6, 11,12; L2,3,IIl,5, Dr, Boch Instituted a course of care consisting of hoVcold packs, electric stimulation, supplies, and mechanical traction, Dates of service have eKtended through to at least 5/23/94 from the dally records submllled, I am also aware of eKtenslve test procedures performed on the claimant Including multiple dates of radiographs (2/22/94, and 418/94 for same views), range of motion testing on 21 reo glons (performed on 2/22/94, 4/8194, and 5/9/94), as well as needle electromyography studies performed on 3/2/94 (upper), and 3f7194 (lower). At his request, Dr, Boch was contacted on 7/29/94 concerning this file, I was informed that treatment Is stili being rendered to the neck and lower back on a 1 time per week basis, Dr, Boch further Informed me that symptomatic relief was being rendered, The conversation ended shortly thereafter, Having reviewed Dr, Thomas Boch's records, the following Is In response to your questions. 1, Appropriateness and necessity of all treatment rendered by Thomas Boch, DC The submitted documentation supports a short course of chiropractic care administered to the claimant, Tina Haus following the 1/28/94 MVA, however the length of noted care has not been demonstrated as either appropriate and or necassary for this Incident. Minimal objective findings have been noted over the course of care administered to Ms, Haus, and even according to the treating practitioner, care has been ongoing for symptomatic relief, As allo mentioned, Ms. Haus did not Initiate care wllh this practitioner until almolt 4 weeks post trauma, with unknown, If any care was received prior to this 2/22/94 date, Thll would ap- pear to be an Inordinate amount of time If complaints and conditions were as severe as stated, Taking this Information Into account, along with the findings presented on evaluation, and the diagnosis listed, a short course of chiropractic spinal adjustment wllh use of soma adjunctive therapies can be construed as appropriate and necessary for the reported alleged Injuries of 1/28/94, 2, Appropriateness and necessity of all diagnostic testing done to date, The Initial radiographic evaluatlonlanalysls can be considered Justified as performed on the date of entrance, however the follow-up studies are nOI considered appropriate and or neces. sary for the claimant, Tina Haus, The routlns use of repeat )<-ra~' studies Is not considered a customary treatment practice or necessary from a chlropractlcJmedlcel standpoint for most conditions as determined by accepted radiographic guidelines, Limited repeat sectional radlogrsphs are considered acceptable and necessary from a chlropractlcJmedlcal standpoint In the following conditions: documentation of cllnlcel regression, significant re- Injury/eKacerbatlon, suspicion of advancing underlying pathology, periodic monitoring for frac. ture care, periodic monitoring of slanificant underlying spinal mechanical alleratlon, periodic monitoring and evaluation of a spinal scoliosis In patients who are receiving appropriate treat. ment and management, Unless a provider can submit clinical documentetion which estab. IIshes one of the above criteria, the chlropractlcJmedlcel necessity for repeat radlalion eKposure has usually not been established, No criteria has been observed to warrant these additional studies, RE: Tina Ree Haua Page 3 The range of motion teatlng la considered a vital and Integral portion of the eKamlnatlon pro- cedure. II ahould not be considered appropriate and or necellary to perform this test as .eparate and distinct procedures, constituting creative I'rocedural practices. Absolutely no justification has been shown from the documentation presented for the elec. trodlegnostlc evaluatlona performed under procedure codes 95864 by this praclltloner, for the allaged Injuries sustained by Tina Hausln the 1/28/94 MVA. 3. Was the length of treatment lime appropriate? If not, what would be a more appropriate treatment plan? In reviewing the dally notes presented for this review, the subJecllve complaints ahow eK- tremely slow response to the care rendered. The notes have been provided through to 5/18/94 noting only a resolution of headaches during this time period. On an ObjeCtive basis from these same dally notes, response has been even slower, nollng same trea ment areas, with minimal changes over the approKlmately 35 dates of servlcas during this same time span. In my professional opinion following the review of the records, a course of chlropracllc care rendered for a period of up to 8 weeks In duration should have been more than appropriate and sufficient to address the complalnts/condlllons and diagnosis stemming from the 1/28/94 reported Incident 3. If treatment were appropriate and necessary for the alleged Injuries sustained, . a) has maKlmum benefit of treatment been achieved? b) If so, when A courae of chiropractic as described In this report, and eKcludlng all dlagnosllc procedures eKcept for Initial radiographs can be considered appropriate and necessary to address condl- tlona aild complaints atemmlng from the 1/28/94 MVA for a period of up to 8 weeka duration, and dating to 4/18/94. A maKlmum benefit from the care rendered should have been ellllned by that date. II was also noted that a stretching eKerclse was not Incorporated Into Ms. Haus' roullne until 4/1194 by this praclllloner. A home stretchlnglfleKlblllty eKerclae program Ihould have been Inlllated Into Ms. Haus' dally activities soon after the Initiation of care from thla of. fica. Further In.office treatment beyond the 4/18/94 date has not been considered appropriate and or necessary for the reported persistent complaints, without objective findings to warrant eKlended care. Thank you for the opportunity of reviewing this file. If I can be of any further assistance In this case please do not hesitate to contact my office. As with all reviews of this type, a profes- sional opinion Is eKpressed. This review was written without bias to praclllloner or pallen\. Yours for beller health, ~/~.c. 4~lh, Doctor of Chiropractic Certified, Independent Chlropracllc (Medical) EKamlner Diplomate, American Academy of Pain Management , . ,~" \ 9HI99 LAW OmCES OF RUBINATE, JACOBS & SABA 214 Senlte Avenue, Sutte 503 Camp Hili, PA 17011 Telephone Numberl (717) 731-0988 Attomey. for Derendant, Oanlel W. Peters, Jr. IN TIlE COURT OF COMMON PLEAS TINA R.IlAUs, PLAINTIFF CUMBERLAND COUNTV, PENNSYLVANIA VS. No. 95-5462 CIVIL TERM DANIEL W. PETERS, JR., DEFENDANT CIVIL AC'I10N . LAW JURY TRIAL DEMANDED DEFENDANT'S HEARING MEMORANDUM This lawsuit arises out of an automobile accident occurring on JanuaJ}' 28, 1994. The Defendant, Daniel Peten, Jr., was operating his 1989 Cheverlot Conlca In I generally northerly direction on North Hanover Street In North Middleton Township, Cumberland County, PeMsylvanla, In the vicinity of the Church of God Nunlng Home, on which occa.lon the Plaintiff, Tina Haus operating a 1989 Hyundal Sonata In a northerly direction on North Hanover Street, lost control of the vehicle, and stopped up Igalnst the right .houlder, cutting diagonally acroll the northbound lane of travel. Due to the Icy road conditions, the Defendant was unable to avoid striking the rear of the Plaintiff's vehicle. Photographs wlll be presented at the aroltratlon hearing depicting the low speed nature of this Impact. The Plaintiff did not seek medical attention on the day of the accident, but presented herself to Thomas A. Boeh, D.C. on or about February 22, 1994. Dr, Boeh's treatment summary letter of September 18, 1996 Is attached hereto as Bxhlblt "A". As noted by Dr. Boeh, the Plaintiff was seen on some fift -three occasions between Februa 22 199 through Au st 24 1994 at which t me t e Plain I" In rea hed m um m cal/chlro ractlc 1m rovemen." Thereafter, the Plaintiff's chiropractic care p ed "under her group health Insurance" from September 7, 1994 to October 16, 1995, for an Iddltlonalthlrty-elght visits. As further noted by Dr. Boeh, the Plaintiff was seen In the spring of 1996 for neck and left IIpper extremities symptoms evidently related to some gardening activities on five occasions. Indeed, Dr. Boeh prepared a supplemental report referring to the appointment of August 24, 1994, attached hereto IS Exhibit "8", during which Dr. Boeh noted Improvement ranges of 80-95% with respect to the plalntlfrs neck, shoulder, arm, mid-back, upper back and headaches. The Plaintiff was described as being 65% Improved with respect to her low back. The restriction percentage of range of motion for both cervical and lumbar spines was noted to be :51. The Plaintiff was discharged on August 24, 1994, and continued on Mmalntenance treatment". This Mdlscharge" In treatmcnt allegedly related to the t, coincided with A. Roth D.C. on behalf of the fint- P!!1y fnsurance cOmpany dated AUI'III t, 11)1)4 anti altarhNl ''''....In al Rllhlbll .C". Therein, Dr. ROln wllclUoed, in part, as fol!g,ws: . A course of chiropractic as described In this report, and excluding all diagnostic procedures except for Initial radiographs can be consldcred appropriate and necessary to address conditions and complaints stcmmlng from the 1/28/94 MV A for a period ofup to 8 weeks duration, and dating to 4/18/94. A maximum benefit from the care rendered should have been Ittalned by that date. It WIS also noted that a stretching cxcrclse was not IncOIporated Into Ms. Hlus' routine until 4/1194 by this practitioner. A home stretchinglflexiblllty exercise program should have been Initiated Into Ms. Haus' dally Ictlvltles lOOn after the initiation of care from this office. Further in-office treatment beyond the 4118/94 date has not been considered appropriate and or necessary for the reported penlstent complainll, without objective findings to wlrrant extended care. Additionally, the Plaintiff has been employed IS a mall handler It the U.S. Army War Colle.e, and has not missed any substantial periods of employment relatlvc to this Iccldent. Additionally, the defendant Is not on notice IS to any unpaid medical bills In connection with this Iccident, and any such billings should not be recoverable It the time of the arbitration hearIn.. For the foregoing reasons, the Defendant respectfully requests that the Arbitration Panel enter an appropriate award In this matter based on the evidence presented. By: Donald R. Dorer, Esquire Attorney for Defcndant Identification No. 39126 Date: December 26. 1996 EIltIlbIt A ." t!~'I',I..., ."11'''''.'' I'" ...,,,,1,, (i) , ," ,j..., <I " ~ BOCH CHIROPRAC11C CUNlC 323 VlIIIl Road c.w.. PA 17013 T~~17171243~ Fu: (7171 243-6444 September 18,1996 Lawrence F. Barone, Esq. "'503 North Front Street Harrlaburs. P A 1711 0 RE: Tina Haus D.O.A. 01/29/94 T'IDI Haus presented herself to my office on 02122194. She related during her Intake conaultatlon that .be bad been Involved In an automobUe accident on 01128/94 and had been seen by another c:b1ropractor, Dr. James Wharton ofMechanlcsburg. prior to being .een In our office. Her entrance complaint. were neck pain. beadaches, upper blck pain, mid back pain, lower back pain and pareathea1aln the left ann and hand. These symptoms were worse In the momlnss and were qaravatecl by lIftlna, aleeplna an~ any type of physlcal,activlty. - . 0-'" . ..' ., .. . . . . ~'...' T1n& nah. ~II, at tIiat time, ia weli-nP~rished, wbl~e female of no~ welaJlland av;;qe'hf..~t: - . __ .... ....._.\100-...._ ..- ... .-..-. ...... - .-. " '. ~be ap'~ '0 understand_III of,ow' cciliiultatlon' questlona regudlna tier condition and 1 bad po ":', ~ " ,,; '~p:)#~.~e ~)be,w,~ exIIlI!AtIna bet,lYD.IPtoms or ~erin& b~ on 'my p~~7~';,\f" ,', 'yean~encelndea1lnaW1thJnJUI}'CIIOS ", ... .', ,.,., ',..'.', "':'_~""','_1\""''''',~''' .\ ~:"?'!'.:~~~J;:;:_';;.:'::"'; :'. ':..;:::":;::;~ :',::~:. ;-:-:~:,~; ,: · ':. " :::).;:: ::.~:'.' ;:00:: ::'_.::~'::.'"~:.~d~~n:1~~~.~'!( : ". Her pt#!oUatrlum. historY Included I broken aDk1e In 1973 ,and a car/moiorCycle IcCldent m'o' ' . , 1987., Siirjpcal blstoi)i Wla ~ted to tWo o-aectlOnl wbldl were pmonned In 1914 and i916: <'.~' , On Intake; wheiiulCed If .be wuon any prescription drugs, her response wuln the nealtive'. ~::: ' ' . . ,.. ...'....,...,. . , . " Our evamlnatlon ofM!. Hauslncluded x-rays and a physical exam. There was tenderness to palpation In the parlvertebral muscle at tbe following levels: C-5 to T-land L-3 to L-5. There WII UmIted range of motion In the neck and low back during flexion, extension and lateral bending. Cervical foram\nal compression test was positive In hyperflexlon and bypereKlenalon. The muscles palpated were and Judged to be In mild to moderate spasm at the following locations: C-l,5 T-7,9and L-3,4,5. Spinal x-rays revealed vertebral subluxation at: C-2, L-3,4,S, and wedged discs at: C-5,6 T.3,'" T. 5,6 T-ll,12 L-2,3 L-5 S-l, These areal correlated to the patient'. symptomatic complaints. Also present on the patient's static Isteral cervical x-ray was cervical kyphosis, whlcb is a classic finding In cases ofwhlplash. Some artluitlc changes werc seen at C-4,5,6, Thc left Isteral bending x-r.y revealed a loss of normal motion blo-mechanlcsln the lower lumbar spine, whlch along with cervical kyphosis were objective signs of trauma and vcrtebralsubluxatlon. Our diagnosis at thst time was whlplash, cervical, thoracic and lumbar sprain/strain and vertebral liP II 11 . .0-. . .... IUbluxadon. MI HIUI was treated In thl. office from 02122/94 to 08/24/94 Ipproxlmately fifty- three times before belna releued as havlna reached maximum medlClllchiropractlc Improvement. Her treatment In our office conal.ted of c:h1ropract1c .p\na1ldju.tment., Interferrentlal etectrical therapy, bot packl and lnteneamental traction. At the time of her release, she was stUl exper1enc1aa neck and low back symptoml. We continued her care under her tp'oup health 1naurance from 09/07/94 ,to 10/16195, treaJIna her for neck and low bsck pain for approximately tb1rt)'-elabt more villtl. . . Moat recently, I was conaulted by MI. HaUl around May 23rd of this year for treatment for another acute eplaode ofnock pain and left arm and hand pain which resulted from lome prdenlna actIvltiel. I saw her I total of 5 tinICS. WhIle MI. Haul was being treated for her accident of 01/28/94, I advised her to Ivold heavy IiftIna, repeated bendlns. twIsUns of her torso and overhead work with her anns and hands. I "10 preacribed I home cervical traction unit for her to use out.lde the office to help re.tore her normal 'lordotic cervical cwve. In my opinion, Ihe Ihould follow these suldellnel permanently. ~ my opinion, to I rcuonable desree ofmedlca1lchlropractic certainty, the UVUriCl for which I treated MI. Haul were the direct re.u1t of her automobUe accident of 01/29/94. The mechanics of . the accldent deacribed to me by MI. Haus were conalatent with our f1ndlns of cervical, thoracic , aiKt lwiIbar lqJury In that her car Wu not only hit from the rear but was .pun around; c;niatina I , _':~~~,C?f.~~~.t~~~e.t~~!Ip..m..!:_,;J., " ' , ,,' ' . ~..:.:~~'~.~~.~7~1~'...';;...~",,;":'! ;';"'l.':''"f:ol~ -., .~,..: .. ..... :', " ........,,:. " ,..'....'. ;..:~":'. ..,: "', -~~i-' ,.:.'. -:::. ..-' '.--:. :. ..'; .,:::..~"~.~...::~ ,":;~~,- ..~:.:: . ':;'1bble4l~ i1teiatUre that Ihive'read, iipeelal tiducationallle'!11narl thit ~ have atten4f1C1'M.d mY " "~:',': '. , . ~iial.~i#ence In,treitlns liVury ~ fo~ lIm.oB!~eo :d~e.; .liowl thai due to'the ~.~",",,:': , ". ~~~~Vorm. IS part' of the h~ i!I these. type ~ofIPr.w~_ iI\IUriCa,.ympto#l~~,:';' ,,'.' :':', "', recw'rilicClcan coDtlnue for an indefinite period of time. ' ." ." ,... "I. ,.' ,',,~,. . .""."".':::;:.. :';'.;-', ,'..." ':'. ': .~ ......~.. ....~.:'~:'~ ",. .,....:.. ,. :..;,..... 'It" my t\}rth~r opinion, to I rcuonable dep ofmedlcallchlropractlc certa1nty,that ,the, '. : " proanol" In thll cue II that theiewIU be eucerbat1oni' fot in indefinite period of time. Th1a ".' opinion II bued OD the fact that thI. patient has continued to experience the Injury related IYIDptOIDl followinS limo" 100 treatment v1a1ts to our office. Sincerely, ~J~cJ . ,I Thomu A. Boch, D.C, .ore. EKhlbll 8 . , . ,- \ , . -SUPPLEMENTAL REPORT, " lploW.r: ploW": eollnjurw: ;- ~ If . ~v 1m': 1../(" AJ o.'3SS:J '/~o7.7 SUBJECTIVE COMPLAINTS: Ar.. /J'y""f~$ 1/ ;N.ck I~ 'i- ~J'?a 16houldtr 'I' )- 11 qc. "} CJ lArm N ')I qo ,,~ 1 Mid Back '), ~O?~ Uow Bleil )G i 6 (" '9... 1 Hip 1 L'. I Bullock I O~~:~'ILl'If\.. l( qo '70 o PIII.nl,"",rltncln. h..dlch... C;.; 'Y/J wonK STATUS: PIlI.nl workln. with no IImltlllon., Pld."1 workln. whh IImltlllon.. PIII.nl ,bl, '0 work. bUI nOI working. PIII"'I Un.bl,'o work. 0.1t PIII'fll'.P'CI.d 10 ilium 10 (j Ulull, 0 Modlfl.d work: BRIEF DISCUSSION: Pili.", co".ldll.d 10 b. "mluic.1 only," PIIII"I,lIog,,"lng 1IIItl.c,orlly. fl'lIlerfl progr...lng.. Iflllclp.,ed. P.,II"!'t pro.r... b.I"g hlndl"d dUllo mlt..d IPpoh\lI1I1"", Pllle"!'t pro.,," ~llnu hlnderld dUI'o '\lIUhl prDbllm, r'IIJ,,!,. cu"dltlo" "UUIIYI,"U UUIIO nalUII 01 wOlk. .. 0". olla'l Ajlpolfllm.nl: Nlml 01 Pllllnl: ..,-;.., A 1< 6lghlollnjury: (\ '..!"MAb:/e.. MltCllllnlDUt: ~ 1:J.'1/f</ t'C1h f IJC( ..'/~..I- 2. OBJECTIVE FINOINGB: o Nonl Pro~I"n '1:!1 R"Ulcllon 01 C.rvlcal R.flue 01 mOllon Q,R"lrlcdon 01 lumbll , R.n.. 01 mOllon ~U'CI' 'pllma o Mu.cl'"lophy lJ lOll o'"l1n.lh In Perclnllg.: P,rc.nllg.: .' ..!"% fJ"'/.:.o 8'C.rvlca!>Cl Tholldo>EFlumb.r o C.rvlcal 0 Thollclc 0 lumber o Righi 0 l.h H.nd .vId.nced by J'ymlr OynImom.,erl"', o PlIl,nl holding 0 Itlt , 0 rl.hl .nlllglc po.ltlon. o PIII,n,'. 1111.... dimlnl.h.d. lJ PIII.n". 1111.... .bllnl. o P.lp.bl. .....Illn. .nd ,d'llII II: o CII..lc.1 0 Thollclc tJ Olhll: o Lumber ~. HISTORV: Onlll: /.,;,If> -~"/ TIt.lm.nl bW olher.: b I I. lh. ..I ~'" 0.1.01 11111 IlItlm.nl 'or Ihl. condlllDn: j /2l/'" N.~'" H.d Ihl. condlllon bllolI? 0 VII ,.d-No tJ PI,I.nl up .nd duwn with Iymploont. L:J PllllnllggraYllld Injury. o Plllenl..perlencld 1I.".up of Injury. IJ Plllent "lerred 10 InDther doclor, lJ N.me: Field: U Commenll: o SUbJ'CII,," complllnll "' .""11 Ihln obJ.ctly.'lnding.. o Bu....t "hlbllilltlon .v.lultlon. ."...,'",. ., Elchlblt 0 't) ,. , LARRY A. R~TH, D.C. 3545 RVAN AVE. PHILADELPHIA, PA August 1, 1994 KATHLEEN VABLONSKI, R.N. CLAIMS REVIEW ASSOCIATES 660 AMERICAN AVE. SUITE 103 KING OF PRUSSIA, PA 19406 RE: Tina Rae Haus Claim: 46N0385212027 CRA': 988,760-1 001: 1/28/94 Dear Ms. Yablonski: In reference to your request of July 20,19941 have reviewed the following records and docu- ments relating to the above mentioned claimant. . 1. Thomas Boch, DC SOAP Nota 3m94 Treatment Notes 2/22/94-7/1194 Examination of Travel Cerd NID Supple mente I Report 3/11194,4/15/94, , 5/18/94,6/22/94 Consultation 2/221fM Roentgenological Report 2/22/94, 4/4194 MUlcle Telt 3/2/94, 317/94 ROM Worklheet 2/28194-616194 ChlropractlclOrthopedlcINeurologlcel EKemlnatlon 2/22/94 , Letter of EKPlanatlon N/D Billing Statements 2/22/94-5/18/94 2. Application for Beneflll/Authorlzatlon 4/8/94 3. Notice of Loss NID The records submitted for review Indlcete that Tine Haus, a 35 year old female, allegedly sus- tained Injuries In a motor vehicle accident dated January 28, 1994. Ms. Haus stated on the Application for Benefits that she was struck by another vehicle on an Ice covered road. There Is no Indication Ms. Haus sought or received Immediate or emergency care following this incident. The first Indication of any cere sought or received by Ms, Haus was not until February 22, 1994, when she presented to the office of Thomas Boch, DC. A report dated 3m94 reported entrance complelnts of neck pain. headaches, upper back pain, mid back pain, lower back pain, pain and paresthesia In the left arm and hand. EKamlnatlon findings listed on the seme report noted palpatory, limited range of motion in the cervlcel and lumbar spines, and several orthopedic test findings. Radiographic studies appear to be taken on several dates, noting subluKatlons/mlsallgnments, and a cervlcel kyphosis, as well as narrowed disc spaces In the thoracic spine and canal stenosis In several regions. A diagnosis was subsequently listed as RE: Tina Rao Haus Page 2 motor vehicle accident, radicular neuralgia, vertebral subluKatlon compleK C2.5,6; T3,4,5,6,11,12; L2,3,4,5. Dr. Boch Instituted a course of care consisting of hoVcold packs. electric stlmulallon, supplies, and mechanical traction, Dales of service have eKtended through to at least 5/23/94 from the dally records submilled, I am also aware of eKtenslve test procedures performed on the claimant Including multiple dates of radiographs (2/22/94. and 418/94 for same views), range of moll on testing on 21 re- gions (performed on 2/22/94, 4/8194. and 5/9/94), as well es needle electromyography studies performed on 3/2/94 (upper). and 317194 (lower). At his request, Dr, Boch was conlacled on 7/29/94 concerning this file, I was Informed that treatment Is still being rendered to the neck and lower back on a 1 time per week basis, Dr. Boch further Informed me that symptomatic relief was being rendered, The conversation ended shortly thereafter, Having reviewed Dr. Thomas Boch's records, the following Is In response to your questions. 1. Appropriateness and necessity of all treatment rendered by Thomas Boch, DC The submllled documentation supports a short course of chiropractic care administered to the claimant, Tina Haus fOllowing the 1128/94 MVA, however the length of noted care has not been demonstrated as ellher appropriate and or necessary for this Incident, Minimal objective findings have been noted over the course of care administered to Ms. Heus. and even eccordlng to the treating praclltloner, care has been ongoing for symptomallc relief, AI allo mentioned, Ms. Haus did not Inlllate care with this practitioner unlll almost 4 weeks post trauma, with unknown, If any care was received prior to this 2/22/94 date. This would ap- pear to be an Inordinate amount of time If complaints and conditions were as severe as stated, Taking this Informallon Into account, along with the findings presented on evaluation, and the diagnosis listed, a short course of chiropractic spinal adjustment wllh use of some adjunctive therapies can be construed as appropriate and necessary for the reported alleged Injuries of 1128/94. 2. Appropriateness and necessity of all diagnostic testing done to date. The Initial radiographic evaluallon/analysls can be considered Justified as performed on the date of entrance, however the follow-up studies are nOl considered appropriate and or neces- sary for the claimant, Tina Haus, The routine use of repeat K.ra~' studies Is not considered a customary treatment practice or necessary from a chiropractic/medical standpoint for mosl conditions as determined by accepted radiographic guidelines, limited repeat sectional radiographs ere considered acceptable end necessary from a chlropractlc/medlcalltandpolnl In the folloWing conditions: documentation of clinical regression, significant re- Injury/eKacerbatlon, suspicion of advancing underlying pathology, periodiC monitoring for frec- ture care, periodic monlloring of sianificant underlying spinal mechanical allerallon, periodic monitoring and evaluation of a spinal scoliosis in patients who are receiving appropriate treat- ment and management. Unless a provider can submit clinical documentation which estab. IIshes one of the above crllerla, the chiropractic/medical necesslly for repeat radiation eKposure has usually not been established, No criteria has been observed to warrant these additional studies, RE: Tina Rae Haus Page 3 The range of motion testing Is considered a vital and Integral portion of the eKamlnallon pro. cedure. 1\ should not be considered approprlete and or neceuary to perform thll test as separate and distinct procedures, constituting creative I'rocedural practices, Absolutely no justlficallon hes been shown from the documentetlon presented for the elec- trodiagnostlc evaluallons performed under procedure codes 95864 by this praclllloner, for the alleged Injuries sustained by Tina Haus In the 1/28/94 MVA, 3. Was the length of treatment time appropriate? If not, what would be a more appropriate treatment plan? In reviewing the dally notes presented for this review, the sUbJecllve complaints show ex- tremely slow response to the care rendered, The notes have been provided through to 5/18/94 nollng only a resolullon of headaches during this lime period. On an objective basis from these seme dally notes, response has been even slower, noting same treatment areas, with minimal changes ovar the approKlmately 35 dates of services during this same lime span. In my professional opinion following the review of the records, a course of chiropractic care rendered for a period of up to 8 weeks In duration should have been more than appropriate and sufficient to address the complalnts/condillons and diagnosis stemming from the 1/28/94 reported Incident 3. If treatment were appropriate end necessary for the alleged Injuries sustained, a) has maKlmum benefit of treatment been achieved? b) If so, when A course of chiropractic as described In this report, and eKcludlng all dlagnosllc procedures eKcept for Inlllal radiographs can be considered epproprlate and necessary to address condi- tions aild complaints stemming from the 1/28/94 MVA for a period of up to 8 weeks durallon, and dating to 4/18/94, A maKlmum benefit from the care rendered should have been allalned by that date. 1\ was also noted that e stretChing eKerclse was not Incorporated Into Ms. Haus' routine untIl 4/1194 by this practitioner, A home stretchlnglfleKiblllty eKerclse program should have been Inlllated Into Ms, Haus' dally acllvllles soon after the Initiation of care from this of- fice. Further In-office treatment beyond the 4/18/94 date has not been considered appropriate and or necessary for the reported persistent complaints, without objective findings to warrant eKlended care, Thank you for the opportunity of reviewing this file. If I can be of eny further assistance In this case please do not hesitate to contact my office, As with all reviews of this type, a profes- sional opinion Is eKpressed. This review was wrlllen without bias to practitioner or patient. Yours for beUer heallh, ~/~.c. Larry ~olh, Doctor of Chiropractic Certified, Independent Chiropractic (Medical) EKamlner Diplomate, American Academy of Pain Management , . ,~\' \ 95.099 LAW OmCES OF RUBINATE, JACOBS" SABA 214 8euate Avenue, Suite 563 Camp Bill, PA 17011 Telepbone Numberl (717) 731-0988 Attomey. for Defendant, Oanlel W. Peters, Jr. IN TIlE COURT OF COMMON PLEAS TINA R.IlAUS, PLAIN11l'1' CUMBERLAND COUNTY, PENNSVLVANIA VS. No. 95-5462 CIVIL TERM DANIEL W. PETERS, JR., OEFENDANT CIVIL AC'I10N. LAW JURY TRIAL DEMANDED CERTIFICATE OF SERVICE Donald R. Dorer, Esquire, hereby certifies that he Is the attorney for the Defendant herein, and that he Clused I true and correct copy of the attached Defendant'a Hearlnl tdemorandum to be served by regular fint class mall upon: Lawrence F. Barone, Esquire Anglno &. Rovner, P.C. 4503 North Front Street Harrisburg, PA 17110 Date: December 26. 1996 nald R. Dorer, Bsqulre Allorney for Defendant, Daniel W. Peten, Jr. ~ :., ,..'.' . . , '~~';,~i1;~~~ .. ~ t~ ,.. !';i' .tl. ":,:" ,,' ~Jt~!:\';"", " "; ,', ';i""I,'t"c~~ """'" ,':> '. ".1': ' '; '" !':'::,:,;,,'.' ,:' " ': ;,o ;,:, " ;' :~;C:;>:" ':"~: '.,.,;oo ';" " ,', '.~, " ' "'" ,,:, ,', ." ,:,,~ ~>:\:r, (c,;:;.'":;",,, ,', '~,' ~" ~,j'.~';" '>",:" :', ,~ ,"; " ;,'~ 't," ',:" ';:'1' "I,.'>'::,. ': : ,':',' ., ,<::,~... ~ ,:': ",v' "" " ::..,;,,; I'F."""',."'. '"" "''"~:' :,.,' ~"',, :::' :': ", , ,,~,::.; " ~,:, ,i~;J.'. " ~'~~, w~-~ h'ti r~-t :," ;::~'~i: ,.',:x,..> ;'t 'L ", ,"', ': ,,:" ~rf;f . ,','C":', ",' ':':.'; ,,", , ",'; , :.-', ' ",' C! " ':', , ", ,'" :>~~""~'ri ': \"0, ': ,; ",;":': ' , " ' ,1 ",' "L,' " ' .:' ';" l:I>', " ";';"'" . '~L" ,':~:," ,<,: ':,',' , " "":":"'1:< .. <: " ' ' ' ":: "f' '" ," , ' "u ,:'.'_::::' ;;::., ;;Y , ';. ' '. C, '!' , ,.'.' ,-'--- , ' . , v. I IN THE COURT OF COMMON PLEAS I CUMBERLAND COUNTY, PENNSYLVANIA I I CIVIL ACTION - LAW I I NO. I I I JURY TRIAL DEMANDED TINA R. RAUS, plaintiff DANIEL W. PETERS, JR. Defendant _MIen Le hln demandado a uated en 11 corte. si u.t.d quiere defender.e de e.taa demlndaa expuestae en 11. plqina. .uqnuiente., u.ted tiene viente (20) dia. de pllzo al partir de la fecha de la de.enda y la notificacion. Usted debe presentar une eparieneie e.erite 0 en per.ona 0 por aboqado y Irchivar en la corte an forae a.erite .u. dafanaaa 0 aua objecionea alia demlndaa an eontre da au peraona. Sae aviaado qua a1 uated no aa deUanda, le eorta to.ere .adidea y puada antrar una ordan contre uatad .in pravio eviao 0 notificaeion y por cualquier quajl 0 elivio qua aa padido an 1e patieion de da.enda. Uated puede perdu dinaro 0 aua propiadadea 0 otroa deracho. importlnta. plra uated. LLEVB ESTA DEMANDA A UN ABOGADO IMMEDIATEMENTE. SI NO TIENE ABOGADO 0 SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DON DE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. court Adminiatrator Cumberland county courthouae - 4th Floor One Courthouse Square carliele, PA 17013-3387 (717) 240-6200 . TINA R. HAUS, I IN THE COURT OF COMMON PLEAS I CUMBERLAND COUNTY, PENNSYLVANIA plaintiff I I CIVIL ACTION - LAW v. I I NO. DANIEL W. PETERS, JR., I I Defendant I JURY TRIAL DEMANDED COlIl'LAIII'1' 1. plaintiff Tina R. Haus, citizen of the commonwealth of Pennsylvania, ie an adult individuals who resides at 51 East South street, Carlisle, cumberland county, Pennsylvania. 2. Defendant Daniel W. Peters, Jr., is an adult individual and citizen of the commonwealth of pennsylvania who resides at 910 Ha.ilton street, carlisle, Cumberland county, pennsylvania. 3. Ths faots and ooourrences hereinafter related took plaoe on or about January 28, 1994 on North Hanover Street, North Middleton Township, cumberland county, Pennsylvania. 4. At that time and place, plaintiff Tina R. HlUS was operating her 1989 Hyundai sonata on North Hanover street. 5. At that time and plaoe, Plaintiff Daniel W. Peters, Jr. was operating his 1989 Chevrolet corsica in an easterly direotion on North Hanover street and was travelling in a lane of travel direotly behind Plaintiff Tina R. Haus. 6. At that time and plaoe, weather conditions were icy and foggy and extreme caution was to be utilized by all drivers in operating their vehioles. , 7. At that tillle and place, the car directly in front of Plaintiff Tina R. Haus stopped suddenly at which tillle Ms. Haus aoved her car to the shoulder of the road bringing her car to a complete etop. 8. At that tillle and place, Defendant Daniel W. Peter., Jr. failed to bring his car to a stop, violently striking the rear of Tina Haus' stationary vehicle. II. The foregoing accident and all of the injurie. and damlge. .et forth hereinafter sustained by Plaintiff Tina R. Hau. are the direct and proximate relult of the negligent, clrele.., wanton and reckless manner in which Defendant Daniel W. Peter., Jr. operated hi. motor vehicle a. follow., (a) (b) (c) (d) (e) (f) (9) failure to have hi. vehicle under such control a. to be able to .top within the assured clear di.tance ehead, failure to keep alert and maintain a proper watch for the presence of other motor vehicle. on the highway, failure to apply hi. brakes in .ufficient time to avoid .triking the rear of Plaintiffe' vehicle, failure to travel at a eafe speed, failure to keep a proper watch for traffic on the highway, failure to drive hiB vehicle with due regard for the highway and traffic conditions which were existing and of which he was or should have been awars, failure to keep proper and adequate control over hi. vehicle, and 2 (h) drivinq his vehiole upon the highway in a .Inner endangering per eons and property and in a reokless .anner with oareless disregard to the rights and nfety of others and in violation of the Motor Vehiole Code of the commonwealth of pennsylvania. 10. plaintiff Tina R. Raus sustained painful and severe injuries whioh inoluds but are not limited to oervioal strain/ sprain I upper, mid, and low baok strain/sprain I restrioted motion in her neok, baok and shoulder I and pain radiating into her left ara and neok. 11. By reason of the aforesaid injuries sustained by plaintiff Tina R. Raus, she was foroed to inour liability for .edical treatment, medioations, hospitalilationa and ai.ilar .iaoellaneoua expenses in an effort to restore heraelf to hellth, and claim ia made therefor. 12. Beoause of the nature of her injuries, plaintiff Tina R. Raua has been advised and, therefore, avers that she may be foroed to inour similar expensss in the future, and olaim is made therefor. 13. ,.S a result of the aforementionsd injuriea, plaintiff Tina R. Raus has undsrgone and in the future will underqo qreat phyaioal and mental SUffering, great inoonvenienoe in oarryinq out her daily aotivities, loes of life'S pleasures and enjoyment, and olaim is made therefor. 3 14. Ae a r.eult of the aforeosid injuriee, Plaintiff Tina R. Haue haa been and in the future will be lIubject to Qreat humiliation and embarraelment, and alaim ill made therefor. 115. Ae a r.eult of the aforementioned injuriee, plaintiff Tinl R. HIUII haa aUlltained work lOIS, loss of opportunity and a permanent diminution of her earning power and capacity, and claim ie made therefor. 16. As a result of the aforosaid injuries, plaintiff Tina R. Haue hae .ustained uncompensated work loss, and claim ill made th.refor. 17. plaintiff Tina R. Haus continuee to be plaqued by per detent pain and limitation and, therefore, avere that her injurie. may b. of a permanent nature, aaueinq re.idual proble.e for the remainder of her lifetime, and claim ie made therefor. WHEREFORE, Plaintiff Tina R. Haue demand a judgment eqlinat Defendant Daniel W. Peter a , Jr. in an amount in exce.a of Twenty- rive Thoueand Oollara ($25,000.00) exclusive of inter. at and aoata and in exaees of any jurisdictional amount requiring aompulaory arbitration. Oatel Oatober 11, 1995 , ROVtf~.C. :;;., '/3-- F. Barone, Esqu re 1.0. No. 68921 4503 North Front street Harrisburg, PA 17110 (717) 238-6791 Counsel for plaintiff ~ ~ ARBITRATION EXIDBITS TINA HAUS EXHmIT A B C D E DESCRIPTION Police Incident records Thomas A. Boch, D.C. Reports Boch Chiropractic Center records Boch Chiropractic Center bills Tina Haus Medical Bill Summary c I ..-.--........ - ~~..., ~ ~ Inc. '1'1-000Z~r NOfl"CATION 0' ACCIDENT NO~TH MIDDLETON TOWNIHIP POLICE DEPAIITMENT 211 North Mlddlllon ROld . CirUlli, Plnnlylvlnll 17013 Phonl, 17171 243,7g,0 DIII~ o REPORTABLE NOTICE 18 HEREBY GIVEN THAT THE ACCIDENT IDENTlFIEO BELOW IS BEING INVESTIGATED BY THE NORTH MIOOlETON TOWNSHIP POLICE DEPARMENT AND THAT THE COMMONWEALTH OF PENNSYLVANIA POLICE ACCIDENT REPORT WILL BE SUBMITTEO A8 PRE8CRIBEO BY SECTION 3UBICl OF THE VEHICLE CODE, M NON.REPORTABLE r NOflCE IS HEREBY GIVEN THAT THE ACCIDENT IDENTlFIEO aELOW 15 NOT BEING INVESTlGATEO BY THE NORTH MIDDLETON TOWNSHIP POLICE DEPARTMENT AND THAT THE COMMONWEALTH OF PENNSYLVANIA POLICE ACCIOENT REPORT WILL NOT BE SUBMITTEO AS PRESCRIBED BY SECflON 374BIC) OF THE VEHICLE CODE, . },/ul ~CJ 1Q04 Z:Z.,O A.'.~Ilt.e oj"' C C~cJ<<1-{ Of ([,0 (J ~.." '\ _ 'IWi Lollrtoij -J ",9.~';I';ANL w..;t~t.:;11~"'!( (JI!OO!<<II . ('~ DOB (J.J/31 h~ PHONE2'J1'1-.f"j,;9 I 9/0 H/f.-tll.7t:JAJ6r t!Altt.lSt-? ~..... 110/3 '1Z0,U2,U",," i"olI, ADORnl e,IV llATE liP TITLE YEARIMAKE/MODELE~ (JHt:IIAOL~rrO(ftlCA 4;.6za (JA IGIL T.tJ"yj,'FKE. ~o8/18 VEH REO ~O I STATE VIN INSURANCE CO NIIfTlOIJWIOI!.!t1l1rt1AL CODE oDa67 POLICY S8~7~6a91QJ PHONIJI7)2VJ-7J1.,J OWNER NAME UDDRESS .<;AtI1[ AS nl'u",.n;1t. PHONE 9~ ~ C'1'11 DOB t7/nr/f1 PHONE~"I-I"fCn OPER"OR'O II" E elAII " d1L<;#wI~Ic.c. ,,1I~6 /?4 I )()~~ - T1TLE~J.. 1"111' ADOlInl C'IV ITATI liP YEAR/MAKE/MODELE" HYUIJD-41 SONArA S5U~1 ~ VIN Xb1HI3FdISS'Kl1024if69 /] VEH flEG_ "0. . . TA 11 INSURANCE CO r/"f{)IJ~Ttrl1L CODE ~ POLICY ;2F/:2.M3'.r",1'1 OWNER NAME UDDRESS 77/JA Jt~ o/~. ~Cj(In.J sr tJU,USU: PHONE :2.~,~ ."':'-IJ.,- OWNER NAME. ADDRESS WI_ ..... -... WI_ - -... ~, ~ ' ~~~~:/~~ ' ~~~ Office' Slgnllurl PHONE ~,~dt'VU{JaI l f/b WEA THER o CLEAR D SNOW DSlEET DRAIN )2l' FOG ROADWAY D SNOW 0'ICE e DORY o WET I 94-000239 COMPLAINT REPORT Page No. 1 04/19/94 1...,.........................tiU...titititititititititititititititititititiUti.ti..tititititi.tiUtititi.titi..... ........ ~ COMPLAINT NUMBER -> 94-000239 Received bYI RONNY ANDERSON Date/Time receivedl 01/28/94 , 22107 HoW receivedl Radio dispatch Time dispatched I 22107 Time arrived I 22122 Time cleared I 22150 """"""""'6'66666666"666666666666666666666666666666'66666666666666666666 COMPLAINANT -> COUNTY CONTROL Addre.sl CitYI Phone I ""'6""66"66666666666666666666666666666666'666666666666666666666666666666666 TYPE OF COMPLAINT -> Traffic accident Nlture of NON-REPORTABLE ACCIDENT, N. HANOVER ST. (IN FRONT OF CHURCH complaint I OF GOD HOME) 2 VEHICLES, MINOR DAMAGE How handled I Officer dispatched Location code I ZONE4 Location dispatchedl N. HANOVER ST Officer dispatched I RONNY ANDERSON Officers assisting I 1) THOMAS KIBLER ""'666666666666666666666666666666666666666666666666666666666666666666666666666 TIME ANALYSIS Queue time Travel time Response time Action time <time received to dispatched> . <time dispatched to arrived> ~ <time received to arrived> . <time arrived to cleared> . o minutes 15 minutes. 15 minutes 28 minutes ...............titititititititiitititititititititititiUtitititititiitititititititititititititi..ti.ti................... (.. " I 94-000239 INCIDENT REPORT Page No. 1 04/19/94 1IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIItitillllltillltilllllltillllllllllllllllllllltitiltilll INCIDENT STATUS _> 94-000239 Jurisdiction number I 21208 Brief eynopsi81 UNITll , UNITI2 COLLIDED ON ICY ROADWAY -., ~ Date incident occurred I 01/28/94 to 01/28/94 Time incident occurred I 22107 to 22107 Inve8tigating officrl RONNY ANDERSON A81isting officer I THoMAS KIBLER Reviewed bYl JEFFREY RUDOLPH - 01/28/94 Cleared bYl Not applicable Date olearedl 01/28/94 Cale statu81 Closed Date cl08edl / / """""""""""""""""""""""""""""'66666'66'6"6666'6666 Date reported I 01/28/94 Time reported I 22107 ACCIDENT PRINCIPAL ROAD -> N. HANOVER ST Nesrest pointl MEDIA RD Type of accident I Nonreportable Distancel 60 ft. Injury severity: No injuries Illuminationl Dark, with lights Weather I Fog,smoke,eto. Road surfaoel Ice-oovered Alcohol/Drug used? N """"""'6'666'6""""6'6,"""""666""6""6'6"6"'66"""6"""" SUSPECT COUNT -> 1 1) Namel DANIEL W PETERS JR Address I 910 HAMILTON ST city/st/ZIPl CARLISLE, PA 17013 At time of inoident - Agel 75 Hairl Heightl Eyesl DOBI 03/31/18 SeXI M Raoel WHI Phonol (717) 243-7323 ,,, Weightl lbs. Buildl complexionl SU8peot interviewed? statement taken? '6666""'666""""""'6""""""""""""'"""""""""""""'6 VICTIM COUNT -> 1 1) Namel TINA RAE HAUS Address I 36 EDGEWOOD DRIVE city/St/ZIPl MECHANICSBURG, PA 17055 DOBl 01/19/59 SeXl F Racel WHI Phonel (717) 691-1656 Type of victim I Individual Victim interviewed? Y statement taken? Age at time of incident I 35 Type of injuries I No injuries ""6""""'6'6'6'1.~"""""6"""""""""'""""6""'6"""6"6'" VEHICLE COUNT -> 2 1) AUTO - 428222, PA (89 CHEV CORSICA 4SDN ) Type of property I Disposi tion I 6' " 6' " 6' " " Destroyed/damaged Value of vehiclel $0 " " " " " " " " " " " " " " " " " " 6' 6' . I ~ , "'" ~ BOCH atlROPRACI1C QJNIC 323 VarIl Hold c.w.. PA 17013 TtIIphone: (7171243.6396 August 4, 1994 I,awrence Barone Angina' Rovnsr, P.C. 4503 North Front street Harricburg, PA. 17110 0"'1)1' 111'. BIIl"One: '!'hin lotteI' is in regard to our patient Tina Haus and your requcst for an update on her coml.ll:ion. Currently, I continue to treat Ms. Haus on an active basis. I am seeing her once every 1 to 2 weeks. She continues to o~verience intermittent neck and low back pain. It is more than likely she will continue to experience these problems for an indefinite period. We are attempting to spread Ms. Kaus' visits out and once we can get her to a point where she is only being treated once every 4 week., I NiH release her from active care. I anticipate this will 1Jt' 111 another 3-4 visits barring any complications. I am onclosing a sample of an A.M.A. Permanent Impairment Examination and Ratings report for your inspection. In my opinion this is the best way to ascertain any l,ermanency related to impairments or disablilities. Our normal fee for this service is $450 and is not normally covered by a patient's insurance. If you would like to have this done once Tina's conditon is static, let us know. Sincerely. " . 'lI...- ,,_ lr.,&d..cQ.<!.. "'I'fiomasA. Bach, P. C. TAB:dis Enclosures Dictated but not read . . .-.. r... .~ .x:H atlROPRAC11C aJNIC 323 VarI< ROId ~. PA 17013 TIIIphone: (71712436396 Fu: (717) 243-6444 September 18. 1996 Lawrence F. Barone. Eaq. 4503 North Front Street HarrlIbura, P A 17110 RB: Tina Haul D.O..\. 01/29/94 T'IDI Haul preaented henelfto my office on 02.122194. She related durina her Intake conaultatlon dill Ibe had been Involved In an automobile Iccldent on 01/28/94 and had been leen by another ClbIropractor, Dr. Jamea Wharton ofMechanicabura. prior to beIna IMIlIn our office. Her eDtrance complalntl WIn aeck pIin. head.".... upper back pain, mid back pain, lower back pain and parutbea111n the left arm and hand. Theae aymptoma were wane In the momlnal and were ....vated by 1if\Ina. a1eeplni and any type of phyalcal activity. Tina Haul WU, at that time, I weI1-nourlihed, white female of normal welaht and IVerljJe helaht. She appeared to undentand all of our conaullltlon queatlona reprdlna her condition and I had no nIIOn to believe that she wu exageratIna her aymptoma or malInaerlna. bued on my put 27 yean experIlDClln .1I'lI with InJury cuea. Her prevlOUI trauma history Included I broken ankle In 1973 and I car/motorcycle accident In 1987. Suralcal hlatory was limited to two c-lClCtlona whlcll were performed In 1984 and 1986. OIl1ntake, when ukecllf Ihe was on any prescription drup, her reapollle was In the negative, Our examination ofM!. Raullndudecl x.raYI and I phyalcal exam. There was tenderneu to palpation In the paravertebral muscle It the foUowlna levell: C-5 to T.land L-3 to L-5. There wu UmIted ranae of mati on In the neck and low back during flexion, CKtenalon and lateral bend1na. CervIcal foramlnal compreulon tcst was politive In hyperflexlon and hyperextenalon. The musclcs palPlted were and judSed to be In mild to moderate Ipum It the followlna locatlona: C-l,5 T-7,9 and L-3,4,5. Spinal X-fIYI revealed vertcbralaubluxatlon at: C-2, L-3.4,S, and wedSed diSCIal: C.S,6 T-3,4 T. 5,6 T -11.12 L-2,3 L-S S.l. Theae areu correlated to the patlent'l aymptomatlc complalntl. Alae preaent on the patlent'l Itltlc literal cervical Nay was cervical kypholll, which II I clasalc findlna In cuel ofwhlpluh. Some arthritic chansel were seen at C-4,S,6. The left lateral bendlna x-ray revealed a 1011 of IlfJ:II1oII motion blo-mechanlcsln the lower lumbar Iplne, which a10111 with cervical !typhoall were objective a1JP11 oftrauml and vertebralaubluxatlon. Our diasnoall at that time was whiplash, cervical, thoracic and lumbar sprain/strain and vertebral . ,~ ,-.. . . lUbIuxatlon, MI Haul wu treated In thll office tTom 02122/94 to OB124194 approKlmltely fifty. tIvee times before belna releued u havina reached maximum medlcallchlroprlcllc Improvement. Her lnItmentln our office COnallted of chiropractic Iplnal adjultmentl, Interferrentlal electrical thenpy, hot packl and Inleneamental traction. At the time of her relwe , she wu It III experienc1na nedland low back aymptoma, We continued her care under her poup health inlurance tom 09/07/94 to 10/16/95, treatlna her for noc:k and low back pain for approximately tb1rty-elaht more v1I1l,. MOil recently, I wu conaulled by MI. Hau, around MIY 23rd ofthll year for treatment for another acute epilede of neck pain and left arm and hand pain which relulted tTom IOme prdenIna activities. IlIw her I total of 5 times, WhIle MI, Haul WU beIna lnIted for her accldent of01l2B/94, 1 advlaed her to avoid heavy IIft\na. repeated bcnd\na. tw1st1na of her torao and overhead work with her 1/11II and hand,. I a110 prellCribed a home cervical traction unit for her to UIIl outalde the office to help mtore her normal lordotic cervical curve. In my opinion, aile ahould foUow theIIl auidellnea permanently. In my opinion, to a reuonable dearee ofmedlcallch1ropractlc certainty, the injuriel for which I treated M,. Hau, were the dIroct reau1t of her automobile accldent of 01129/94. The meclwUCI of the accident deacribed to me by MI. Haul were conalltent with our findlna of cervical, thoracic and 1umbar Il1iury In that her car wu not only hit tTom the rear but wu lpun around, creatina I coatbInat1on ofwhlpluh and torque to the 1Ip1ne. The medical Ulerature that I have read, lpeCial educatlonallllmlnara that I have attended and my personal experience In lnItlna Injury CllCI for aImOIt three decadlll, aIIoWI that due to the ICII' tIasue whlc:h forma u part of the healIna In theae type of IIpralnlllraIn Injurilll. symptomatic IWIUITIIICIl can continue for an indefinite period of time. It Ia my ftu1hur opinion, to I reuonable dearee ofmodicallch1ropractic certainty, that the propol1,in thI, cue I, that there will be exaceroatioDl for an indefinite period ofUme. ThI, opinion II bued on the fact that thll patient has continued to experience the Injury related aympIOIIII foUowina a1moat 100 trel\ment vlaltI to our office. Sincerely, ~J6,c1 , .I Thomu A. Boch, D.C. ,j),.c. ':"" .. i '. ~"'~~ ~lv~ r~~,~ ~~ 11\ '\ i0r~ ~ )C ,\ ~ ~ \I\I~}~ " _ _ II J~ I) OJ 1\.', ,,:' I'~~ , _ _ _l_>/.11\ " " ':'<~-"- \ \~'~I"''\~)s~~~; .),), \ \l'\I\~ \. I ~::~ >'-' N \ \;~, ~l~~ \'0 ~ ~~, ~ \ \ ~ ~ \r\r\~~_ "i n II ~ l! I .~ ?-i~ ~!\ "I'" '( _ lI" ~ ~ ~~ ~ ~~ Q; ~I~I\I\~ ~ \ ~~~liiiiflAIII ,>~ :\"lr'~:~~\~:tl~:r;~~~~~~~~~~~\ 4;--.~~ \ ",,~,~I,~\~~~ \. ~rT\ ,,~ "\"I\~~" \ ..,~~~~ t: \" ~~ ~ )...\~~~ ',,\ ~\~ ,)\ \K~~~~. '. _ n ,~;-~ ~ \ ""~,,~~~~\ ~I~I~~~~~I~~~ \r\~ ~~~ ~. :: ~ ' \ "" "i.~I~ '/:~:, \.'" '\ ;.'\ :-01\ \ \ ~~I~ ~r,-i,?~~ .~ 'Jp :! \~t\I~~~'~.~~, H \~I\~I~\ ~\f)'~<:~~<,~~ 1. . ~~P\~~Ib\~~~\~~~~~I~~'''~k~~\l\,\~,''~\.~\.'"~ ,~~~~ t! \ ~',.., . ~~~~\~~:~~~I~ ~1'lJ~J~)I"\~\~~~:~'~ ~ \~ ,~~ ~ :: \~ " "-,,. I~,~"\ "~I~~~:X~~,~ \~I\~'~_\ r~~ ~" () - I~,~[)(. :-.- S. ~ ~~.i'. .;.;;,t: ...,.~ &;~", ~\~~I'~I\,II'\I~\ \\\ \J(~\~\~~I\I~.~~ .'~' '1:..~~\) ~*, ,,-or \:1. 1\, "r. , \ \' I'u." 10..... ,,\K'\: ''yy .~ #..-..:.0 ~"':-....... .I''''I~ ~ '\ \_\1-':> ~ "',",I ~ ",;< .... '\ ___I..~~ . \~~~. ,~ : ,~q(.. >~::~::: .. \ " ,,", ~ \ \ \ \ '\ \ \'\ '\ '\ '\ \ \ \ \ \ ~~-:;: ~.'~?>-~x: 1. ", - o-'-l--'-- I\~ \.~ ~~ :;.<.." ~ "~' ~~ "I\~ ., I~~~I\ \\J\I'\~ ~~\ ~I\;I\.. <'. ~~\'. \ "-....., q.l~ '\ >.-I' . rc \ - :,"'. \~, [\ I'\, IlL 1\,,, 1\-' t::.:.~' ~ ,,~.~ ,,< ~~ WI \4. f\\LJ....:., \, '. ""'( "" "I'dl'l;: ~I''\ ~I~~ WI ~-1 ~ ~ !!~~.u~ "\~~~~ ~~~f3~~~\~~v~ ~ "\~~~~~'''~ ' . ~~ · \ 'i-- ,,~I'!l~~'\;'~'" ~I\ ,,";\. ,~I\I;~~~\.\ u,~'~, 9J" ,\. ," I\. I\. I, ",," '" '" ~~_I\.- . '" ~:\ ~ r-...... ~ OJ " ", ~ "I~ \ \ " " '\ '\ -.;,;: \1 \1" OJ 't, ~~ ; "'~ ~ ;.:; ~ >~::t:-o \" J" ~ '<: ,,\~ ~ ~ '. '~~ ~~ i \i~ ~. '. ~ ~~~~ '.~~\'~!&~ ! .~ ~! ~ ~\ri~ ,,:-:;)1.. ~ 'I ~ ~ \(:;~~, .~I.~ ~" ""\..:,,,v~j',~~.~ ~ \~t( \ WI ~ $ \\\~~}~"'~~'~~\~"\~il)\ \~ - " , : ~ 3 ~~ ... 1 ~ ~ ~ ~ ~ ~ Vl ~ \j I~ \~ ~ : : ~ 1III1 ~,~ h" , ~ J~, ~I,( ~lv ~.~ ~ 'II.- \i\. ~ ?I~ f ,,_ f. ~ ~ ~ I,.~,~,!t \~~,.1~ il: ll' IllI ~ -\\."'.....(, \S L 0", N,... -;,.... l'( ~ c '" ." . , . l g ~ ~ ~ _ H~ ..J ! !~!~~~~~~~~ G '~h' r;,,/I(--'I;)/IUI ou. ';'D!il (t ,J] !,IlVII ~11 r)\ \ \J U \ L_lInuv,j <:;;/..... ,'-_. ,._. 4 ., "{''';'', 11~1~\oI~r.~~';~'-\"~:~~~"~t~:i\:~;,~~:~,& . \ ,~., ,,' '.' 'I' .... . . 1~'\.I~ , 1.\J'.i\I" ' ..J~I~If\ .~r~ ('a\J,~ ~ . . A'" \ ',.'4i;',,~,' :' ". '" . '. ',", " ,.'''':'~'~ ''''1''''' ~,." :.,(.' .. '~" ~ . V!~ .. '.' .'~;\ i' i;\'->> .;'!'; , '.N~ ,., ... ~;: ~ .~. " " . :~ ..~ "~I ..' . "~i"~~ ... ~ .... . ....'V~:::'l..r., i "~~ " ..' '.~'~N~, ," . .' : .~~; ':., '. .. . I"II~~,\!. II . - I'..... ,1!''' tl ....~, .. ~ ...' . . \:\. I. i'~ "'I .. .....:~ .....: \ . \ .~ '., "~~,, .. ~ '. .~. ,,' '1"..~II...',\"",:I...~! ~' "." ., ~r,,~. i: :. :" ", \ ~~t&. . CI .;, '-'IiI" ~:~';'., ~. . .' ',' ...... " ; . · ~ \:"'\T . .~. . "l ..-' . ." ,-,,'. I', '.;1, :rrJ . ." :. ~ ~: :. r.~ ~ :.: "', - I ' ,~~ ~;, ~:, ~~ t.. '. ~: . ,'~.,I'~. "'" '~~~~',.::,r., ...~". ~~):;,~,;~~,~~'1,1,., ~'. .~~ .... ,,'.- , . - '.'.. J '"", J.\ .,..).1,"" ~'_\' ~ ~ A'~ :1:. : ' · ;; ;~'?-'I ~'. " .,' .~. R' I~~~l~~~:.~ ' .' : :':', '~~'.. : ~ ~l 'L"" '.., ; · ~ " lOX" , iII,' , '~-. ,....'.'.'fl. . ~,~~~~. ;II~~' , , 11, ";'. .. ",~ J~~;'i :~~,:'~.;,; '.: ~IIA~\'XI~ '~~ .1"!.1: '. ,', '.,,:.~I~' "~~~'J~~~.'.':\1~.:."" ;:~~ \1'; :,~, "':'t.:.,lf,Ir; ',. .,. ['t' ',,"' ~, ." -. ,,,111 J 1>= ... ~~ :-"'<, ~ . I, ','~..:.:" '~\'" 0.' Ir' ,~~,': .;;"~ ",~'"'''' t~ '. ~ ", ,',:ll, ':"~"'~Il'" : .,.,~;.q.',.I... ~I. .. ',Ii.. ~I'v-II' '. \,' .' ',' .., ~ lE:~' N' ,~ , "\" '~~.~. .;.: ~ .,.'.. .\ 'J\~,~.~. .; . E~'" '. a.~S;~::t\~'~ ':, ,-., ,,,... I' "~' ...~ '. ',.' , ....... . .., ,.. .... .'~ . t. . iii ~.. .), ~ . . ~ ~ .( , .... ' .... ~ , l j' .~ t: "~. '. ''''~,''' ..~~-. tl~ ".. ". "" I,.t '''-:;: t, \t . ':: I . D '" ':-r . t . i~, ....~ : I~\I~ I~, ,. ~. "~ '; ",~,~, ~., ", · t ~~ f.! J , rn . .~. Il\ ~, " ,;, . r' ,.:1;\ 8. ~,'. ". 'j. -.'l:!o.'" .":.' f' ~ t.. ,- ,. ~:. "I~" ,t... - ,Ilo."~i ,..... ~..~" '..' '''" " ':,",'; .. ~ ~ ,,~~.~ . ~... . 'I. l~ 10 r . ",. U"'~:A' " \ -:'1 , '. . 'i.. I' .'t.,'fff.. :".1 I .". l ., !.:.. .. ,', ,.\.N"i\. r.'g'~~~"~'" .., . . ",",. .,... to- , -'i' ~ .. \",1.1' V,.' ~ ",. '-......l'\... '" llt '. S .... .", ,I' " -' ~' .. N: .~~. '~", ~. . " ,', . . ''Ii ~ ' . .... ,.. ') , " , , "' , , . " ',. "', 'J., .~, ., 'll' ~~< -:. ~ il'lf ~. , :X:' ..' I' . ~ ~ :'!' " :', ~, ~., "'. ' l;St',,;,' ,~,li'\~i~~;":~~ ~'~~I~:!~'R~~A."": l:,..., ',~~/~:~ R. B J ... . I,~ I~~\: ..OX \,\ ,. , ~ . l~i.X 'X " '~. :. ~,') If ~. ~~ ~~' ~ ~ ..J' "\ - I'- ,,'~ . . "~. ,~K'~ r\.~ 1{1,. ~ 1\0: '~""';:", '.~ ~ ',1:' 1- .... ~'} I;''N::.~ _ ~ i\ttT~~ I:r' 1;\.i:'\I~ !. i",~~:" If '-" ..:;......:' 'j "', ." .... ~. X 1?0o..,,,,,, ..' ,'; i\. . ~;, , \.",~ ~ . . ~~., " . ,~. IL ..' I~ .. .\: .).I"'~" .,'I.~ IRI\.I':\I',~ '! ,.\ '. ,_ ." .~. ,\ .. ;~ '. ~"I,... ' . '. '. oi. . i\..~' : '~~I~'~~ ;:'.' . , ~ I ~~-~I~'" . ')..~I 1"1\11~ '-.: '" I:' . t I ',' .'# '.; \ ,...... . f :'.~~. , "" 1 ~'-'\I"'. I."" :~'" .., ~ ~' ~ . '.'1 ," ,. ~'~ t~~~ ~"> " I ' .~ J~ ~,:fJ$; ~ ", '- ~I!~:' : ~~~ ~{~" ~\< "L:, .:-:~ '~I' .. I~ '~"".~ "'.' .la, ~ I . II'" '..~( -'"i ;;" .... 1-'" ~~ .. ..'" ~ ';"S~t :-, . ..' .. oJIII ~ '. . '1" <1' W ;;..~'~' ~~ ,..,: ,., . ',' '. .:-. I~' , y" "*''' l'it- ''''. "" 'ti." '! ','. :0:::/ 'f; r. 1... :, I.i ,'; . '. 'I..:" · . ~~ ~ ' ;jJt ');?; ';:;. .j If,: . . t'. . C. ~ .. 'l " ." ~ :\~'I ~. I, v. ... ~. ~ ~',W ,l' .1 ~ i~ t I...~ ti i... ;I~, ," J" l~ I.." ~ N~: ,~j ~t ~ ~ .. :' 'of, "-:,: : ~ I~." ~ '~"'';' . ~:I~\.~ 'VI'~'( ~:.~ ,'I' " .:.1;.a~~W I],:.: i. ~~ It...:' ri;.,::'\~~~ .~ .'1 " ~'til .'C ,(, I)~ ~~I~' ~ IJ:n~ J:., , .i! l" .J', ~, It ".,....{~~~'~,ij~~, I~~: :-Ir~ l'~ 1~~I~~.' ~ ~ r'I~':~'I:""ii' \', '~i . ('; i\II"~',,~I~I~,;m~'~,~ ~ k '" 7~flt:, . ~ l ~'~I~ ai, ~t~~': ,~,' "~ICi' ~~~ \~ ;".. 8~ t 'It 1:~~I~~, ,'Ii.!'l.. .I~}l . ""., J t'~"1 {8,P<~~ i bi ~ ,M :;,. ~ .~;t! . I,,::. t . .. t~ f* I r ~ " I,~ '!. lat.", ", ~I~I. ~I~'.' . , ,J 1m.'..~ " ~ 'I,~. :'~~ ". ,;~ 1m'..." !~~. ~ ~~ ~lll' III')'~(I. '.:. :. , 'I ,,~::: ,.....~.: :;.~ 11II~' .;~.;~; . ",'v , . /1' '.'~ ~ olol!. ;;. ;~, I' ~ , ! ., . .{~' .~: ,; , I'~ ......~ ... ; 'IE.' ." ... '/0 ',~, J;.T /.... 1', "",l't. IU'; ~lll I'. " ,~ il "a; ';,' ~, :.., ';".j' ~ ;"li~; '..~ ~,:' ~l:, .': ,'l'!:...., ,'... .,' 1111 fl,,' 'I ," . '. "w, ,,:l f I;~I. I , I., :l...' ~" . I "J.~ t.. Ji .. .... .. t,.:: "...,._"" .., .... . . "_,,t..'h~,~,~~,':II tt.I,,"',1~f.'. .::":.:" "OJl,..t .I..,....l! fl". ','-- :.. t '. . I '. " ". ..'....l."t"P tt:,.....':. -,t" t, ;.>1, " . ,:"'V m;( ." In- .j:.'S- 'i.l{nyl'~ l~ ~J.S ~ 1) ~~'''''; ~r'C~t!~'\~~1\1\ \~[\I\n .. ~~lh\.I~~\~'~'\\\"l\h .1 . ~-{,..~ N ~. ,'N~N:l ~ '\1\; i~ '\ '\ \ ~ ~ \. ~ ~QI l! i ~~~ flK~, '~11~\1\:'~~ \\ ~\;R~~~.. Rill , '--"'~~~ l! \~. "I _ ~ \ " \1\1\1\ ~\}. "'" ~'u.. .. . 1/i;t" Illo...~'- l! \. &:t.' .,~ \, \, ~ "'" \, \ \ \ \.. \. ~ ..... ~ . ~~' lh.: '"( ~ ~I~ I.."\~'\,.....\ '\ , ~I\!~~ ~.~ IO~, .>::.' t: ~ \ .... ,\!lo.,\ 1'1- ," \.\ \ \. ~,,\ '\,\~ \I'\~~~\ .1 . .. "-....,h\ ;....'9~ ~ '\ ...... \. f\.J\. , \ \. I\. \.1\. \. \. \. \. \. \ ~ ' ~... n.! .....~I~ I~I" ___ ,'-'" " - .', ~ \. I .!.!-a.... ~I.:J""'!!' 'al~ ~\, .. \ \ ..., , 1\ 1\ I\.~~~~:~'" .~.. ~~ ~ ""I' Wo..'\ ""t '-. ,,~I \ . , . I \. ~.. "'~X '~ . "'t ~. ~ \, .' "'~ \, ~ '\l" \.. 1\., \ I\.!\, '$ ~..' ,r;.... .'..""'. 'i ;! ~ ,,1'"\ I~II'I( ~ ~ g.;"\" \"'" \1" I"'~~\~\ ~ '" ....""C..~ . :;;-:l: "':l:ItJ'" ,\" , '" ,1\ I', I\,' I\, ~ ~ \~$N-S: :..: S.....< "';"Qi3-, ~ lI.' " " , " \, \, \ , \ , , '" \. t! ~ \, '" .~ ~ ' _ .......:T~l \, ~." \, l'\-I\, . I\, \, ,..... lo..,:1.. ...:, "to ~......... t!.... ""I\~ ..... I~IR, ___ , \ \..\ '1t ,J~~~~&.. "'" ~ \:G ~~ ~~"(I ~ J4;\~ "\ A. r'\ '" ",' I\. $: ~'\ ~~ I~~ l!~~ \'I~~\\~~\\.~\~l!' ,,~. '\: 1 ~~ · ~ ~!l'\ ~ ,~~,~ ,'I\." \ \I'\~..' .~: ...~ '~~ .I~ '~Il-.r,,'~~1\. ~ ')..,1\..' 1\ \, , \....." ~ \ ~ ...., . ..$\ \.~ '~"~.~I~.o:.~I~~\.\.\,"~,,~,, .~~;!~ ... r ,~ )(s(1~~'~" '.... "'\ ,,, Ir ~'" '\.~ .,.. "\.1~ '\ t' ~,..~ ~ "'( ~ ~ \. ~ \.. \. ~ \ \: \. \.. \1\ ~~r. \.~~ ,~:.: " " ~ 'J\f\. :-r.1\.\1 '('\'-- " r\~ ~.. -.. (0 .. N'~:J ~I '\ ~ r~OO r\.. "'lo. , \. '.. ~>' _- ~~~. ~~~I~ tEll. I'\. ~\ ~~~~~~I\l\l~. :. l! I~ ~ "). ,,'~l~~ '\ ~, .. ~ ~ ,;I:I~f\ I\\. ~ k ~\S ' r.......~ to ~I.A!Q '\ '<;1"\1'\, ~ ~ \ \. \.\~ to ~ ~~ ' ~~~_~ I'. \., 1\.:" ~\, ~\ \ \I\~~ .~~ Ii r- f ~)...,~ ," . I,;;, ~ r .) ,J c .' ~ IIli . ~ ~ '11 ~ ~ i tl V1 ~ j ~ ~ ~ !' ~~'.~~ ,~' l. : ~,~ $Q !9 r- ~ ' ~ l~ UI~ ~ \.~~ ,,' "'co ~~ ~ ~ ~ 'I\. ' '\. '~ti' ~ '\. ~ ~ ~ \ \. ~ '\ \. ~l~ '{ '\ ').,~ ~ I ~ ~ II - ~ 2 -' ~ ~ V) I~ t 2 Vi ~ l~ ~ 5 int ~ ~ II' II \~0 ~ ?'- D C6 ~1lI ,.l . ~ ~ r; -t: '31 l..j If) ~ -...J -i ~ I' ~ u. . . I ~~ T\ ~ ,'~ m i~l:- ~~:fi.s ~13~~~~j ~~ ~ ~ ~ ~!'!'!'! ~~ ." -: ! ~ ! ; I! ". 'tt;\! !,~,~.~c'iu , ~CIDENTAL INJURY REPOC II your clinic villi II dUI 10 In Iccldlnt. pi.... dlacrlbe III IVlnll ..IOClllld with II. DATE OF ACCIDENT - - i) HOUR OF ACCIDENT -1 (\ " 1"(' TYPE OF ACCIDENT: [] WORK RELATED th'RAFFIC [] OTHER . ._It .If' 1J1I "Oel8tH' "MPLOYER " WAS'~NY E IPMENT. MACHINERY AND/OR OBJECT RELATED TO ACCIDENT? WHAT KINO? " WAS A IDIiNT REPORTED TO SUPERVISOR AND/OR EMPLOYER? [] YES [] NO HA WORK~'1l COMPENSATION CLAIM BEEN FILEO? [] YES [] NO TIIA",O AOO/DINT / WHAT KIND OF ,?HICLE WAS INVOLVED IN ACCIDENT? [] TRUCK P'CAR [] MOTORCYCLE [] OTHER WERE YOU A e(DRIVER [] PASSENGER [] PEOESTRIAN? IF A PAsSENGER. PLEASE INDICATE YOUR LOCATION IN THE CAR D~\\! E.R WAs YOUR VEHICLE MOVING WHEN THE ACCIOENT OCCURREO?~S [] NO MPH? !\PrRMIC" It.lC; ~ \...$.,\.t,. DID YOUR VEHICLE HIT OTHER VEHICLE/S? [] YES ~ WHERE? DID OTHER VEHICLE/S HIT YOUR VEHICLE? Il1'ES [] NO WHERE? ~'6\\ WAS ACCIDENT REPORTED TO POLICE DEPAR!JAENT? ~ES [] NO WERE TRAFFIC CITATIONS ISSUED? [] YES m1l0 TO WHOM? DESCIIIIE ACCIDENT INCLUDING CAUSE/S ANO SURROUNOING CIRCUMSTANCES . f.R ~ t'b"5JRn!"':{)~ ~~ t\>1(;tIT ~I$r, ~~ ~cruU~Jr Cl~~\\!ER (ml'B."'~ , ~'t:"\~t> ~ ('....\h!.l-~~ l\i'; (Cor)\' \"tS",~ ('t!tIpjf;TF.L~ ~1~1 H'"NT OOIl"""NT II'kEAllACHE 61NS a NEEDLES IN ARMSI\.EGS D HEAD IElMS TOO HEAVY If NUMaNESS IN FINGERS. ARMS. LEGS D HEAD a SHOULDERS TIREO a HEAVY [] CHEST PAIN D MENTAL DULLNESS [] SHORTNESS OF BREATH D LOSS OF MEMORY D EYE STRAIN D EOUILlIRIUIoI PROBLEMS [] PAIN BEHINO EYES D DIZZINESS C EYES SENSITIVE TO LIGHT cs=v C FAINTING C EYES LOSS OF FOCUS C TREMORS C DOUBLE VISION ~ALPITATION C EARS BUUINGIRINGING C.. ,) ECK PAIN C LOSS OF TASTE - ~ECK STIFFNESS C LOSS OF SMELL ECK MOTION RESTRICTED ~INUS TROUBLE r::::-::l PPER lACK PAIN/STIFFNESS II XTREME NERVOUSNESS -~) II"joIlO lACK PAINISTIFFNESS ENSION ~. ....LOW BACK PAlNISTIFFNESS iii IRRITABILITY ....' D DIFFICULTY IN EXCESSIVE ..IsTANOING C WALKING [] RIDING ueEN IlilECK. LOW BACK PAIN a STIFFNESS UPON RISING, / D'l'AlN RAOIATING INTO llRlGHT ARM C RIGHTLEG C BOTH C LEFT LEG JlI'LEFT ARM [] BOTH CPIFFICULTY IN EKCESSIVI' LIFTlN~[] LIGHT C MODEjlATE C HEAV't C REPETITIVE lI'PAIN RADIATING INTO lI'NECK uBASE OF SKULL II'SHOULDER "'ARMS CHIPS C LEGS 010 YOU REOUIRE POST.ACCIDENT HOSPITALIZATION? eYES g{ N~ IF SO. WHERE? HAVE YOU HAD SIMILAR ACCIDENTS OR INJURIES BEFORE? C YES., NO . SYMPTOMS OTHER THAN ABOVE ~ AIR ~ Dill'fli ctb~ .1C.1.S", S INIUIIANOI COII'A"III '''~QJ.~'O - !it'.3'1~ l'12.Wl~('I1 INSURANCE COMPANY OF PA'tlTV RESPONSIBLE FOR PAYMENT .~ruim\IU I ~l HAVE YOU BEEN CONTACTEO BY AN INSURANCE ADJUSTER OR COMPANY REPRESENTATIVE ABOUT CLAIM? 1lO-=-buJ; / :r dilL ( l)fItt~d.1\'1GM HAB YOUR A"ORNEY ADVISED YOU IN THIS CASE? C YES Il'NO . A"ORNEV'B NAME. ADOREd r~EPHCU>l~ .-t~.tl ~ . ^ PATIENTS SIGNATURE ,If) ."t _ ~ (UMd DATE ?.,?,'z=Q4 At.@) TYPE OF BUSINESS C ANXIETY I!"tXTREME FATIGUE C INSOMNIA C NEURITIS C FACE FLUSHED C FACE PALE CjXCESS PERSPIRATION "OIGESTIVE DISORDERS C NAUSEA. VOMITING C JlIARRHEA ....IlONSTIPATION:;;O~\o!. II1lEPRESSION C llWOLLEN ~EET/HANDS COLO 1. LAl) C DIFFICULTY IN PlIO- LONGEO CAR RIDING -' ... , CO~ ~ENTIAL PATIENT INFOR" ~ON Thllollowlng Informlllon I. n"dld lor our 111...0 w. eln blUer "IVI you.. I p.Ulnl. 1'1... fill In III portion. 91 Ih lorm, II you n"d Iny hllp. pi.... ..k Ih. flelpllonl.1. _ ,:) () _ <- DATE WERE YOU REFERRED TO A CERTAIN DOCTOR AT THIS CLINIC? IF SO. WHO? -\~() WHO REFERRED YOU? ~{"ie"ll' (~fII ~H,~ IS YOUR VISIT DUE TO AN ACCIDENT? ",,:es 0 NO IIF YES, PLEASE COMPLETE DOHl SlOES I WORK PHONE (~I ~8 'ATI'Nr DArA-T- n ... ".:l ._.if ';l at=:' NAME HOME PHONE (:1J1. I ~ ADDRESS r;' CITY 1 :: STATE .Ell.- ZIP J2D.l3- AG~35' BIRTH~~~ ,I -:.\ ~':e~ ~ARITAL STATUS _ NUMBER OF CHILDREN ~, OCCUPATION ~f"~MPLOYED ByfA~l!~J1III\ ~)~l. - _ NAME OF NEAREST RELATIVE h~II.II.I'li' 8N"li~"""\;R ((~I;(~ PHONE NUMBER (1.lZ.) ~"I" C\1'15 DRIVER tlltl' ar trJlrt eR 111I8B...IIB L1C. OCCUPATION E""l aVEI'I ADDRESS PHONE · HII'NrCOM'LA'Nr "\"'fllI ",' J..rC' (I ~~'~~:-:(~~k-nLJ'fv..'- BnlEFLY DESCRIBE SYMPTOMS ~~.lI\, tS\,\ \\ol(5C; Ill"'Jl~ r)~ -. u\!~ LIST OTHER DOCTORIS SEEN FOR THIS CONDITION ~S \1I~ .lalCAL HllrOItY (II Iny of Ih. following orl flll..nl 10 your midi ell hl.lory. pi.... chick Ihl Iccomplnylng bel,) o CANCER 0 MUSCULAR DYSTROPHY 0 RHEUMATIC FEVER o POLIO 0 MULTIPLE SCLEROSIS 0 SCARLET FEVER o TUBERCULOSIS 0 CONVULSIONS U"t.ERVOUSNESS o HIGH BLOOD PRESSURE 0 EPILEPSY 0 ASTHMA o HEART TROUBLE 0 CONCUSSION t,t. ") ~~' IGESTIVE DISORDERS o DIABETES 0 DIZZINESS f V' INUS TROUBLE o HEPATITIS 0 ARTHRITIS f 1ll]IACKACHES o GERMAN MEASLES 0 NEURITIS B"NUMaNESfi. I') o VENEREAL DISEASE 0 RHEUMATISM . I ....L , ANEMIA (tlr<Jtr IIlI' DESCRIBE THf. ~ERATIONS YOU'VE HAD: PI'" .....~ .1"b,."W.....I.l~ u: I'lH ,I... P' .....in us-...... WHEN? V\~~A~t~~a~E~ T~~A~~~'~~A\~~cfAr.;.fo~;r~,r?H~~L\~~t~om~.IN THE LAST YEAR? 0 YESII'NO DESCRIBE CONDITION DATE OF LAST PHVSICAL EKAM '? ARE YOU ALLERGIC TO ANV MEOICATION? 0 YES rio WHAT KIND? ARE YOU TAKING ANV MEOICATION? 0 YES Irllo WHAT KINO? ARE YOU PREGNANT? 0 YES llU40 DATE OF LAST MENSTRUAL PERIOD 2. -~ INIUItANC' DArA ICllnlc polley "qui... p.ymtnl.".ng.m.nll b. m'd.~n h 11111,"111 -t. paullf:1IT IA~..,v.u( ;;'1 NAME OF PARTY RESPONSIB~OR PAYMENT HATlllIIIl.lIh . ~~1 /&12. Vl'HOHE NIl, (-) 111\"1101. pp;fli~~ (\)kWII . DO YOU HAVE INSURANCE? Y S ONO COMPANY PIlUlI"ut'IAI I /'1\t.:lM!i} ,t'AII un ALL 10UltCII 0' INIUItANC' lp."TIIi~rS~NSURANCE t.--In~\LL1".\bLL:Ii!C, .LjEMPLOVEE I.D~O, ""I~'" J. .. POLICY NO, -_ (.,'2.AI _ IPS".'" ,....'III:I...."'E GROUP NO. . MEDICARE NO, WORKER'S COMPENSATION OTHERS ~nll. ~H'5 . ~~,,"J. Clbcw~ ~~m \\ry I und...I.nd .nd .g".lh.1 h',"" .nd mld.nllnlUllnco pollC'" "..n "..ng.menl b......n .n In,ullnco Utll" .nd my .lr U und".tand 'halthl' ofliu Willi...,.,. tny n.C....ry "ports .nd lo'm. to .UI,1 mil" m....lngcoll.clionhomth.ln.ur.nc.com 't an .t.ny .mounl .ulhorlrtd to b. Jl.lddIItCIl'f 10 thl, olllel will bt ertdU,d 10 my IccounlUponftc.lpl I p'rmlllhllofflclto endo,,,cooltlutd ,.mlnlne.. tOf th, cony.yann 01 crldllla my .ccount uow,~", I CI"'ly und"'llnd and .g'ttlhll.lI"rvlc" ,.ndlled milt' charotd dlfull'f to me end thlll.m p".on.llwo ,,,pantlble fo'~.Ymtnl I ,1'0 unde"tand Ihlll' I IUlptnd 01 t"min.l. my ClII and "..tm.nl, tny t... lOf ptolH,lonll ."vle.. r.nd.ltd m. '1" b"lm".I.'r due '~bl' PATIENTS SIGNATURE ~ \ . _ ()).11) DATE '2,. 'l,'l. q.4- SPOUSE'S OR GUAROIAN'S SIGNATURE DATE If yourol,.n Iccld.nt.II"jury. pl.... campi. I. the ,...... .Id. 01 Ihl. form.. w.IL Copyrlghl ,n. . Do Holl.produc. Unaulho,kM loproducfton k I""", PE ~~NAL INJURY QUESTION NAIF ~ ~ Nlme IAS Phone(117 I ~:3 .43~5 -Addrlll .5..L.J=. SOU11l =..rRl)~T-cIlYWl..\SL.t:. Stile .fA. ZIP.l1.O.13 AU' .3r5 Blrlhdlle ---1:- 19 ,- ~ . 'sex~ 515. J.9d . 5:;>, - <D'Z 4..L ~ Employ.r'l N.ml c.mU,\SLIl BI\Ri'J\O~S (lnll\rtW~'S~nPIOyer's Address caBU5,LI;. BAgAA~~S ' , YoLW~.lco.~IJ1)f.t,mI\LJ Policy ..2.B';?,A<=\34~2.4-- Agenl's Nlme '1'11 ~i 1.0\)1> - H3.OL N......ft PvlllV (It .'her '''.R 1,1'''' 'R..pon.lbl.Pllly'l Nlm. f}A.~lk-:L W. PI:.-n=RS .1R. ~ Add"l. 31O..1\1\1'f\\LTO~ 9iR~I!:-r cllyillRU'5L.tr _ PollcyHold.r'.Nlme \)....I,1>l:.TGifS hn" 1"l\llbl..lvJ\bl,;" , ATTORNEY ~Nlmt NCI>lE: (-4t::i") Add"l. Policy. 51 lie .fIL- lip .t1O.13. pollcy.~ (,0111: 003&'1 Phon. I Clly Stile Zip _W.rtth.rtlnywllnel8ea? (v(ves (INo Nsme(sl ::SCUN \'.WAl.TGRS (1l1l\~"'\lINIIU~I(I,lI;llll~~OIS . , Of Mt&) NATUIII OF ACCIDENT: _ 1. Oil. 01 Accld.nl ~ Tim. 01 D.y .Ie '.00 'P,,,^. ({.n~) _ 2. Will you: I vfi)rlv.r I I PI..snger I I Front Sesl I I Beck Seal - 3. Numbir 01 p.opleln your v.hlcle? -1- Were you wesrlng sea' bell.? il5S _ 4. Wh.1 dlrtcllon were ycu he.ded? I .{Ncrlh I I EIsI I I Sculh I I Weat onlnlm.olllr..I\---tL..-\i{\I'lC>\IbR S iRbb-r (\~l\r~ u-) ,C.4\R I.\~L~. - II. Whll dlllcllon WI. olhsr v.hlcle hllded? I ,.)NOrlh I \ EIII I )Soulh I I Wesl onlnlm.oltlreell o.m - I. Will you .truck horn: I II Behind I I Fronl (Ilelt side I vlRluhl II de _ 7. Aoeroxlmll. .peed 01 your CII '1- IS mph Olher c.r '? mph _ I, WII. you knock.d unconscious? I I YII ( v(No It yes, lor how long? - 8. WII. pollc. noUlIed? t .{Yes I I No _10, In your own words, plea" dsscrlbeaccldenl: (X(,'f Ko!\\)) t-.II:t\~ Itlle; 11\ E R6'D t.16", I V~H\CL.~ Altl;.tsb l\mmPt" Th s,.~ ~ C:.GlTING I'HlT t\.a,.,..:m c:o)ffil.OL 'S1<i:.t..\M.frtl m~'br.Lf Th G\HC.U-'f t'AA\lE.l'St'l'/\'1 M~ ~()I'l'\ 1.'l~l:.C~I~G.l {;oT m" rl\R ~U(-mL'I SLOIlllOI> Tt>'S1Ot> t'I~ Ro~ \' I U ~ (~\'1:tIll 0Ib1c.:y4, 6~1"Oc\) t.41tEN tAASt\. mR. ~\'t"5 r1\ CJ\\l. c;,1'1H'S M..'4 ~ '1.1Il '4 f,\C.ltl&ll\'iCI\R'Tllli ~ 'C'~blJ:':r~AIHtuNra(';f.!:!' 11, Old you liavuny hy.lcal compl.lnls BEFORE'rHE ACCIDENT? t I Vis O~"'cP () "yes, pleaslilliicrlli. lTiIillllF.7'K1 ~ -12. Pl.... dllcrlbe how you '.1(...' I, DURING Ihuccldsnl: S 1-l('\C.~El) b.IMMEDIATElVAFTERlhuccldenl: MC~G' Sltod(Eb c, LATER THAT DAY: U'lL>I",. SmM<1llt1" Trl Be" (3I1S1"~Off UlOIl~ ~nm 'lMllO '11\1'1) , d, THE NEKT DAY:l\I:.A~&Q~~""'~llt.hl~........AL^It4 S!iollJ.ltERJ:Bi\C.K ST\"'r,)'\~ ,.et..\s I'm "St\t:d ~~~ ). ~ . -'" ~ -13. Whlll"yourPRESENTcompl.ln .nd.ymPlom.7~..1\r,,(~ \'fl.11u':> 111.\ Io.\Gt~ I\~ U'lGt.\,.. ~ ~\\:coTll\$; C.e.nl.\.\,~LV\c~-+~~\1\I~S \JP Ie-, f>ASC: ()R.B1\C~ Of \\~~ \H~.I\i)r\~~'~S ~r\ \0:(" bU~ ~~Mnlt .~n~f~e:," ~U,~I'\\\\ ~~r~ t, {h-,IIY\~S \~c.,Lo$I.:lI~(; \...G~"s~ L-\)&jl.I\~lt~. rc _ 14, Do you hlvl .ny congenn.lltrom blrlh) leclora which rel.le \0 Ihla problem? I ) Ve. I Yl No \I yes, pie... dalcrlb.: , , ) Ye. t vfNo II y.., pi.... d.lcrlba: _ 15, Do you hive Iny prevloullllnenel which rel.le 10 Ihll c...? .- _ '0, H.ve you ever been Involved In.n .ccldenl before1 I v1 Ves I I No II yel; plea,e delcrlbe.lncludlng dlle(l) .nd IYP8\.)olacclden'I...well..lnJUlvllea)recelved. IO\A'l .. CJ\l<: \ \111'il'l'lKL'jr 1 !~ (MI') - CI\.R'I\T STO? ~\(l,I...I'\'>\.)LIS D\1T_I\I'\'\IMr"I'l\I!.I'lM HlliUJ: S~t'lF' ('I;: ~i c..'1(lIFj ~~tlv..G: \~r.;r", ~~h,)I' S. th,) LDI!ill.5 ~~ I(~\.\-'" L.I~ B 11\\11\\,11"1 (l..J'l'.(,lI\r'~ Y" _ 17. While were you I.ken Iller IhOlccldenl? \-1.-n.'14 h{1ud~t JI I)Ru\ll: m'j~~I_i ~,)l\I. II) \>~l\C.. _ IB, Hive you been he.led by Inolher doclor .Ince IhOlccldenl? I .(Yes I) No II yel, pleese lIal doclor'l n.me Indlddr888: ~mE:S ~j{foN b.O.. 5~"ti. SIMPSON f~'i K'D.)tJ..l:~'I~I'I( 100ft 1 -0\5"8 Wh.llype ollrellmenl did you recalve? C\\.l~DPR/\:l':r Ie'. 19, Since IhlllnlulY occurred, are your aymploma: I) Improving 20. CHEYJ( SYMPTOMS VOU H~E NOTICED SINCE ACCIDENT: l>'l)teadathe liflllllablily 0 Numbness In Toes I'''' ~etk Pain 0 Chili Pain ' 0 jihorlnm 01 Blealh I.f'Netk SIIII 11 Olulness Itl'fallgue 1.t$IHplng Ploblellls II Ilead Seems Toe Iloavv IJ Oeprosslon Itl'jlatk Pain n PII'S & Needles In AIIlIS IJ lights Bollier Eyes I,(jlelvousness n PIns & Needles In legs lJ less 01 MemolV I"'Tenslon 0 Numbness In Flngels 0 Eals Ring Symploms Olher Than Above )< Hive you loel IImelrom work as .'88ull of Ihls .ccldanl? I. La.t D.y Worked: 1.1 Gelling Wo,se , .same o Fate Flushed IJ BUlllng In Eals \] loss 01 Balante I I r alnling I I loss 01 Smell \] loss olllste o Olanhea I] Feel Cold [1 Hands Cold I;(Stomath Upsel loYConslipalion I' Cold Sweals leVlI I.1No II yal, pleu' . complol" '1,la que.llon, )Yel b. Type of Employment: ." '1 . . ,-'. .." " \ ',' ~. " \\") \'.'.j \\ ~ \I yea, plelaelllle type 01 compen..llon o. PIII.nl S.lary: d. A,e you being compenlaled lor IImeloaltrom work? I) Vea I) No you arlllcelvlng: _ 22. Do you nollce Iny .cllvlly r88lrlcllon. .1 I,e.ull 01 thla InJUry? ( ,.,rYes I I No II yea, pla..e deacrlbe, In del~lI: , -r~\{~I"c:' ()1~"T\l..-n>>(') I'l~ ",E.f\lL,E:.~CISIMG) ~OOI~ Sl-\~I~(; i'OG-'~I'\S bo..t:dv :i1L~.l.\l>tl. :\u'Sft'la-INc; L~lsuR.~ (')~ CC:lm~ol2.."t'M)L"/ LCllJ~61t..\~. ~ 3f>B IIC.I\t..l be ~llT WITH \'l\I~ .\~\)\Sc.Dm~ClR\(~LL\":rCjbDl\-onl~5: _ 23, Olher perllnenllntormlllon(... v~ 4t .Et\\N. i:. blScnti\trctt\ \.II\\u:Y....J33....wJIt\ ffi" o>Jl::R -{\L.L tl\EN\~l~c;"I('AL ~DtL ? \ - [I Z - 9.qJ bAll RtOlde. H J "0" to lr III IJU1JO " ""'" I"'. CONSULTATION NAME: "\ ~ H t<<vJ DATE: 7.~ ~;;24r MAJOR COMPLAINT - '1(1;t' ~ ~ ~ ~ &.. 4,~ Jt;I ~~ p"" ~.ftwt;1 ~~, UJl1 /fJ>>~ ~ L)f)~ UI3{~ L -;>.t) ~~ t.~ ~ ~ U.hllt J,JI . ..." 1...1 IV. F"JtO,.~;4/ :" /fA- IA{Iv.JJtJ~. P/~,~ IiIlt l~'tIr ~~ /~ Jr6 c.Or: : '3 ,., fJf Gi) ('f ~ -r.t ~ - p, C!i,J I'a:.... Jf.1~"Ifi/ ~ tit II CJJij) t/JI L~ -~ ~ -~o 4. WHEN F1RST NOTICE nus -(j) Dcur ~ 111//;1 . ' HAS H PPENED BEfORE - 1 {J. /fit!, i/fJp 4)g~ L/Jf.~ ~ ~".t ~ (WORS R.~ - ~~ ....p~ (~ ... ANY RADIATION OF PAIN INTO AN EXTREMITY (WHERE) ~. L+ "~/I'I~, . ANY POSITION REUEVES - . '1 f ~ LOCATION - /J 'Ii ....I /J _.7L,~ . FREQUENCY (PAIN) Da!o ,~ -~ "'" .IH ~f DURATION (PAIN) '~12 ~ ~ OTHER on SEEN CONO, -D,..lv~~'j;;~d~ ~..;{~ ~ WHAT DONE fOR CONDo YOURSELf - 011> IT IlELP1 - Q 'l\ ~ ~ ANYONE REalM, SUROERY (YES.NO) ~ ~ MEDICATION TAKEN fOR THIS COND, _ ANYONE REalM, ..~EO. ..(YES,NOJ. .." NOTE w~ ~. ;t1tJ 1't./1 L .~. /1J.J ~ u/~ @@ifJW I) PT. OIAO, - 1(..,.. Z) PUST, CARE - 1,2,3,4,5,6~,IO , SPOUSE q 1./ d4~ MJ ;: ~ )UJ?-; 'j t~ ..' .... , BYMP. B. CORD PRBBS A . IA- II HEADACHES ~,~~..........'REO~ ~ :II DIZZINESS (YES.t!9(.~. .... ..'REO. 31 ILURRED VISION (YES .~..'REO. .1 COHCENTRATIOIS t S~I.'REO. !II DEPRESSION E HOI.........'REO.., {~~. 61 NIRVOUINEII ,NOI........'REO. ~ 11 DI',.SLEEP OI.........'REO. II LOSS IMlRGY ~OI........rRBO. ~ .. 911UZZ/RING EAR .NOI.....'REO. hfi4V ',101'AINTING tYEB ...........FREO.' J 11) PALPITATION Y .NOI....... .FREO. 1f<.<fttJ7 . . , (t'""I , '1\ . \ '." DUR. DUR. DUR. ~UR. ~ p.u, UR, Jl. A DUR. DUR. DUR. DUR. OUR. DUR. L,;/ .-.~ V GENERAL PROBLEMS W/FOLLOWING 11 HEAD ~r!\""""""""REO' :II lINUI~ .NO:i" ........'UO. 31 NICK PAl TI" ,NO\....,UO. .1 lMOULDIR PROB.- ,NOI.....raao. !II UrPlll IAClC. . NO I .. .. .. .. . 'uo. 61 MID IAClC .NOj..!.;.........raao. 11 CMlIT .AI YlI~.........rRBO. II LUIIO (VII, .. ..lJ.:i...... ..rRIlO. It HURT/H.I..t t.-"'........rRlo. 101 lTOMACH (BS ~. .........'REO. ~ III INDIGESTION ........'REO.~~ A..R -, r 1:1 I ILADDER (VI I .. .. .. .. .. .. rRIlO. 13) LIVER (VII M ..............rRlo. U I KIDNIY tVlS. I.. ...... .. .. . 'REO. 1!11 COLON (VII, . ...........rRIlO. " 161 CONSTIPATIO ,NOI...... .'REO. f/U#';:r. 111 LOW lACK ,I...........'REO.~ 111 HIP tYES. ,........~....'REO._____ 191 LBG PAINI PS (BS . .. .'REO. :101 POOR CIRCULATION (VIS ...'REO. __._ . _ r___'---'-'~~---_.~_._----' OUR. OUR. OUR. DUR. OUR. OUR. OUR. DUR. OUR. ~~' ( DUR. OUR. DUR. ~ll tI-::: DUR. DUR. DUR. DUR. .,_.n____"_"~_ .---...... --- PREVIOUS INJURIES 1) HOSPITAL/SUjlGERY Q'~I EXP. m '()J 2) ACCIDENTS/~~LS/A~<<JB,NO) EXP. tr' J) ACCIDENTS/JOB (YES, XP. 4) ANY MEDICATIONS (YE EXP. 5) MOTHER,FATHER,SIBLI ACK PROB.(YES,NO) EXP. 11Wk'ot~) C!JA~~ - """" f"""I PA'l'lENT: lTflet CERVICAL SPINE t ijlegattve for recent fracture or groll oteopathology al vllualhed. evSLollof e IBeverely decrealed I IH11dly decrealed cervlcal lordotlc e INegatlve for dllcogenlc lellon. e IlIpparent cervlcal lIIyolplllml. << )HUd I IHoderate e IUextro-lcol1olll. I IHUd I )Hoderate I ILevo-lcol1olll. ( IHUd I IHod~ate It.-(Nerrowed dhc epacel between C '1- (~..~ - c:; e 'lJ:ncroach..ent of the 2.eurl.for!.mlna between e"10lteoarthrlUa of .. I 'i', Go I lot her ROENTGENOLOGICAL H ((vS REPORT DA'fE 'J- ')~-q'f curve ISevere ISevere I Bevers IIpex at IIpex at IIpex at THORACIC SPINE t INegattva for recent fracture or yrose oeteopathology aa vlBual1zed, I I Kyphottc curve appears normal. f lllpparent "yolpallll. (IHUd IHoderate ISevere ( INegatlve for dllcogenlc leslons. ( IDe.tro-scollosls. I IHlld I )Hoderate ( IBevere lips. at_____ e ILevo-scolloels. e-1Hlld e )H~~r,te ( IBevere _~pe~ at ("1Nanowed dhc epaces between-1l-1i;Ll'.(~JI~ - 1-'T~P7t'./1 1i, -,,~("~~ e 10lteoarthrltls of I 10ther LUMBAR SPINB t INegattve for recent fracture or groes osteopsthology al vlluaUzed. ( ILoss of ( IBeverely decreased I IHlldly decreased lumbar curve. I lllpparent lumbar myolpasms. (IH11d ( IHoderate I IBevere e !)le.tro-acolloals. I IHlld e l~oderete ( IBevere IIpex at (V'iLevo-scol1olll. (v(Hlld~J ll1koderate I IBevere IIpex at L~ -L1 CVi1/anowed dhc spacel between lJ - t] (v~~d." L" - ,. I C IlIrtlcular facetl appear to be ( I'P9ndylolllthesll. grede ( 11 ( 12 ( 13 ( 14 lLA"Rlyht 111um rotated~... ( ILeft lllum rotated ~ t(..ol'tJther__JIIP -192 rt')14!'''.... .,fT1_-= ~ ar,'" /~~ 'f.lp~ . ?~~y+t~r~1 'St/Uvy'"IiOl1-:' tff c'). ,l1/Y iI'). (t.1~~1l"-' M.<~'f"Yt~~~ t~ .::;l-e 1~~_!:3~-r.q Qk.lL.;N,' /~vt'l. ~~~....i "'f=. 1;f"'",..cLIk.1._f];;.M t(~ if' OVERVIBW OF x'RAY FINDINGS _D~' I , '-'-UA1U~i~:!L - ..---..----.. ..- t:IAlllllllu "UIIIIIIII~ Ual-?~ ilL, 1:111011111111 UIl1u!tM.9_ ""0m 1"1,, Ulllu --- I ~p ~ ' 3 4. U'. ~ It....... id.A ,I F1L L"'y~ , _;t-'t ", jJf,,~ flit rw C~ Ul-' r · L C. UJ'f. J . r-~! '')f ~~r- I Or~ f<- O.fv1 ~ ~ ~~ ~ = - .-- -.e~_ +.. . .__ . .- ..... ..- - - -- - - - -- - - - -- . , .- - - - - --- - .,. & - - - - - H- --I- - -- - ..-..--- - ,,~.O( -M f-4Y~~f- -/-Ai'-_~~. cJ~ ~/ 14'~~ ~ ,o~/ ~ ~ -. PI. $" ~ .-w1~t<XV -Y --/~.&<A' ~, ~ ~ (! C - C'c au.; @(ID~W -.....-...--...-- tic "fO(~. {f;1/~'f'((- X.RAY 1l1EA1MEIll rnUCEUUntll EI.ECllllC 6TIMULATIUIl r - lit... 1 I~.,l{.. 14' "N'.'\'(!\' . IIIIJlI^Ck; . fill"1I: II" '1:1 flVtt.:^1 .fWIIII: CI C --..-. w .. ._u '1Ut,tW\1t '!wu,,: . ..... .'-'- CI " T2 'III," II . ..... ..--.- t:I".V.~I~1 . .... ------. ---""-- T/1AC1l0N tI 11 11 riD , .':lll\'.....AI '51'1111 Ll CU."..fll 14 ." ,.. (r~, - Lil.>:'-;V;~:2':l1_ l'ltd" 'St.. """ 'fDY'S1 ""H' ,..~. '''... ... .- . -- "'-( 'Y _A,_, 0,0. arn... _ , ::" IIm._ 7;'1111 /-PUS OA" 01' ,MI, I \ -- ..------- -----.----- ------.-.-- ._~-- -'--~-'-- -----.. -..-....-. --~--- -- ---.---.. ..---- --- ---..----- 01' J ' - ----- iiii.uNOsis --?2'-'--- =+.-''fr;.:' . -=-.---- ------------ - -. f~...76l-t-~=-= ~-_._- =--1i;'~I.r.~~,_:~~- ==="f1~:-X!. -.-=: -..-- '-- -._--- ------ ''V1 ""). ------'1'1 L_..... =., .-=:_= =_-=-=:: :~. u ~IDJ. 4(:--~: - --'-'--Pivylrt . ~---- 'I f( fI I -"---... -_.. -.----- '''"'''I ~ PATIENT: TINA HAUS DATE I 03-07-94 SUBJECTIVE FINDINGS: Patient'e entrance complainte are neck pain, headachee, upper back pain, mid back pain, lower back pain, and pain and pareetheeja of left arm and hand. Theee eymptoms are aggravated by lifting, Sleeping and by work in general. These symptoms have been present for over one month. Symptoms are woree in the A.M. A.A. SYMPTOMS: Symptoms started after a motor vehicle accident on 1-28-94. On that date the patient's vehicle was hit from behind by another vehicle. OBJECTIVE FINDINGS: There was tenderness to palpation of the paravertebral mUlcle. at the levels of C5-Tl, T7-T9, and L3-L5. There was limited range of motion of the Cervical Spine during flexion, extension, lateral flexion, and rotation. Lumbar Spine wae limited during flexion, extension, and right lateral fl..ion. The following orthopedic tests were positive, correlating to patient's subjective complaints: Cervical Foramina Compreeeion Test, Cervical Hypsrflexion and Hyperextension Compression Teet, and Kemp'e Test There was evidence of muscle spasms at the following locationl: CO-Cl, C5-Tl, T7-T9, and L3-L5. The Spinal X-rays revealed vsrtebral subluxations of C2, L3, L4, and L5: and a wedged disc at C5-C6, T3-T4, T5-T6, TII-T12, L2-L3, and L5-S1 spinal level, which are areas of direct nerve supply to the patient's areas of chief complaint. The Spinal X-rays also revealed a ..Cervical Kyphosis. Please see X-ray report for relt of flnding\.. @@UJW ~ ~ ASSESSHENTl The patient's neck pain, headaches, upper back pain, mid back pain, lower back pain, arm and hand pain appear to be directly related to our objective findings as listed previously. The working diagnosis is injuries due to motor vehicle accident, radicular neuralgia; and Vertebral Subluxation Complex of the Cervical, Thoracic, and Lumbar Spine. We anticipate a poor to fair result in this case. PLAN: Our first goal is rapid symptomatic relief of patient's chief complaint. We will be seeing the patient daily until acute symptoms begin to improve. We anticipate that will occur within the first five to eight visits. As soon as symptoms start to improve we would like to see this patient three timea a week for four to six weeks, until a plateau of subjective and objective improvement ~ccurs. At that time we will do a comparative X-ray and orthopedic exam to determine the amount of change and improvement in the patient's vertebral subluxationl and positive orthopedic tests. Follow up recommendations will be made to the patient in a comparative exam report concerning the need for follow up care. This patient will receive Chiropractic spinal adjustments for reduction of the vertebral subluxations located on entrance X-raYI. Physical therapy modalities will be used to relieve pain. This will mainly involve the use of Interferrential Electrical Therapy and hot/COld packs. Localized Intersegmental Traction will be used to strengthen supporting spinal ligaments and increase blood eupply to the intervertebral discs as soon as pain is under control and this therapy can be tolerated. This patient will be prescribed a home cervical traction unit to help restore the loss of the normal cervical lordotic curve. The patient will start with 2-5 minutes/per day. The patient will be instructed to perform spinal rehab exerciles at home and to usa hot or cold applications to the Cervical, Thoracic, and Lumbar Spine al needed for muscle spasm and pain relief. Dictated bGt,not read &~w /'., MUSCLE TEST l'A'I'lEN'I': 7T t1 ~ J.I UPPER EX'rRElll'rI ES AND NECI{: ,......." ._._.UfI'I'E "g. ?- if/V B 1'1"1' I NG- lIN'l'. OELT. R: II/I,' 10/'. e LEV. SCAP. R: IJ DEL'I'OIO R: 16/18 1"-;1.8 IS/I,y SUPnASPIN. R: 151"'( "'//" !'IF' ULNAR ADD. It: .JII',8 ~.3/'.8 ,j1)1.1. UICEPS 11: /).lI/I.'/ ;11/"(. J,cJ/I,8 WRIST EX'l'. 11: 11//,'( 17/1.'( IS/I., WlllS'I' FLX. 11: IB/J)';' 17/1. Y 10//,'1' I"'/I.t 1'/,.' I.: /'Il' 1f'7., 1'/1.(. I.: IJ (9) 1!/I''1 l'fl.Y 1'1/;'$1' I.: 1=4"'1 1'1//,,/ 13/1,'1' L: ~ IliJ.~ .Qol.:J od Jlq/JI,;J.. I.: Jl<{jI.{, ~..3//.6 .PI//., I.: ~cJ/I.' t},O/I.1. .:JaIl., L: 18//',f Icf'/I.' 11/1" BUI'INE- NECK FLX. R: IJ S.C.M. It: AJ PEC.MAJ. H: 11/1.8 I()/_.~ IOI;},Q SERR . AN'I'. R: AJ 'l'IUCEPS R: 11/'J,,~ IS/dO 17/1,8 PRONE- NECK EX. R: IJ : 'I'RAP . 11: ,.) '1'lmES HIN. ~l/()/I.., SUDSCAP. n.: I"III,,?,, LA'I'. DORSI R: '''/1./. UYNA,/SCALE-Lbf[ R I "2.t.f I "2:2... I I.: "-If I r..~. I J.. l'OIlCE/TIME 10/I.B IJ./I... IS/',I{ II /1, 'I I'I/I'Y ''1I'.r L ... \t ,.....l.J I.: A1 L: ,J L: II/I., II!'," 1111., I.: ,J I.: IbIM, Mil" .90/;1.6 L: .J I.: ,J I.: "'/1. 'I L: 19/1.,/ L: 1rJ./ 1./. /II !M" I?/I, 't' "/I.Y Idl.~ I '3//.13 Ni'" . rv ~ l@~\P~ ,........., ROM WORICSUEE'l' r". lWl'IE<<'I' NflMt~: ~~ Jla.uJ uuu '. UI\'I'I> UF FIRH'l'OV_,_.__......__,_. ,...' __' _UA'I'I~ OIr INJUIIY.._. IIEl\f.IUN I:Olt EXAM: IH1'I\1IlMEN'I' ItA'I'lNll._ _ 1'1I011IlESS ItEl'OIt'I'_ lJl\'I'B(l'ROORBSS IIE1'0Il'I'): ~'f .~N/qv .-,.- -' - -- CERVICAL SPINE JrLI>XION -EX'I'BNSION -LU(:'.' LI\TBML -IUGII'I' LATBtU\L -I,EF'r ROTATION :IIIGII'I' RO'fA'l'lUN 'l'HOltACIC SPINE lrLEXION -EI'rl\NSION ' -LI>F'I' LI\TBlU\t. -UIGU'f Ll\TEIU\t, -LEF'l' nOTl\'1'ION -ItlGII'f ROTl\'nON =MINIHUH KY1'II0SIS LUMBAR SlJINE SRc:a..u. ~cllAL F"'~XlON -EI'l'ENSION -I,tn:'I' LI\TEML -lumt'I' LI\TEML -LEt:'I' 1\O'I'I\TlON -1110111' IIOTI\TION -STMIGHT LEG MISE (I. ) ::::STMIGIIT LEG IU\ISE(R) MINIMUM LORDOSIS -..... I'LEltlON (1&t1t) :MU' EXTENBION(~) ~ ~ --'L -"-8. .. ...S'l. _ -~.. _:5ll. _ _':1-7. _)k... -...-. ..~ .'- --- .---- -.-- -- ,.-,.- -..-.--- -- -...- -...--. 17 Jl~_._ .-- ~.-._- ...z Q..... .A5-. --- -....-- '" ~_. -.--.- -,- I!J _tR.O _..-- ..-. ~-- -- I 3 -'1 .-...-- .~......_- -- '" -L~.. . .-.-.- --- ~N -,( --- . - ....--.. --- -- -.--..- ~ .~3 ".J.. )C. i ".. ~.3_ -!L- .-J.~L _lJ.[!) _ ~._. ~.- J:.~_ _.1:;._ -~..- ._'l~". -12_ BlU\HlNER' B NflME__. INUIChl'E ON LEF1' EllhHS TO liE COHPLE"EO. .__.,..~ :: :::,,:::' ';~,::. U:::;: ~~U:.::,:::::::. '"'' .". ".U.". .]!) /P./'h u^,m 1.ISTEll ^""'IIE "01' UF E^ell CULUHtl. rtr FUll IHI'hIlIMENT \l^TItIUS. E^ell C:OLUIUl IlEI'Ill:tllmrll IIIU'Il'I'I'I'IVI~ HI~^SUIU::HE"'1'S UUIlINU 'l'llt shim EJlMI. I. DURATION OF TREATMENT: o I . to .... 01.1.... !t14.I-U DI.4_kl a O\htf: monthl D ,. needId EllpI,"llIon: ...-, )l,RAY FINDINGS: 1"""'\ rlC<1SC See A+ttl.cl,((j 7, FREQUENCY OF TREATMENT: ~ 3 Iknel po' wonk U II \1....1 JKlf wuuk a 1 lime per _k a a IlmH pe' monlh D 1 lime pel monlh a ,. Meded Eapllnlllon: T~YATMENT: REGION: -X... SI~"DI ",Gulpul.llon: CerYlcll1 J I LUlIllllI -A- ThIlIPy:ekcJ.,Sllill, CetYIcII LumbII l ThIlIPy:hllt-l"lI'ks =:f: ~ OUter: CIMcII_ Lumber _' Thollclo L Odlar ThoI" L 0IhI, ThoI" L 0IhI1 ThoIlCIo _ 0thIf ~~ ~ ~., ~ ~ ~ ~ : .~.';f~ -' ., -~~'i(?":d,,~'- ;;~~-~.4;; : f5:- e, ORIGINAL DIAGNOSIS: IllIgnOIII ell... (cUIlInII: a Dtlcrlp\lon 01 chlJ1lltl: a None e. UlsCHAROE INFORMATION: a P....... dlIchIrgad: DI" . a PIIlInl \0 III dltchllgad upon ",.1 villi. PalIInl dilChllgad \0: a PtH1july IIIIUI, a ~I and IlIlIonary IIIIu., N..... eIIlablllty wllu.lIon. a MaInI_ II.llMnl OTHER: ~~lfJW (:. .. 7h~JI7</'~ ,A. O'C1.f),~. TREATING aCTOR " I , I, DURATION 01' TREATMENT: 01.10..... 01.1..... III........ 9 . . . ...... IJ 0lhIr: monlh. o ,. nMded E~IIon: "....... X-RAY FINDINGS: ~ }J 01/(, ~ ke 11 7, FREQUENCY OF TREATMENT: [J ~ tlmeI pi! wwk )Il a llmtl pi! ..... o 1 lime pi! ..... o I tlmeI plI month C 1 lImI pi! month C ,. nMded EJpIanallon: TREATMENT: REGION: +- SpInal mlnlpul.lIon: CetYlcaI V I Lumblr -4- Therl/ly:dtcf,SfItI/. CeMceI .i- ThefIP't:hi ~cks = (J (" t.umber -X- 0lhIr: n'\ tch, CeMceI +mc1101l LumbII ThorlClo .i- 0lhIr ThorIOlo -X- 0lhIr ThorIOlo -X- 0lhIr ThorIOlo -X- 0l!lIf _;;~~ d~~tJ"A~~t;;#~J~rffM'k (a3?jt) e, ORIGINAL DIAGNOSIS: IllIgIlOIlI d.....tOlllIlIlII: C o....llAlOn 01 ohIngI: C NoM e. DllICHAAOE INFORMATION: o I'IllInl cIIIcIl...gId; Dele o I'IIIInlIo III dIIcIlIIgId upon 11I11 villi, I'IlIInl cIIIohIrgId 10: c ~ 1lelUI, o "'_lIld IIllIIlellonIIY IIalu" NMdI cIINbIIlI)' evllluallon, C tal' .....1Ot Irlllllllnl OTHER: t:, , Th()ft/o <; A-, fJJ~ O,C. TREATING DO OR . I, DURATION OF TREATMENT: o I . 10... 01.1... J!'4 . I.... 01..'" C 0IhIr: monlha ',~ o ,. IIItCIId 1aplaneUon.: .........., X-RAY FINDINGS: i""""l NONe TA t<~iJ . t" ~ ;t.:"f9I",., . . .J~.... ... . 1 . .r....Lt.l..~ , . 'I". , .' t, " 7. FREOUENCY OF TREATMENT: o :s limn 1* wwk o 1 limn 1* wwk J1'llImIl* wwk o IllmtI per month C , _1* monlh o ,. IIItCIId Explana\lon' '. ' . -. .,. I TREATMENT: REGION: ~ llplnal manlpulallon: c.McII ..,k- I.uInMr -.'z:- ...)L Therepy: l;f~c.l, 0IMceI L ~j.... LumbIr ~ ~ Therapy. tcof.. fkIu 0IMceI ~ LumbIr ...h.... ~ Other: Jl'\ec..\... CIlvIoIl ~ TjC04C 1.umber.6.-' Thorldo ..,.1:.... ~ TllarICIa ...k- ~ TllarICIa ~ 0IIIIf Thorldo ::5- ~ . I, ORIGINAL DIAGNOSIS: ~;~ ~I~~~~~;;~;:~nr~:~'~,. DiIgnoeIe ctIMgI (curren'): o ~ 01 change: o None I. D11ClWlQ1 INFORMATION:' ._, .", C l'8lIInl....lIId: o.te . o ,.....,. 10 bllIIchIlgecI upon "'.. viall, ,j, :, i : (~:'" I'IiIlInI dIIllIIIIgecIlo: "\ c I"re-lnjuIy 1IaIuI, : 'I ' o ....n-.M IIld IIaUonaty llelue, NMdIdIIlblIIty lYIluelloli, o M8InteI_ lrtalmtnl ' " ' ". " .:: )....... . ,Il:.: '.... I""!"".l, OTHER: t. .', '" 't,' ~1" :~~ '. 't' , (:. , , !-t" II', ,'.,'" .., " ";l -I; . '" '.\ ,'. .. t. . I', .." ' ." .1 -r h ,..",UJS' near 1. 0. tJ. , TREATING DOCTOR, .1., ,.., ',' !., ..f; . . ',; '.. .. ,. ,," ",,',"""1 . , " . . \ : ~ .' 1"""\ f"", ROENTGENOLOGICAL REPORT PATIENT :_11"'4 CERVICAL SPINE I ))It'gaUve for ncent fracture or groll8 oteopathology ae vl.ualhed. (~Loa. of ( IBeverely decreaaed ( IH11dly decroa.ed cervlcal lordotlc curve I )Negatlve for dl.cogenlc le.lon. ( )Apporent cervlcal .yo.palma. I lHl1d ( IHoderate ( ( )Uextro-.colloah. I lHUd ( )Hoduate I I )Levo-.collo.h. I !1lUd~ IHoduate I l/f1ial:'l:'owed dhc .pace. between [~- -r. I' 4/At'!1") ( )Encroechment of the neuroforamlna between ( IO.teuarthrltla of (I1Other..1f),., )"'/ r"A/t'..,<_.. ,. ".f' r~ 6;/6).... 'ri.! it... vA..~ /0 IV ""':rl.,. TIlORACIC SPINE ( )Negetlve for recent frecture or gro.. o.teopathology a. vlauallzed. ( lKyphotlc curve eppear. normal. I )Apparent myo.pa.... I )Hl1d I )Negatlve for dlscog.nlc le.lon.. I )Dextro-.collosl.. I )Ml1d I ILevo-.collo.h. I MUd It.-t1fal:'l:'owed dl.c 'PSC(l' between _ 7i. ,I )O.teoerthrl U. of ( lather Ii Q.v '5 DATE 1i- J7-<; It )Bevere IBevere , )Bevere Apex at Apex et Apex at ""&""t ~r."""t"/' , )Moderate )Severe )Moduate )Mo er ..: LUHBAR SPINE I )NegaUve tor ncent fracture or groll8 osteopathology a. vhuslhed. 1 )Lo.s of 1 )Severely decreased I IH11dly dacreased lumbar curve. I )Appanllt lumber myospaams. (IHUd I )Modente 1 )Sevue I:tU tro.scollosls. 1 I Id ( )Hoderate 1 )Severe Apex at 1 evo-scollosh. I Ud ( IHodeJa~ I ISevue Apsx at l. ~ 1 Narrowed dlac space. between ~ ~~~~, 1 IArtlcular facets appear to be 1 )Bpondyloll.thssle. grade 1 11 I 12 ll-tffI'ght 111um rotated 4.... 1 lllen 1llum r~~,;e~ il ~;,;;i.fOli~p~1:li,;'lan~ 1 t~tr /t1j~r.1~~~',,-j:!~d"l~~:d 1c:J OTIlER ~ 10 )(-r~y, {I I IV- ,vi> i"'I't'N~",,,.t 0""- L] ",U{lLy,liCI.. )3 I )4 11_- OVERVIEW OF x-iAv FINDINGS , , chii')ractlc/Orthopedlc/N.L~loglcal Examination 8840 - 4th St. N.. St. .tlraburll, FII. 33702, Suit. 0 Home OffiCI: 1-113-W.aoee eemcln\2:plr1mlnt: 1-30&-331411I81 HAIII li~" H ~,,'1 HEIGHT "5" / 1 WEtGHT _J )0 V). DATE ILOOD PULSE ~-;;t.2 -tit-- PREIIURII1 JO<r/~(l &f ~ Jft, Doctor. Un: IE "I 1.. EXAM,ILUI 'PI IME 2nd EXAM'RED we ani EXAM.BLACK '\HTALGIC 'OITURE LA RA 1. PAL'ATIOHIMUICLI IPAlM/IDIIIN,,"CUIIION: __ATIOIIAIlI__ : ....... Tonder"", !W" ;;-:-ri I - IoIIlII IoIIlII Loll IoIIlII loll IoIIlII loll - ,00 00 00 00 At At At At All All All All III III III 10 to to <<l <<l III III III III tel tel tel III JC JC ,C ,C " " " " " " If If " " If If ., " ., " IT If " " IT " " ., " " " " .T IT " 'T IT " " 'T r '" ." lOT 101 '" III '" III .IT In ." 'IT .1. II. '1. II. II. I\. .1. I\. II. II. IL IL ... II ,1. ,1. IL !l !L IL I ... ... ... ... t "" Rn RIl RIl LIl I" LIl L" Doc Coo Cae Cae /..// ~ t /.,' ~e c. -_... 13-' ~. . E lA, GANGLION PALPATION: A. IU'IIIIOII OCCIPITAL NIIIVE: 1..1: onl Inch 11'lrlllo EOP. 'II/onl/.: roper IH/lnll 01 nlIV' . 'n".m.'lon. ., IU'III'Oll CEIIVICAL GANGLION: '1.1: oppo.lt. Irln.ftI.. proce'l 01 IUI., ,.I/onll.: I.ne/.rn... wllh "re..ure . 1"II.,lon. C, MIDDLI ""VlCAL GANGLlON:I.I':enllrlolll.r.1 10 C5 ytlttbrll bodr. ,.,Ion.',: I.ne/ernll' upon ./llIhI "re..ure . '''''''Ion. D. INFalllOll CIIIVICAL GANGLION: II..: Inllllol.llllllo OJ ylf1lbr.1 bodV, ,.I/onlle: I.ne/.rnll. with ",.nure . I"II.I/on. I. '''ACHIAL 'LIXUI: 11.1: Immtdlll.IV po""lo'lo Ihl cl..lcll'. ,.I/on,'e: I.ne/',"II' . ,,,II.//on 10 n.rv... POI. 'OS. 'OS. POI, poa. a. CIlANIAL NEIIYIIIlAM 'OLFACTORY.. ..... ....... ...... ....... II " .~.II II OPTIC,...."...,......,.......,......, VI.JI',f"'I\d-, III OCCULOMOTOR...",., L' .......,.11:"" EV' tol,v.m",r.) ,. IV TROCHLEAR" , .. . ..I.'.. , .. .. .. .... EV' l4l!Y.l!ttnl i .' III - V TRIGEMINAL. ,'.".',.,. ......~...........,.. fllflk',' ,..1/)/// VI ABDUCENS.,.,.,. ...,...,..,. . ...', EV' MOVlm'l1\IV ", \'11 Ff,CI',L, "..".........,.."..,.., .. ~",!ia VIII ACOUSTiC...., ,. ..............." " Tunnlng Fork IX GLOSSOPHARYNOEAL..,.., Olg R.t1IIl1Uvull R.lllng K VAGUS", "",.......,.........""...., Swallow XI BPINAL ACCESSORY, , . , . . . " . , , . " Shlug Shouldl.. XII HYPOGLOSSAL,.. ,... ,. ,..,....,. Tongulln Ch..k 'MAN" TUTI S, CEIIVICAL IIANOE OF MOTION: 4, JAW .U.LUIlATION TIlT: C~ C:" f,"lfL: p/l7 1.1 {, ( I (A, FLEXION l. () B, EX 1 ENSION MIAS, MEAS, NORM.JO.;-- NORM, 30' LIMIT i- LIMIT ~-i PAIN ~ PAIN-'l ..lIon./t: "l/n 0""0'''' ./dl 01 mollon . mu.e/. "'tlell, ",'n ..//11 mollon . comp,.../on. , bll""11 lHII.ur. on "ldl. ..II: ,,"n . .en.lllvllr PCS. I 1111: optll Ind Cloll moulh "lIonl": clrln mI.,,, ....r from 11cI. 01 .ubIUllllon, -4- <? I. '~~~ iJ (; ~ ~~~\r \If (~I/~ r~ ~" I _~_J f (- /1 . - ", I L, I Lilt' C. LATERAL FLX. U, ROTATlOtl MIAS. I MEAS. _.1....- NORM, 4~" NORM.~ LIMIT . . ( LIMIT T PAIN I '" PAIN~ or , p/(; I, IA RE.LEI U SION: A : BUctfllNG VERTEBRAL ARTERY 3YlmRDME, '"I: 101.1. p.II."I" hlld c,u'lng r.nm",""'llnn nf v"",,hr..llu1"rv 1 ( L fl NECK fLlllOM 01. , 'If{ I ...~ ". '.-, ~~ \ J Lt2 NECK IllTINIOIII , 'L'"e LATERAL NECK fLEXORS !'OS. PIU1J / l'OI, I1}IN J CIIIVlCAL ooM'''IIIION TUTI (Cent.) I. clr"" '" COM'III111ON TUT':\ )'\ . . -t '- ,el CERVICAL~"ION PAIN ", "I/on.',: ._'n, '"' ,. Iocall" ",III. t) I Ji\: ~ .......-- t. IOTc)'HALL TUT: -- 1 I J-.)' Lv,e'Q fORA~"I'RE~'OI PAIN ,{- ,.'Ion.": c,.... 'V,. Ioc.llrld _ ,..., ,."/lIln, __lOlI' .--- 10. CEIIVICAL DlITIIACTION I SHOULOEhEI'R:iiION HY,.k-~ L f(!... L 12- L ~ HV.....IllTINIION TEST: MIN_'\- , MIN r-, PAIN , PAIN , PAIN , FI),.".II: IorNIu/ ,.'lon.II: ... "IIon.',: comp,..... .,,.lell :1It 11IO'''''. "",."II.lon 1IO",,,,,"lon. natv.lNlltI" In'o ,,"'., lilt: pl.c. h.nd on 1111: 1111 h..d firmly, :;:' .""., cllftl, II.. onlo cllftl. ,.,lon.II: """ -, ..}/ @'V ,.,Ion.',: ",In - declllIlI . fIfIndld.,. polllbl. 1IlIIf1bt., '0' e""Ie., ,,.c'''''. ~'~ ([If: ,,.e'"11. ~ ~~ ;i)" .,..J I,) ;, 11. MAXIMUM 11. O'DONAHUI 11,VALIALVA 14. AD.ON'. TUT: 1S, ALLIN" TI.T FOIlAMINA IIAHIUVIII: TEIT: INCIIOACHIIENT mT: Lt2 I IHI: '''' chln..hould" ,.., .Ilh .olln.lon 01 'h. neck. "lIon.II: p,'n 0' .,d. 01 mo'lOn . n.... rooln.c., "'I/OM"""', p.'" oppo.II. . ",u.elll" ,',,'n, ~ L~ PAIN ---, L 1<- I PAIN ,.'lOn.',: llOm.'rie . .."," "'..,.. . Spt,/n 1111: C'OIl .,m., h..d down dMp br..lh, hold, "'" down, "IIon.'" p,/n ., .11. 01 III/on. 1'08. 1111: I.k. pul... lu,n h..d, ..,1ncI ....d. d..p br..'h, hold. "I/.n.II: filiI.. e..... 0' dlml",IIt.. . compII..lan 0' ,". .rI.,., lIy "",1e.I "II 0' 1Ie""", A,IIIOII. Irnd, I? 1'08, LI Z ll,( ,",: ..I.. a,m, maka 11.1, eomPl"a radial and ulnar a""Iet, 10... arm, ..I.... OM a""" "pilI 'or olhlt a""" '"lOna/" no 1/11'"'''' . va.eul" occ/ll'lon. .WI '* .. TOt WAI 'WTl ',-, \ If. Hal. WALK TUT: I "II OCNIIIIUI III., ,IITUT: t-.. I. "nt" 10 fin", THl: L,e. POI. , L f.. L ~ I, "nt" '0 NOH Till: POI. , POI.- 1'08. -- POI, , " H..llo IIIIln TII': III': obHIYe pIlIlII' 'HI: obHIYe pIlIen' '"t: loa wltk tll', POI. w.lk'nt on 101', w.lkl", on hell., "//On.',: "'1"'lIIr du. ,,'lon.II, In."IIltr . "//oIt.II,/n."II"r . 10 ....kn... po"'''/r .. IIhombtrl TII': to' nln'l _I.. L41LB nam /110". "r 5'1S. InWl,"",.n'. POI. ",/oIt.,,: 1Il''''''r . ..,..."., ....,IIMIIiM. II. ualIUI" TUT: 11. IMlllARD" II. 'AoIlllmAolN'. a. HOliAN" TUT: TllTI TIlT: POI. ~. 1M': 1''':-':'':. ,,1M with MIl . 1I,1IIi.,,: po."'" . ,,'.'/0, ""lthl /la",,'''''''' .. '.IIIII.,.TIIICI( TUT: L ,e 1'08. ...,: ".lgn 01 'our." "/Ion.'" po."'" 10' hIp pllho/otr, L 12 1'01. - '"I: doIIllI.. 100' ,n IIIlow polnl 01 pain 101 1.UIqu.'. 'Ill, "'/on.II: po."'" I", .011'/0,. .. LAQUIIIIIU TIlT: LtZ- 1'08. , till: ...btra-I'ltrtck 'H'. lorce lamu, In.o .ceIlbulum. ,,'lon.II, paIn. hip Pllholofr. > L f!. 1'0'. ,",: ""'lag 1I"I;h' lag ,,1.lnt ..11, "'/on.": plln In ./ck /If po."'" lor .p.c. -upr"'l ",/on. If. IIUIeLI TUTINI: L ~ PlRIFORMI8 I'OS, ,",: II.. .hl;h, Inl.m.My ,ollt.lag. 'OIC"1g 11I.,,"y 1;.lnll ".I.t.nc., ,.,Ion.',: ....kn... . 8'1S"nwe,"",.nl. - L It!.. 1'08. '"I: I.'end lag, 'II.. 30' oll'lbl. dofIlIlI. 'oal. "IIonl": c." plln . Ihro",lJophleIJlII.. ~ L-- If... OUAOfIICEPI POS, II. POIICID UCI LOWIlUNQ Tm: ~ ~ J- 'f!- 1'01. 'H': ,,1M ..'andld 111I '0 3O',appl, downward PIH'ur. "lln.' ,"I"lnee. ,.//on.,,: """"'" . IIIu.oII _MIl'. ... HOOYIII" .laN: R \. Lie I'OS. ,",: 1I1b111l. cllcan". o'lIOOd lag, have Plllanl ,,1M bid lag, ,.,/011.", no down".nI "...u,. w"h flOOd ,." . III.,ln,.""". ""ALlNcJ.IlINO ~) c:e> ..I 4 L f2 PIOAlI MUSCLE P08, 'lit: "I.lllllnd call.p,o., till: ,.'.nd 111I 'S'._I 10', ...bll".nkll, ,.'.nd 100', 'orca 'oal down Ind IIg .;.In.1 '1IIIIInc., oulag.ln., ,..I,'.ncI. ,.1I0n.": ...An... . U/U 1_""""'" €I ,~ , ~ IIODI QIIROPRACTIC a.INIC 323 York Ibd c.w.. PA 17013 T.!ephotl<< (7171243-6396 Fa (7171243-6444 Explanation of Travel Card Th. followins de.oribe. the purpo.e of the .even differ.nt .r... of the Tr.vel Card u..d by the Booh Clinio. Ar.a 1-, Show. p.ti.nt'. na.., phone number, and birthdat.. Ar.. 2- Showe date. patiftnt wa. eohedulod to reooiv. tre.t..nt. rf undor that d.t. nu~h.r. were written, the patient did receiv. tre.tment~ If unrter th.t date a line h.. b.en dr.wn, th. r.tient did not r~o.iv~ tre.tment and mi..od . .oh.duled appointwe~t. Area 3- Show. p.ti.nt'. .ymptow. Ind are.. of co.pl.int. Und.r .ach date the p.ti.nt will ..If-...... ..ch .y.ptom or coaplaint on . .c.le fro. one to t.n. Th. hilh.r the nu.ber the .ore proble.. the p.ti.nt h.. be.n h.vins with that partioular compl.int.on . peroentase of time baai. (i.e. a "5" .ean. the p.tient ha. h.d 'y.ptoaa 50% of tha ti.e ~inoe the l..t viait). Are.. 4- Showa partioul.r level. of the .pine which the Doctor ex.mine. every viait. The followinl abbrevi.tion. .ay b. u..d. T.S. . Tender Spinou. Proce.. P.V.S. . Parav.rt.bral Hu.ole Sp.... C . Cervioal Vertebral Level, will'be followed by a number whioh denotea which .p.cific v.rtebr.l level ia involved. T . Thoraoic Vert.bral Level, al.o will b. follow.d by . nu.b.r. Examplee u.ins the above abbreviatione. T.S. L5 . Tender Spinoue Procee. of the fifth 1 ullber vertebr.. . P.V.S C2 . Par.vertebral muecle epaem of the .ooond cervioal vertebral level. " 1(:.,.. The Dootor will from one to ten the nUllber, the rate eaoh epecifio area on for that partioular date. woree the oond it ion. a .oale The hllh.r , ',' " ..1., .. /, . .-,..... PATENT: '(~Ue' t(j,(cR OAIF.: INFO, AtoNE , l'I;';.i.~~;~;(i, ~~ ~ 1"'""'\ .. ~ i i ~ ~ I .. ~ i(ilififili I' , '.' ~J, >u_ i_ I . ~ . I ~ . '\: I1I1I -:-::- !u~n.~~ 1"E""UlI rnOC[OUIlE FHOINCkq M.UlR eot.f'lAtoll5 ~ -- . .. '.. -. ._- .-- ~ ~~:,,;, j'; S ~ ~ a - ~~ - ~~~ 11111 ~ j I 2~ '- '" '" \j:' ~ ~ J. J h e - .. ~ ~. 'll",,~, m:.; ""~" """"~""" I ~ I · i0: Il' ~ .. ~ , ~ ~ ~ : ~ \ \ \ \ \1\ \ \ \\\\ \\\\\\'\\ ~ ........ o..r~ "- ~ ...\\\\\\\\ \\\\ \\\\\\'\\ ... " " : \ , ~ \ \ \ \ \ \ \:, S \'\\\ \, \ \\ \ \ \. \ ... "--.~ ,-, - - - '. \\\\ \\1\ \ \ \ \ \ . '-....... "...... ... \\<'\ \\\1\ \\ \\ .. ......... "......... "- ~ \ .\'\\\\\\\\\ \.\\\ '\\.\\\\\\ ~~ .. 'I ~ '. i ~~\\\.\\\\\ \ \\,\ \\1\1\ \\'\ \ I, ....... ... '. .... - ~,~\\\\\\\\ \ , . ......-.. \\\\ \\\\\\\\ .. "- ........., ........ ~ "'\\\\\\\\ 1\\ \\ \ \1\1\ \ \ \ \ ................,. "' ........, ~ ~\\\\\\\\ .. \1\ \\ \1\ \ \\ \ \ \. ............... ................ g :; ~ \. \ \ \ \ \, \ \1\\\ \\\ \1\1\ \\ ". ........... .............. ......... ;; , . ' \ , \N\\\\~\\\ \ \ \1\ \ \ \ \1\'\1\ \ ...."--. .............. ~ ... ;;; \ ~\ \\ \\.\\\ \\\\ \\\\\\\\ ............................. ~ l!l \ ~,\I\ \1\ \ \ \\ \\1\\ 1\ \. \ \1'\.1\1\ \ ~ ...............~ ~ "- ' 1\' 1\ .................~ .~\ \ \\\\ \ ' , . \\ \ \1\1\\ \ \\,"- ~ IiJ ..........~ ~\I\\ \ \ \ \\ ' \ \ \ \ \ \ \1\ \ \ \ ~ \ . ' ii\ , \\ \1\ \. \ \ \ \ \. ' , ' ............... ................. \\\\ \ \ \ \1\ \ \ \ :; .. ~, \~\ \ \ \ \ \ \ \ \ \ ... \ \. \ \ 1\ \ \ \ ;; ................. '........... .. .. \ ~\ \ \ .. , \ \ \ .. . \ \. 1\ ......... ~ \ .. .. '. .. \ \ \ '. '. '. , , , diGllR'1:. \~ \ \ . , , , , , '. .. ........ \ \ .. ... ~ \ , . , . \, 1\ \. \ \ ~ ~ \ \ \ .. \ l!l , .. , , ;:\:ItlD4~\\ "'" 1;-' .,--' ~ ........." "'" \ \~ \ \ \ \ ... .. .. . , \ \ \ \ \, \ "-....., ... , \ ~ f ' , . \ . .. \ \ \ \ -I:-' -;- ~ .............. '., .. ,t,j, \ \ \, , " '\ \ ~ .......... '\, , .. I:l I " " , , '. , ...... I '.. . ._-f-": - -~ , '. ----, \~. "- .- '\ ....... ~'. \ \, .. \ "\ '. \ \ \ \ \ ~ ' \ \ , , \ & ' '. '. , ...,. a I eKlSE II ~A~~J 1~.~1 ~~1~S~' \~ 11 I 1 IPICA HEALTH INSURANCE CLAIM FORM I ..OICMt. ..OICAID CHAMPUI CHANPVA ~~'Ol!.~, !.~~~.. oHltn I. INsunlDBIU NUMBER "1_" nt-... "nt_.55NI n WAf"" n '11~il':::ltNnB~=tM"Or1~'OI ~E,NO ~85;::-12027 (t'I1Nlme.'lIIiN.imt.t.hddIrtlnltlil) ';'!'.11 I \f~It. fiEl( 4 INSUREOSN......EtL.llHame '.llName......kvlllll HAU~. "1 No!> r.. 'I" '6'l: ~q~ .,9 "n , r'1 HAU~,. T rtlA RAE . P"'IlNt. ADOnns tNo. 51,.,11 . PA,IENt RElAtIONSHIP fO INSURED 7 tNSURED8 ADDRESSINo. 61'"'1 ~,l '~, ""OUTIJ ",Tf<EE' ...13.......0C....O """'[] ~,1 E. l:,;)l.ITH ~TREET Cltv ITAff . PA1IENt SIAlUS r,IfY ':'I\Rl. !~U: P~...,ll 0 0 C'ARLI$l.t:: 6lnOItU """1ed 0..... I'HEPUOH1E IInWdl ",..Code) ( 71 24~~-4JSc;. I_"~ ,,,"_~ P..,....~ . I I SluM"' I I sIUlWll-1 I 'N....ll..,N....,"~N....~_) '0 "."~U"ION"tl."UIU HAt'~. T l NA n,'''' r.'RUDE~T III' P.I), eOXf""\7 Hr.:R~HA~', ,,\ DA 1E SI(lt,rD tit, PAHun liAS HAD SAUE. onSIU1LA" ILLNl6S I If, U_'(5P"'I[NI UN_RlE towenK tNtunflFfIt OCCUPAtOI OI\lEfIRS1' DA1'1 MM , DO ' YY "'U DO '1''1' UU pn '1'''1 I' L_~'lf')l.t 10 U. ID HUUBEROFREfERRINOflffSICIAU .11 Hospn"'LIIAlIOPiD...tH-~HAtfDtocunnENI SERVICES "'U DO 't'" LlU 00 n fROM to ~ OU1'SIDE LAO? I . CHARGES n... n"" I " MEDICAID Rf.SUBUISSION COOE I ORIGINA\. RU NO U PRIORAUtHORlIA11ONNUMBER l , DIAGNOSIS COOl , CHARGES 12~'" 100,(,'t;' , , 1,;>'34 l30.00 1::!34 100,(,',) , , 12~1\ 120.00 , , 122\4 '.r:.('l~ ZIP COOl . lll)!:' .. otttlRWSURED& POLICY 00 OROUP NUUBER . EUPLOYUENT? (CURREN' on PREVOOSI Ovu ~"" b AU'OACCIOINn PLACE tSl.I.1 OVI6 0"", , c otHER ACCIOENl7 [jvu 0"" IOd RESERvED fOR LOCAL USE It OlHERtNSURIUI DAlE or BIRtH Slit "':oo:YV I"n Fn c fMPLOYER 8 NAUI Of\ SCHOOL NAUE ('(\1'>' . ','Ir:,r"v I'.'; "0~H'H':,",ARY II "SUA~CE 'L..... HAUl OR PnooRAU NAME .!~D ~.c. 0 'Oftl COIIiilltlHG' 110...0 n.. F"""", I' PATIEN1'.8 onAUlUonllEO P["5OO& SIGNAtURE l.u\ho'IIIlht I,.n. oI.n, IN<kIl 01 oltwf ""OI",lIlI]n MC.IUI, to pOCftt 1M dIIIfl 111Io .tqutll pI,mtnI at OOVt'nmene btnt"" Hhet 10 ",,,.. 0110 tht pII1y 'IIhota:.111I1Q'WMI\1 - SJGln~'."rE' On File 0,~-01-94 SlQIltO U.Q~lEorCURf1ENT- ~ IllUrSStrwll'rmplomlOR """ 1lI\" yV . ltuun,,;._"n OR " o 0.1 .:.~ .. II PREGNANCYllMPI ~ I'. NAME OF RfflRRINQ PHVSICIAN OR O'HER SOURCE " ..&lRVED FOR LOCAl USE 11 DI~IS ~ ~.'UAE or ILLNESS OR INJURY, IRElAlE ilEUS 1.1.3 OR ~~~ nE~ 2.( BY LlliEI t . Ir:,~. "." ,8. ,O~ . ,_ 3 ~__ 7 "II: . . ~-" . . . "l)tTEISIOf' 6EHVICETo PI." " WI DOYV"."" YV t'-..: :9.\ ,..,,: , '14 ~ I . ' "'. ::'::1 (' ): . ::.?: .. , ?2 : ')I~ .. ':'1\ ~ . ,- , '" , , , , '.':;' : ? I"'J Q "'11 ", ~-I,1 :~ , U . ... , ~~ :0:1<1 ':',;: O.~t ,0', .,~ 3 . ..- " , , , , "" 22 :...", ",., ""I ,:,1 J I "- .. . 1 ~,:',? 21 C " Type PROCEDURES. 6ERVICES, on SUPPliES of I IE,plalf\UnuIua.l.~II_~llInc..' I "PT.urP"" I unnlflt:R 1 j i?,;>>~?O;, I : I nOH'1 : I ~ I i I .0 )Q70 \ f I: f L~ ?4 ~ PA'IEtH6ACCOlm'tfO Ir'1 r:CCEPI A5SlQt~UWI' .. go_ rl!~~, S" bel"l H,..,I..I'~29~:"C YES -'1 UO 32 "........E ~tiO AoonfSSOF FACIlIIY WIlERE SERVlcrs WEnE ntNOEnEOllto~ ttlan home Of o"nl " ':7~OS;! I 11 SI'721ZC I 11 ~701C' 1:. . ').?: ,.:~ !'J1 ",': ; _ : .'-1 :' t U fEDERAL lAUD HUUBER 6SU EIU '11"1".,'" nn 31 SlOf.AIURE or "H'f'lJiICIAUOR wrrLIEn ffClUDINQ DEGRU S OR c:n[[)[tj II~l S lIt'tf1tfr"'.lltltllllttntnlIOnlt..'......'" IrP'.!..IO It\tI blI.nd .'. maM I ~ lNiIOf I, {" "') , I.' " 1.4. J' 'If ' ,/ 'I! JI'," ,') ".1i~" ':It! , , - " . ."';'[0 .' 001;' fArPROVED BY AUA COUNCil. Oti M(OleAL SERVICE 1111 tiN ... ....11 Arh ,,,,, CtI...... IIIDUtll,. PLEASE PRINT OR TYPE .. ... ~....... Pr..,.,.."'i.r-....-."...~-.~I"..f,i"':'.rr_;..:...'J..--,.L 0,' . '0' l'~04t\ roc. i I I IfOAPKOORAl,flftltlU II SIAIJ' Pf\ TUEPHONE IlHClUOE "REACODEI ( 71'l 243-4385 II tNsunEDSPOUC'f'OROUPOOnCANlN8ER liP COOl 17013 I INSUREP'.~DAll? fURIII "'Ot .'1 V!!;q so 'c!1 "0 b EMPlOVE" 6 N......f OR SCHOO\. N"'UE ~ARL, BARRI\CKS COMMISSARY c INSURANCE rt AIi NA'Ae OR PROQRAU N"UE PRlIDSNTIAL d IS THEAE "'NOtHER ~EAL1H BENEFit PLAN' D.fES 0"0 Ht"". fII'h""h.rwtrnm(llel.llillm'rrd I] INS\lprOS 011 AU1Hmll.rtl PEn!;OO s SKiIl^'UnE I rrlllhOllll ptlrfNIlt of medIC_I two""I,"lo Ihf ~s.gned phrllClln 01 suppIItf for Nf'tUS dttO'lbtd billow Eignature On File o J . RESEAVEOfon lOCal USE II on film., COB UNIIS Plan EMO l ,,;;,r'~ 1 \l ~~ -, , , .?~, .00 II lotAL CU"_~~~ , T" AUOU,..' P~IO 20 BALANCE ~E , M. .,,0.., <:'"OC, 485,,00 n PItVSICI...',S 6UPPllfn S fUlLING NAUE. ADORESS.IIP CODE ~f~J.f LHIHOPRl\t l'lC CLINIL: 3,,3 YORK ROACI ':ARL1SLC. P~ 1701~ 1'1~.(~"l"\a47c I. rltit '.. om', H'f1U 1t{'f"'5f\O II' fOl rnnlrA ower I~ .onu RRB 1&00 1.IIU.......tl..t'...1I1 Uw __I....... f1t,.,..--rr. U.I..I.....~ . , ..... ..... I I jroco HEALTH INSURANCE CLAIM FORM roco I "OICAAI MlOtCAI(l CHAMPUS CU,..,IPVA an~I' ~tt'" Olllfl1 I, INSIJIllUtilU HULlII[1l IfOflPnOORA1UWEM II Il-"O-"'''D,_,5SNI n"""" n~l~I,'~:l:Nne\;J.r."r1'1/11 ',l;i'lu~I..\;..-12u;!7 I' tL.ltN'''''.'uIHlmt 11 11"IVl.~lt 6U . IlSUIl106NAi.it 1l.,tN-;;;",.,.lH.1nf Udlllelnlhltl ~."".I~" T:' ~.,' <JII, 'e',: If\~ Vb';' .. n 'r-1 HAU~,. 11 WI RAE ~iN"'ADVRII&INo.611"'1 . P,"TIINl "ELATIONSIlIP lQINsunEU 1 INtiUR[06AoonE6S1"0 , 6Ir'.1I ~,1 1::, ~CL'r,' '.,"r.:l,~T ...n.......oC.....o """'0 Sl E, SOI.'TH STr\EET ell't' l'''Al1 . PAHfNI SlAWS tllY I"A1I: (M~:<;LF. P/l -d .......0 --0 CARL!SLE I PA ''''COOI 1'lLEPltONE llndudl At.. C<ldtl liP COOE ITELEPItONr IlNCtuOf ARIA COOft . 1701? I(?l~ 24;3-43<35 I-'''n~::':::'n~~''''n . 1701:> (71i) 243-43eS I'DfHl"1 IUtlNamI,fll,IName,MOIIIIfWNII 1U lllt'ATI 01 "';u ,0 llIN8UREDlf'OltCYOAOUPORHCANUUBEA 'IA'.!~. T ,! '~,: ~I'.O:: . a'''R IHIURIOS POlICY OR onoup HUYlER bOfHERINSunED80AtEOFBlRUt 6U ... , IXl , VV I .~ I I "'1 I c EMPLOYEA 6 NAUE OR 6CltOOl ""foIE ",I ~". I:f\r\l~~,,~. l~. C'JMHI ':~.-:AF" . INSURANCE Pl~ NAME on rRoonA'" N......E I ~~ hPLE IIN THIS AREA r:'RULIENTI( , F','.', rlOXI"""V H0Fl':,!'M'l. ,'~ 1 '104'\ 'n . ltr.lPLOVU(HU ICURRENt on PREVIOUSI OVU C100 b Auto ACCIOfNn PLACE 15'1"1 DyES 000, , t OTHER ACCIOfHl' CI YES [] 110 lOcI Rl6EAVlOFonLOCALUSE ! , I . INSURIP..~()AltoOf .untH '1H _ q '~,9 IU "0 'Cj b EMPlOYERSN"...[ 00 SCHOOL NAUf CARL, B~RRACKS COMMISiPPY c If~S\JRANC[ '" A~ "AUE on ""()(iRlU NAUE r.RUtl::NT ! .~L d IS lllERE "'f01HER fifAL '" BENEf't rlANl Clfrs c:t"o "..... ,,,I,,,,,I,.ndffWl'lClk>tfll_t.d 1:lllj!-".\IJI[USnn A'Jlllllfll;((If1I;RSOPl5SIll"A1UAE l.utI1(llI" ra,".f'rll 01 Ndcal tMl,...lotl to th, ~.~ phrllOan 01 &upcII., lor HM:tt"'W'l~t.lo'" Signature On File ,~~~."~~. o!.~~,~..!!aRI !",!",LI""O III...... '''''aRM 11 rAl1EN1 lOR AU1Hom1fOrER50N8 61O.."tURE ll\lltlofll.thtl."n.ol.n~ mtdlealOIO~ 1n1or"'.100lln.c'''lr, to pent. '" dIIm 1 Mo 'tcpll PlJ"lM olgoyt'rwntnl~'" t*let to rnyt" Dl to '" PIrtr w.t'CIlCUpll I\1qWNI'll - .:i9rlo!1..\lr(l1..1nFil~ O~-Ol-94 5K'''ID .. OOIE or CUlllllN' W', 00" ,,'t, .. ., .,..... 't DAtE SI(1NEO " "rAtIlIH liAS HAD &AUE on SlUllAR tlLNESS I Iii (J~t(S""lt(N1 UNAf\l( 10WOIt)!, INrUflJUfH OCCUPA11(\tl QIVf 'IRSl DAlE UM , 00 ' yY "'U DO H UU DO YV , . '"1)1.1 '" ~ t1.\NESS1,.,I,,'"PtomIOA IIOl'F''!' IAcCllt.n11 OR A pnfDNA"CYllUPI 17 HAUl Of' nEFfRRIf<<) PU'fSK.IA" OAOHtER sounCl 17. to NUMBUWF RUERRlHQr..,SICIAN ~111.IOSPI'AltlA~II"'I' Ilrwrotnt\lltnlNI stnvlCUi UU on 't'v MY DO YV 'R()tJ 10 10 OUF6IDElAB' ,CIlAnQU o,n DNa I I r2 UEV~AIOREIU8U15SIQtt COOl I OAtGlNAL fUr NO ;3 PRIOR AUlHORllAl1OPt NWOER I I " NHRYlD'OR LOCAl USE " OIAOHOIII OR NA1URE Of' IlLN(SS OR iNJURY IR(LA1111IUI 1,1,3OA 4 10 I1(U '.E BV LINEI ~ E!1.20 e?~,Qe t 1 ~,_ . L-,_ .. I 2 t 7;'-' ., " . ,.itlEISIOf BERVICE,o .... .00 vv ...... 00 VY C"': ,~ :'),1 1"1": :'t: 941 1 - .. . r~.o!: ~ ~, : '';'4 (, ':; J~: <;4 ~l , , , , "",.,1 ~c, la,1 r .:~ :'t',: Q~ .., . .....' ..- . I:~, .~: :'~, : c.'~ '''"?: ~ ~ : 0..1 ~ ~ I;' : ~~, :~4 f'.:: ;',: : ":'4 ., I ,. .' "f. , ': :! , :<1 . ," :';"1 .~ ,;. , '1 ~I II fEDERAl. 1A): to HUYSER S5N (It, '\",'1".;'/ ., -.mrl 31 SIGNATURE or rUYSlr.IAflon surPLIER eHClUOIfffl DEGREES on cnEOUHlALS tlno1ol, the111w e1.I',"",'OllItl,tt."" _, to thrI W end .r'INM. pelt I"-'toll - '.,. ' ~' /':" '",. t'" /..:; ',05QI' Pi , .,'. ." .. 600llE0 M" e C PIIt, 1",. .. .. . 1 f' :>~, 21 a RCX:!~UR!~LSERV~l_S OR SUPPLIES t'PI\(2.,:.~~.u.~c::;':t.f'IC"l l'~'O.11? I ' .,...... ' IIr.4O coe , , OIAGUOSIS COllE 'CHARGE S 1 ~, :1/1 30, (1(' , 1'::~ 1~, ,OC' 1n4 I 2Q,QC , 1: :>11 40.0e' 1 =' :~,~ J') ,oe) o " Jim '.u on '"""1, UNitS Plln J . RUfRVEDFQA lOCAL USE 97010 I , , , , 1"97014.'1 , , . , ! :9Q07C I : I , , 90-'1" I , . _ h r- -:"\\1 ~ U( -' ~ . ' . Q 7 0 l' I: l.~ ~" 1 ~" , ~'I: 1 PI PAllEN1 BAceOUN1 NO I ~'J ~cct.rl Asslm4i.iii,r;- 1ItOlALCiiAilOE J" AUOU~'iPAI(J 30 BAlANCE bUE lfOlpG'f'I ~~;~ '"badl I (61,':- :~';.5J':' I YES L'] NO , 1 f.)' ('e' (I, ('(' 1 flO ,CO 31 NAl,lf A~40 ADDnE 55 or , AC Ill! V WUf Rt [,t R~K.1 sViTi\[- )) hivioo S6\W'>111 nin~L.NG;;.l1ol1 ADOniss lIP cri,F "1"0'.'01........'''_....." 'jt"~~, O.'lR','fT,f.\CT'C CLINIC ,J2,"J vr";F.'t. f",(' 'Il' (A"'L::.~r:, ff :701' ~ J "n".~,_ 'it I rl/a ." lil1f', t rc)fIMIU'A 1!t00 l!llK!, f(ml,l O~U. Ir,oo fORM RRB 1100 IIllta ........,....", lltII....l..._'I'IU~.,..I.I....~ IArflnovttl Bv AU. c'cxmcll 0" UEOteAL SERVICE ..I, ..~ tit .....1 ",It ".., ttI...... llOO.It'I't PLEASE PRINT OR TYPE 'J' I .fl!lE ;.I}.jOT 'ftAPLE IIN THIS AREA ,.""...I......_..~-- Pk'-'t:e:Nn~' P.C'. P'(lX~7 HORSHA"', ,... 1 -'0/..: I I !pICA HEALTH INSURANCE CLAIM FORM ""OCARE UfOlCAIO CH""PUS tHA"'PYA ~!.lour ~fCA 1_.....i. O1tt(R 'I ItisunEDSID NU"'BER "_...,,nl_.d '/n,Soono...SSNI n (VAF.../ n ~IW~lilrn'I;JM"Gn ,10/ 1~'NO~'tlS2 "12('27 'l'AllmTl. rlHWlllil.ilrfl"" nlN,,",,t.Wdle""'''' ~)'lnT~f,~'l su . INSURE08NAMEll..INam..h,INam.,t.LOdltlrvh.11 HI'I'J". I",,' ,,~,: '1"'I:'ool,~,'~ "n ,r; H,\U';, TIIIA R~E ,IUlIfll:Kor 0 IOIOlllO""'O " rATlENT S OR AutHORIZED rEnsou 5 SIGNAtURE I turhalllf ...,..."' olin, ft'lf(kllllf 0"," inlolm.lOOtl hK""')' k1,,0CftI"'~ 1 fila I~'I PI"""'" ot~,."..,. .",hlt"'" 10 nt,.... or 10'" ptrf,....., 1Ct1Clt. ''''0''''*'1 ~ $l~n~~ure On file, 03-01-9~ .'OUlO DA 1E SN'\NEO "..2:1' Of' cunnJ"t ~ klNESSt..ll'':1:'''lon " ., PAttiU' HAS HAD SAUE on SIUllARfLlUl 651'" UA'fS pa'IENt UUARlE 10WOlll( 1~r.unJntlt ~CUPAltOtl t: ~:'i .1" ., ~~~~~~~~I (\ GIVE fiRST DA'. W : 00 . VV . 1 Rnt.t "U.. DO 'tV In lAY VY " HAUl OF RE'IARI<<JPHY&ICIANOA01Hfn &OURCE t,. 10 NWREAOF AErlRRING rItYSICIAt4 III 1I0srlf'LIIA'IOf'IIJ"'1 f. PELA'rU 'OCURAlN' 6F.AV!CES . ""'1.1 00 YV' UU DO 'YY rnotA '0 10 outsiDE lAB' S CItAnan nvu nNO I I II UEUICAIO n(SuOuIS51ON COOl. I OfUGINAL REF NO 2] rnlOnAU11t0RIIAlIONN\JMBEn . PA'IEN' "nAtlONsHIP '0 INsunED ... 0 -'0 c..,O "''''0 IllAlE I PAtllNI StA.US PA ......0 ,,~,.... 0 ....' D TnUPt~E lftlude "'" CoMI (;':'1 2'D-1\3a~ IHAUlll'''''tIftt.'.a1Ntme. ......lnIMIl HAIJc;.. T! N.' 1i"L I ''''.N'IAOORU8tNo.&h''IJ 'j 1 !-.. ;,un..:: 1"[' E T Cltv 1..~f.:L ~.:t ; ,. coot: . 1.:".)1 ',I lmpo,td -- rull .IIM.......... P..t l.".,-t -I I 11,,"",-1 I 6'~ I I tD IIPAlII OIHOHREU,l1010 .OIHln",'II'lOIPOl.lCvonOAouPNUMlEn I EUPLOYUEN" IcunnlNt OR rR[VIOUSI om dNO b Auto ACCIOEN" PLACE ISIII'1 b QfUI"INSUf110SOAlfOFllnlH SEl "',00,.. I_ I 1 1.11 I c (MPlOVER B "AU( OR 6CltOOl NAUE ~ tot';,:. ;tl\r~r,."." f. ::'J!.,r.~! ~~i.AR), d IfoIsuAmcfplNi HAUE OR pnOORAM NAME In Om c otllER ACCIOlN'" c::JV16 DNa 10d RESERVED 'on LOCAL USE DNa I 'I "ESlRVlO ron LOCAL USE " DIAGNOSIS OR NA.unE Of ILLNESS OR INJURY InHAlE IIEMS 1.23 OR. 10 ItIMl4E BY LINFI -. l:rfl ,. n":. . llH ,L-...::"::' ,~,.:.. . I I "1 ~'~ ... . A ",ettllllOF SERVICEto .... ..~. VY lilY 00 "'-;".4 'It . L...:......::... .iL_ I C PIK. t,pe .. .. o PROCEDunU 6lRvltU (,/1 SUPPliES rPT~~":a ~'UI~c;:,~'~lflC"l ''''701 ~ I E D1AOPMJSIS COOE yy ,-":: ~.~, :<1.; ':-.~: ::. . IJ:JI. :I/'. ~ , ~9,~~~ I 02: ~'I" ; ':. 1 " .. '" ..,~ " , ...;' " .' : t , , , , I ., ., :!8 : ~.. " -).., I: 91; " 11~7('IC , ~... , . " '"'..~ : .~ , ,"'\,1: ~a "'7014 I , , " '. , . , . , . I ~ ., . ; ;; '? ~: . ~ : ' .,~: '=i, ? ~ 'jI5El~, 1 , ~ . : . ~..:- . ...",'" ~ ~ ~~4 12'4 I I ~;? ~~ I t.I::~.),?:":.', ~:'.:': ~l~:,?.1 ~~._~ -''1.5F.l~1 12: 12~" "FlDfRAl 'AIIO NuI.IBln IiSH flti ,. PAtiENts ACCOU'H 1<<> U' AC(frl .551('.III..U,,, I ~. A .J'QI'goll1d"~""baC'1 l,: .':0::1'" '.~', --L1ll -1(\1.1' .!'1. ( _ ..L~&__J~.~~____~__ 31 SKlNA1unE or rIlY6ICI"'1 on GtJrrll[n 31 NAME AlID Allonf 55 {" , ACIl.II'f 'hllln[ 6r nVll:f 5 'hI Ilf. INCLUUINCI Dfonff60n rnlfifU'IA1S RENUERlOjl1 01111' 1"."toom'l;II 01111"1 Clr1If1t',thlllhfstll""""'ClflI"llh"'. IPPfIG_btl'I1d"'~' ,."'!No."' I -1:' (.1",(, I{' , I'll I, "I.' ~ II. (,..1(. i.'ti'14 I.,nll'" b',l ,arpnoV(O 1I'f' Ai,lA COUUCIL Oti UIOICAL 6ERVICI ..., .... " ......1 A,,, '"U tI.I.... IlOOlnll" PLEASE PRINT OR TYPE PICA I , I ,re)R PROORAIoI'N nUl II 1 INSURED 8 AOOR(5S lNo. SlI"'1 Sl E. ~OUTH STREET City IB'''''E CARL:SLE I p~ ItP COOl IfElfPltONE IINCLUDE AREA COOEI l701:3 (717j 243-1\305 IIINIUAIOIPOUC'f'OAQUPOAflCANUtM(H . INSUAEP..fiDAl!.P" "Inm ."l ul"~ v'!,9 &10 "0 '0 b EM"OVER6H"toIE ~~.HOCX. HAUl; CA~L, ~~nRAC~c;. COMMIS~ARY t INSURANCE rtANflAi,lE on pP<Y1nAuNAi,lE PRUOr::m H:'.. d IS IHERE A~'HERt-+fALW BENE,n PLAN' [J'{ES 0 UO H..... '~hllnl,.",lrnrn~'"'''''lIl1d 1:1 tN!>llIlro SOIl j,mli(mi:fri pl;nSOIIS SKUjAIun[ I.UlttQIl', p.'~fNltll oImMoc.1 twoll''''''lo lh. undtI.'O'ttdptl)IIt.." 01 ~ 101 .."".....,.-- Signatura On File , G II , J . Ill!. ,'.U' RESERVED 'OR I CHARGES on ''"'It E"O coo lOCALUSI u,ms r,," -,(( fJ~1 : JC:, ':'(' l , 'Ii , l!:,OO ..... , l ( 'rJ j 'tJ /;;;, ,.., ^ , 20.00 , ....4 ..);/ , 15.00 , ~~:, on 1 '1 tolAl CllAnOE J" AMOUIll rAIO"'1 :to BAlAt4CE DUE I !: '':';,0(. 0..0... 11 t,.OC -- n Nlyf,1C1A',5 SIlPf'UfnSBIWtIONAMr AOORES! liP COOt ~fl.~~Jr '. ",\k')PRAr TIC ';'LltHC n.~ \'O~;r, ROAD tA~LlSLE. PA :7C!~ <llOA"(' H , rltl' . . . lulU" ,oouur.rA 1&00 1"1101 lonuowcp IMXl 'ORUAAII.,&oo nH". ........"11".11 0" ....'......'"1..11.-.11.."11..1........ / {(SI.!;E NOT l~APLE ;i'IN THIS AREA PRUPI:NT IP' p ,(1. ElL'X t"*'v H'~H<:,HA~I. 1-01 19041\ I I "OC' HEALTH INSURANCE CLAIM FORM ~ .-PICARE UlOtCAID ,1-' ,CI(AUrUS nCHAUPVA nr.r~~tP~AN,.....,~t~~UNa_....:.t. OIHEn 1.1',SUIUU6IU Nuunlll 1tMt*,.'ln""'.(f"1 I,~"SSH' (VA'. " ISSHOfIDI I I,SSNJ r~l,IClJ IlL,HO..~8!.~.~"'''.2().~7 flAll n...IN'~ "'1 Name. _. 'II 3 ~AH I ,,~)~All ..lM 4 IUsunWfH'Al.IE1L.,IN.mt' ruIN.me,Uddltkwtllll 'iAlf~,. '1 INA 1,'1.1: '0'1: If'l, :;."1 .. II r r'1 f1~II.I~,. T 11,1\ r~r,(;. I PATItNlIlOORE66 INo . 611"1) . '''IIlNl nU....UOU5UlP 10 INSURED !;1 1:, c..~"\.'lH 'HREET ...[j'-D"""'D OlI~O CITY I StAtE . PAl ifNI &lATUS LAP\." l' I PA -d ..."...[J """'[J IIElEPUONE tVodUdl Al.. CadI) I (' \ ~ 2'L~ -4Jee. J It ".IIrjI~ ILIt' N,me. hll fWM.1IIIdcIII ntIalJ HA'JS. T IN(l ~ I'r;, . OTHfRINSURlDSPOlIC't QRGIlOUPNUU8ER DAlE. SIONEO ,& If PAllENI HAS HAD &-,UE on SIUILA" IllNUS I'" O"1ES~"'IENt UNlnlE TOWORIt IN r.un"rm ~CUP-'TK)t1 GIVE FIRST O-'fE MU ~ DO : 'n ,f "11f..... 00 .. Y TO ...... ) 'YY -L.__ 17. 10 NUMBER Of RUEnRIUO PIlY&ICIM, III "osr,t~lIlA111)ttO~lr! I1H"'IU to(:llnnl,,1 r.r.nvlCt5 u... uti ,..... ...... DO VY FnQU 10 10 OU'SIDE l-.S1 'CHAnoES I E r II II , J K DIAGNOSIS li.~. ~".u, RESERVED FOR COllE , CHA.RGts (\i1 rllm., E"O COD LOCA.LUSE u,ms r..n ~ 2 ~d !.5',I)':' , l.,::"jA 1~1 .00 l ~, , II ,..., ~ ~. :~" , lS.0(' I ,.,~ (Ii J'..., , (J!./L .;.,. :'7 , t :. ~,1 ~ ~l. f)(J , l./ , .~, ~4 lS,N' , , : :1 ~.:~ 1 ~~. ~O , I~ PA.lIWI6A.CCOVNI"O Jd' ACCEP' ".5510ll...U'" ~'TOtALCU"RGE,\" A....Q1.JtHPA.IO 30 BAlAttCIOUf , rOlVOvttt.l""t ...bldl " ' ~t\'.I..J:.."::,'\ ~, r,':).O',J' C,.{)'" 90:,or 31 UA"'E A'm AOUR(SSuf '''C1t11V WtIER( S[flVIC(S WEm ]1 f'11"SIC1AtlS SUPPllfR S BlllltlO NA"'E, ADDRESS, liP COOE R(tmEREOlllot~rlhlnhomuu"'nl \.fI~;'" ;H1RI}P~A( ~.te C~l.lNIC 01;>' ','''''1, r.:CAD ( ,~r-~t. : ~I~..r. r,~. : ','el :-t ~" ..')n,!/' -;-,r. I fill.. '.. - nnp, 'IPCODE I ~.:'O 1 ~, .......,...~ ru"""~ r"'....,-' I I Sludtflt-' I 51ucMn1 I I o 15 rATI IITION RHlollU 10 b OTHlRINSURlOSPA1EOf' BlRlIt au ",,00," I'~ " "'1 I e lMPlOVER 6 NAME on 6cttOOl N~"'E (:,~~:~ I';,,;."~,I~:, ;" '.' (01''''11 :S,~.,.,\l;'l' IIlNSURANCI PLA". NAME OR PROORAM NAME . lMPLOVMENT? tCURRENI OR PREVK>USI om dNa b AUtoACCIOE".t1 PLAClISI.lI,1 'II [JNO 1 O'ES c: 01ttERACCIDfN" dm DNa \Od RESERVED ron LOCAL USE ...g"CK g 'OIl . ""g BIIGN'"'''''''O.'', II PAtIENt! OR AUTttOnllE!l rEASON S SIGNATURE Il\IthO!ll' thf 1I1e1" of I"f'"'flkal 01 O/hIlrllOIf".llOl1f1f<"U"" to poe,.." t\tIm I alto IfCIl"I' pi,,,,,", 01 goy'lnmenI btntMI 'ItIlI' 10 ""M" 0110 till J*tr ..., Kttpll ...~ _ <,i~n".\lr.;' (Ir; FilE' 03-01-0;,'01 SIGUtD .. g.n '" CURREN' "!M:: ~:': vY,l ~ lllNE6S,'If"I,mp'0nl10R "'JUnV IA"Ide"lI OR (J "REO.4AUCVIlUPI ' n. NAMl Of' RUERRIf'<<) PHVSICIAN on OHlER SOURCE It nUERVED'OR LOCAL USE 'I DIAGfIDSlSOR HAIURf or tlLNESS on INJURV. IRUAn ITEUS 1.2,3 OR' toIlEMI"( OV LINE I ---, "'''I ',,', e'~ CP 't I L:.:.....:.:.. , L-.::,':" - ',.'r04 .. . L...:.-.: - . . 'IB:TEISIOf' &ERVICE1o ... 'm .. .... 00 ~-; ~o ","'1 . L....:.:..., ,- B Plac, VY ~..~ C "" 01 PROCEDURES, SERVICES OR SUPPLIES IE.pIa".. UnutU.ll_~Il!.~I.~.nc:'I) ,.bt,Uf"p,.A 1 "'uul~I"R IS'c;l.J~ 1 1- '? : \ "..,,1 .,":' :; '. I ....' {'''II ..c 10:., I ~.. 1 _..' : . , ,..,1 '0:' :;, , " ' ')~ ~ , '.;.\ . I . ~I:" : -~, ,- , ~ : , '-".': ,.. :' .' ~ ( , ,:' ~, 1 ',1\ < .' , . " " .:.1 , ~I\ '" ~ .'t.1 , , , , , , "'1\ ., c; , , ...,t: '~d " ~ ~: 2'.' , ,'1" , -, ,I , t I l I I ..~E.F. ~ 1 I to , , , " ':'i'S(i~,! I~ I , , I l~ , I ':'58~ ~ : , I; .~~1!.1~ ~ , , :,.;\ ;q~~.l!:' 1 I roC : ,~' ~.: ..~, ~ ':14 , 1I'!l flOfnAlTAJ, I D NUUBlR S5N flU f'lll .t:' ,...."j.,.'1 " 61O"A'UAE Of rUVSICIA', on suprllEn INClUDING otGREES on cnfOfU1IAl 5 tl~rtd~ th.Illh1.II'~1 an Ihefh"M '"",lo""'btII.nII"'fNIdfl~l1ftl.'yotl ) '.' '_-) ii" ( ..- II .. "1......('.., ~,t'J?{,.,.,) '" 1..n"En . ' v.;, 1...,....ROvED 8V AMA COlll4tll ou "'EOICAl nnVICE 1.8, Mid "Mf'1U1 _r1t 'nil ttlt.UM .tlIu",m PLEASf PRINT OR TYPE rICA ' , 1 Iron PIIDORAMIN llEMII 1 INSURED S AOORESSING, &11..1) ~1 E, SOUTH SlREET I it All I pp, llr coot \lEU.rlK>NE UNClUDt ARfA COOfl . POD (717) .:!43-43~F. II INSUREO&POLlCYOnOUPOR'ECANUMlln env (' AI~L : SU:: , 1N5URE.p'~~OAtL9' oIR'" .,,1 "l'9 '!,q .u rC1 "0 b EMPLOVEnSNAMEOR5C..ocJlNAUE tA~L, 8ARQAfKS COMMISSARY c INSUn"Nct rl AN t"....E on P"OORA'" NAUE IJRJLIEIH ~,''- d IS WERE ANQ1HEntlEM lH BENEfIT M.A." C~jt[G O' uo "..-_ ".hilnl,..nrltM1cH111llflmlld lJ ltl!jUIl[l!" 011 ^1J1IK\JWln rl:.n!i014 S SIO'I^'URE l.utllQl'l'" r-,_"",nI nI ""'doUl bIooYo1lllllo lhe ut1M,,'O'wdpl,~,~n OI'~ 101' UfYIt.,.w~helow 51'i"'l\tur!l On File [Jm [JNa I rl tolE btCAtO RE SUB"'ISSION com. I ORIGIUAL REF NO ~] PRIOR A.U'''ORlIA11UH NWHER FonuucrA 1~ 111101 ran... owep IftOO FORU nAB '100 fill" - ........."....n UN..to .".... ".1.'........... nil" t" tHII i ! : I I , , I , I I .... I r"'t'I'UWl U UUU WJI Ltl.IOI / I BE "J~OT .'~APlE /INTHIS AREA , PRU['[N rI A' p,r, e'......,.:~ H')P': H'<M, I.... 19044 i . ( , I IIrOC4 rOCA I , I. WUItARI ....DICAIO CttAtr.lrus CUAUPVA o!lOUP !.!~". 01l1tll I. INlilll1f.06IU HUt.lllfn lfon PlloonAUINIIIM 'I . I' 'n, III n n "IA~"t:ilANnu,,~uNo~ "(,I~U :111(',.)- J. 20':.' I f"'*'" I' ,.......11 'I ISpotI.(It' SSNJ (VA'" IJ , 5 Of J ,5, NI - 1101 I 8NNllt IlI'IHaIne. h,IH."".~Inm.11 I ~~.~I~~lqcr~ firM .. tt~Sunl06 NAUE 1\'" H.,.,., h,1 NI~, tr.&cIdIe ""1~11 H,".I~., I 1 r,,l, w\~ 'eI~: -~. "'!'. oj u II " r~ .tAU&. T I tl,'\ R~,E I ,A1ItNt I AOOAEB8 lNo, SII"'I . PAIIlNt nEl"tIOHSItIP lOIN6unlD 7 INSllnED & Al>OnE 65 1"0 ' 61'''11 S 1 E., St'l)' H ' 1'0;1.. E r ... d.......o c""O Olh.C) !1 E, 50UIH STREET CITY I SlAtE . PAtlENI stAtus C"CARLl "Ll: IS!A~A i '~ARL ! ': ..1: PA ......0 U.m'.D """'IJ ,. COOE I1ELEPltONE llndudt "'.. eocs.l IlrCOOE I tELEPIK>NE !INCLUDE AnEACOOlI . . . 1 :'~ll'.' ( 7 l.~ 24,)- 4385 EfnPlO't'tdn rulltlmtl-' r.rt IlIYWr-, . 17\)1 ::' (71:) 243-4:3E\S I SllKMnl Sludenl J II H,we IlI,iN.~. Fllfl N''''', IIIIdlH ""'tall ,.,srATiIN, . """Ult"'"""...u 'u I' INSUREOSrOllCYOnOUPonfECANUUBER I HAIJc;. T!"A r,:' :1 ~ ,I I OTHER INSURED'S PCl.ICY OfIORQUP NUUBER . UAPlOYtr.lENU ICURRINI OR PREVIOUSI . triSUREB8 DAlE or f'IRIU SEX om Cloo L Ofq '!'~ uo ,~ !i " b otHER INSUREDS O"IE Of BIRtH au b AUlD ACCIDENt? PLACE 151.1.1 b EMPlOYER Ii NAUE OIl SCHOOl NAUE II .... , 00 , v. I -n 'n DYES DNO CAF:I_ , I':lfIRRACI(S ~O~H~!SSARY . " .. I " c IUPlovf.R . NAUE OR &CH()CX. NAUE t. OIUER ACCIDfNU c INSURANCE f>l AN N.....E on pnoon"... NAUE it ,:t\f" ~t~\-:po., ,: "I"~' l~, -;.,,~y Q'E6 [J"o PRl!r',= NT! At. It d ,,'URANCE PlAN HAUE OR PROOHAU NAME lOd RE5IR\lt:OfOR LOCAL USE d IS WEnE ANOHtEnl'EA\ HI BENEfll PLAtt' Ii, IJ". 0"0 H.... l"h,,"I'Anct~I.Il.mV..d ,,~,.o lACK 0' '011II""0"1 CO...ulJlKI.IIO..... !HlllO"M ' I' INS'Jflror;OllA'IIIK)IIl;,,(n J'llRSC)t,SSICoU^IunE 11lIulllOIl" I " rAIlfNf'6 on AumonllED rEnsONS SIGNATURE IluthoIlIt lhe I..... of .n, "'flkAl 01 OIM! """,",,,toOn ner."at, l'oltmf'ol nI mflrloeal twofv'''" 10 Ill. urwt"'IQnt'd ph,Ialn or suppr...IOl to "DC"'''' dalm I atao Iflq.Jt,1 paymenl 01 DOYt'rwnerll btnIhtI.....' 10 m,," 0110 lhe par1, vmo Jtt'tPII .urgnmtnt ltfYlC.' dewlbed t-lo. - ~Igno!";'_,,'r< ('11 "il~ O;:l-Ol....' S!gnO':.Ul'l!t (In FllEl , StaNtD DAlE 61(lNro . . U~Il or CURREtn ~ IlUjESSt""'.~lon t& 'f PAlIENt HAS HADSAf.4E on 61MllAn IllU[SS I I" U_'[8""I[NI UH.f1L~ lOWQIU( IHrm1nFtII OCCUPAllOt1 , . 00 I YV INJl'RV I ccllMnll QI'v'E flRSI DATE U'"' , 00 < 'tv t,I... DO .. UY DO VY '.t I ~ 2'1 ,:,.~ pnEGNAUCYllUP, (, ' ,n()t.1 10 17 NAME Of REfl"RINO Pt4V51CIAU on O1UEA &OuncE 17.10 NUUBEROFRlfEnRlflQrUYSICIAU -~iil-iIOSrl"\11AII{)tI(J'llr PEt A1rtll()Cllnn[tU Sf.nVICE5 . ...... on 'tv MIrA DO 't"t f"O'" to " AUERVIOFOR LOCAl USE Xl OUtSIDE \Ao' 'CItARaE 5 , il... noo I I I " DIADNOSIS on NAIURE OF IlLHESSOR INJURY. tRELAIE itEMS '.2.3 OR.. to lIEU '''E By llNEI t 22 f.l68ICAID REsuBMISSION r ",).~ eo~" "€I eEl ORIGINAL nEF NO I I ~:.;.: , ~,.:-. 2] PAIOR AUlUORI1Al1ON NUtr.lB~n I .,...... . . , '33~. 21 I 2~ . . A S C 0 ( . 0 " , J K ~ rf~tfIS) Of' SERV1CE,o ..." I,.. PROCEDURES, SERVICES OR SUPPLIES CIAQUOSlS RESERVED ron ,I 01 rp~~;~~~ ~uI~~lf~,~,~.rv;.'1 I CU"AOES on fII"'ilW (UO COO LOCAL USE .... . nn vv MU DO " Pitt P U In COOE UNIIS ..., . , , '".:. : , ~ , h : , 1 ~:.CC I ..,"" -:~ ,~ 1 ':(-:1<:1. " 9",€l~ ' : 2 Jtj , ~ ~ :1 I' , , , , , , ~~11~B:'i" j;" :~: '~t\ :;. < :":"5851. 11: ~ ~~'3 tl 1 e;. '''l~ e , -, .' '1 f , ru , J ro., I ':l' , 10": , ;1'?5ASl II ;::: , . 't' :a ";-4 ~ f.' , 0:) .~ .3 <; ~2J4 l~,CO ,".' /', ) .. ..' , 1 I. , "- '( ~~I .Vi!7 Ii , , , ' , , ! :- ':: ,: p 1 J'~ 0~: '.1.:.' t"l!\ " <;, I :9~,et'l I 1.': , 1~:;'t& 1~: .oe . ,1 I ~ i , i./ I , , , . C..' 2l? I~l~ 0':' :'"; : ....: " :- 19SeS1 14: 123~ 1:~, (10 ! . , t'S. ,i... I ' t : ': :!~ :'~ :.." f1 1"'. ., ~ ~'~ : ':'I1l :1 .1.;..,6,,1 1 '7., 1 ;::04 l~.O(i 1 . .. .:,. " fEDERA\ lAX I 0 NUUBER &5N EIN ,. P.ltENI S ACCOUNl.m 11,~{fc(r' ASSIG"IAfUI' .,. totAL CttAnOE ~ 111 AUOUPH PAIU 30 BAlANCE DUE l'ln I r" 01 gort rl~m! '" bAtkl 9''):,(''~ 'l ~ t', ..l':: ,I f ~ 'r... H(.\t.,q2'~'3(' ". '1"0 , 9(),.'j~ s ~"CC . 3' SIGNAlunlor PIlY&ICIAtlOn f,uJ'l'llfn 32' NAUl AtlO AODRESsor rACtlllV WIIlllE S(nvICESWll1[ J1 rtIYS!CIA"S SUPPLIEnSBilLI"ONAUE. AOUJ1ES5.1IPC;OOE INC1UOll'ro DEGnlES on f.nrUEUIIAl S R[NOEnEO III Olhfl' !hln hOme (It 0,10(_1 ~'~Jr CHIRUP~""C T 10:, CLIN!C Ilttlt", IhIllhe .1.1fl't1"1' on"'. I.,.,.. IPPr to "'" .lrG II' m* I part lhefeoll 7<l2~ YaR~~ F:OA~~ " "~ I)~' , , ,',;;, JI(.""le/' /~)t..l,.t ~p (ARL!SLE, p~ l?v!~ BIOIl[U . n;.n: I 1.1"'11""'4 ...~ I "Ill' ... J. nllf" - HEALTH INSURANCE CLAIM FORM IArrnovtn fly AUACOIJll(lI ON UIOlCAl 5EflVICE 1111 Mid by ~.I "r" p"" hi'''." 1_lItlln PLEASE PRINT OR TYPE fOnl.lttr.rA ISOO Iiii' 901 roou ower l!1Oll fORI.I nRe 1~ .1l1U . """tt"II"'" uw..,~ I...........' ..-..", ".1..1....... .'.... ~.. "SE .~OT ."TAPlE IIN THIS AREA ~f,'.Ji:'!::Nll~' P . e 0 81;1:-.'-"7 HCRSHAM. PA !90~~ HEALTH INSURANCE CLAIM FORM AI'f1nOVlUOUB un. woe I I l,ocA rOCA 1 i I t "OICARi Uf.DlCAIU cHAurus CHAUPiJA onoup t~fA_ OHtUI 1.1N5UI1E.OSIO NUUOEn IFOI1PROOnAMtHllEMl1 In 'n' nl nIJlA~'~ At.~~O_~~~.?-121J~~7 -"""""" ""'tdll fSpottl(W.SSNI WA'..', , S or, IS$HI 1/(lJ ilittNamt.,..IN.IYW. MldlJIt 1,......11 ~ r:..~.'.ltNI~d" &EX . ..sunEO I NAME lUll Namt filii N.me, MGdlIInltIAlI '1!\',I~" 'I: t;" I"'\~ 'e'l: O~ t," M r'l ' r1 HAU~o. TINA RAe . PAlIlN11 ADONIS tNo. 61'"11 . PA1tlN1 RlLA110NSlllP 10 tt.sunEU 1 ...aunlD I ADDRUltNo, 11,..11 ':'1 E. , ~,(llJ I H ;,I'<f.o:.t ... []' -0 CNldD ""~'IJ t; 1 E. :;.CI)lH 5TREET cny I"A" I ,.AlIEN' .1A'US ClfY I &tAtE r.(,r,;L t \~l ~. ' ~'A -d M,,""'o """,[J rl\f,I.!':'!.C PA 'IPCODE , llLIPttONE 1"'dUdl AlII Codtl 'IPCOO[ TELEPHONE IINCLUDE AnEA COOf.I !:>Ol.' ('l'? ?l'.,Pt!" EmpIo,td n Full T,"" n r." 1lmfn 17013 ( 'II;') :!43-438P', ,. .'. '.. J Sludent 61udtnt 011"'.' lUll N,"", fIr,1 H.me. I ,. "'A"'"'.C ..... ."A"" ,0 II INsunt:D 6 POLICY onoup OR fECA NUMBER I IIt\U~, . llll,. r."!..L+ J .0'HfRJNSURIDSPOUCYOAOnOUPNUMlER . UIPLOYMENU ICURnEN' on PREVIOUSt . ..sunED8 DAf~Of lllnHt ... I om 0'" M 1 I,~ V!'9 "0 ,~ , b OlHER eNSURED S DAfl Of ItR1H SU b AUlD ACClOfNn PLACE 15111'1 b EUPlOYfn 6 HAVE OR SCUOOl NAUE I IN , DO , VV I ,n 'n Om 0'" ~:A"L . BN~f{AI~I(~ COMM!SSAP.Y ,. .. I c lMrlOyER 5 NAUE OR 6CHO<X N"'UI c OHtEn ACCIDlNl1 c INSURAt4CE rtA" NAUl on PROORAU N......E I '. !\Iil "I)!':" ,I l.., .~, ': f}'~~11 ....~'E: I~HV C3m 000 E:I<U,'!'I.'T IAL , : d INSURANCE PlAN NAtr.lE OR PROGRAU HAUE IOd RESERVED fan LOCAL USE d IS lHEnE "~OlHER~EAll~ BENt:flT PlAN? I DVE. 0.10 "..... "'1fI'1I1.ndrnmplellll,,"'9Ild ,!,!,~~..~~~_o" D~1t DI' HiI'DII" 13 IN~U'IE060n AUluom;EO PERSONS SIGNA1URE llUItIOf'" I 11 P"1If.NI-S on AUf.-onllEO PEnSON S 5tO"A1URE I Mhotll' the ""'" 01.", ~lIol othttWlIOl""IIOn~u,,", pay""'"' (I' ~.I bltfw'Itll to IhI undI'I'V""i phy-lOIn 01 ~oet lot :.t.ocn,.. tWm I Mo llQUetl pI,lYWnl 01 ~MIM t.nI"" IlIhtIlo ",,," 0110'" pall, who lCCepI' ..,~ NfvlCtt dnCflbld t>>Iow I:,I'ilnn~I'\'''' Ol~ Flh 0:<"01-'>4 $1 ~lnetul'c On File i ltat,t:D DAlE 6l(';NED ".ll:" or CU"~"' ~ IUN16S(UU,mplomIOR II IF PA11EUI H"SHAD SAJ,ll OR 61UlLARIlLNE6S t If, OA1[$P"II[N1 UN'Rl[ 10 WORK IN CUnRENt OCCUPA101 .l~ ~.:" '( 11 tNJURYI tctdlntlOA P QIVE f1R8' DAlE M'" ' DO I YY t.l... 00 'rY UII 00 yy pnEONANCYILur, I' ftlf'lt.l 10 ~- '- " NAWE Of hEflRRJNQPHY51C1I~..on01HER &OUnCE 11. 10 NUMI[R Of REfEnRlNG PUV6ICIA" ,II HOSPI1AlIIA1KVl(lAI(f flrl.AtrD mCIIRAtNI SEnvlCES ,U"'l)lJYV MUDDYY ,."" 10 1 I' M6lRYED fOR lOCAl USE ro OUISIDE LAB' . CHARGES On. 0"" I I " OIAGN051Son NA1UREor lllNUSOR lNJuny IRE LAtE ilEUS 1,2.30R4 fOl1EUUE BYllNEI t ~2 MMICAIO RESUBJ,l15SiON E >II .,. . . ~ 0'" eEl QRIOIUAL REF NO ~oo'_" ~'- , ._ 3 ,_ 23 PRIORAU1HOnllAflONNUMBtR ,I -; "9 , , I E':~~ .21 , A . C 0 . , 0 H , J . ,,~1rlsIOF MnVtCE10 _. '''' PROCEDURES. SERVICES, OR SUPPLIES DIAGNOSIS RESERVED FOR .1 .. I"P 1~~~~U~,U.~':fQII COO, ,CHAnGES on fIl""', '''0 COB LOCAL USE .... "M YV UU au VY P'ltt P IFI ONUS "I"" , , ':.::: , .~ c G'~(":-l 11 ~ : ~ 12~4 1 r:: .oe I ~.-::' ..;.:! '~.1 21? I 4,~ .' , , \17: I , . , -.~ :':.1" ..' " ,g~t.~, 1 ~.' ~.l 1!;.. (It' 1 V'" " .18: 'J',l ! 2 ~, -. I' . .. -; " " , l'!lr:,'J~l , /. :"\ ".~ ~ .:~ :'~f .: , -, " 1-'" ! 2~q it: .<"C" , . - .~~" .~t1 ~ ~,' l , (} ":h r') (:;~ ." . , ....;': , , "":1 ~ .~,' ' I' " l!> .OC' ".'I"lj " , ~ c ."~~,B!:.l ,~1: I ~ ..: :~ fI I , ' , ' , ~ , '- '(j-' , , , , I ' , , I \~ : .: f) !""'. .' .!~., 9{, ? c ~;'I~Sl ',1 '. 12}11 1 r~ , 00 , .';' & ' '. , ~ I , , , , . I .,~: I , I."t. '!"? : '-"1 ,.... ,:.;: '~~ > ..- 'J~18~ 1 12:34 l~;. (.Ii, ~ . '" , ' '. " FEOfRAL 'AX I 0 NUMBEn GaN fit. 2fI PAflEN18ACCOUtH"0 \2.1{cfCEPI ASSIOtn.IUH' n lOtAL CHAnG~ ~ I tv AMOll",1 PA,IO 30 BALANCE DUE I'l (-'1 Ir OIO"Y1tl...mrl"~('1 .\. '."":1'. 1 .~. : ,,'l.n;.~?~~(' ' n. [] "" , .....',):. O~~ , (' . ~t . ':J(\:.O~) 31 IttG"",unE or Ptt'f&ICIA'~ on surPll(n 32 t,AUE A'lD Aoof1f&50F FACllllY ~mE"( SfRVICE5 W[f1E ]J PHySICIAN S SUPPltln S Olll"Kl Nlt,l[, ADDRESS, liP CODE INCLUDINO OEGnEES on CRllll"'IAlS nENOt:nEO III Ol~ !h'" tlOlM 01 o"nl 'J'l~f.f ':'H! RClP'" r. TIC CLINIC tl ~"y .hal ~ ,tal..",n" on '"" "~"I' 1lPP' to 1M bland ,'. INdI . pal1lMrtoll 3.:'3 YC'r\l' ROAD .' . ~!' -7 \1/lltf.') ('JI.tj b.t ~ ARL H,Lr:, 1'0,\ 1 ?()D If' .#' , f'. 1 ~''S(q\ l. ~,,:' onp. <10"'0 'b... "1'1' IAPpnaVEtl BY AU. COUtlell ON UlOICAL5EnVICE 1111 Mid .., .....1 Ath PrI.. tal'''.'' I Il>>.H W. PLEASE PRINT OR TYPE ran... tterA 1!lOa III tOl rQRI,l owcr I~ fORU MB 1&00 "'I<<_~"lotl""1 UW"..".....,I.IU~.III1.I...'"" I ~/'SE NOT 1!j~~APLE IIN THIS AREA ^1'1'IIUVlUOMP W.lIWOI PRuriENT l~;'-" 1=' ,':), ell>: ' !t:JH~.H''''~I, PA 1 ",044 I . c I I \.oc. roc. :; I , 1 "OICARl UlOICAIO CU"Mrus c.tAUpv", ~!l~P HeA otutll I. IN5UflEU610 HuMOE" If on pnoon"t,IIN IIEM'I . , 'n n n "1'~TH~'Nn8l'},UNOr11 46NOJEi!,2" 1 :~:l27 bfllilldlc""lnf~" (Spo#t.DI.SSNJ IVA'.,! ,SOIl ,SN, /In, '""' ILl.INlIN, ,.",1 Name, MOdIt "''''1 I P"! , 'Vl,.~". 6" . lN5unlO 6 H....E Illt' Namt h,l N'I'IItt MOjleInll..'1 ~'I'l:~O~ ..., M n rPl HAV~11 TINA r' . c: H~I.I~. 1'l'lA J;./IF .H.... . P,,'.N'. ADDRUS ,'+0, &tIN" . '.'IEHI RElA1KJHSlIIP 1OINSUnEO , INSUREDS ADDRESSING. St'"1I "'1 l!. H,I!III ' 'PEt:T ....D-Oc....o """'0 :d F., 5('1.'11'1 !:'1~I::ET Cny \8"" . PA1IENI IUtuS CIIy ISIATE i *: tInt. !c:~.~. "'/' -Cl ....,...0 """'0 ('Ar~L 1 ;.Ll; Ft.\ . ZIP cOO( I1EUPUONE 11ncUtt...... Cadll llPecot ITElEPltONE IlNClUOf An[" COOl I , ~.'~)~'~ ell) 211,3"4:8~, (mplo,tdn rul."n'n P." ''''''n , lNl'J ( 717) '::43-43El~, I ltud,nl Studerll Il'I' NJmf, hll NJmt. I I. ,..."" ,. ,.... "'IONRllmDlO 11INSUAlD6POllCYOAOUPORflC...NUU6lR 1 HAU;, ,., "I,~ r)l\~ II . OTHER MURED8 POliCY OR DROUP NUUIlR , EUPlOVMENl? ICURRENT OR PREVIOUSI 'INSUR[~OATAf I'lnlll SU :i DYES [300 ~ '~V~,9 "0 ,~ bOTHER INSUAlD8 DAlE Of' IIlRTH 6EX b AUTOACCIDEHl? PLACEtSI"'1 b EMPlovERS H......E on SCIIOOl. NAl,lE UU100lYY I Mn 'n DYES 000 CARL. 8AimM..Kf, O:OMt-l!$SARY , , I , c.IUPLOVER 8 tuJotE OR SCHOOl HAME c: OUtER ACCIOf.NT1 c: INSURANCE. rl"'N flAME OR fJRoon.... N......E ':I\'-:! , ~.' r.:f.~ fl. t, I' LU~~~1 ~~, :."n',' DYES 000 F'1~lI['E N r I A:" . ~&UAANCf PLAN NAME OR PROGRAM N....E IOd RUlRVEOfOR LOCAL USE d IS TllEnE ANOTtlEn UEAlTIlSEN{f1l PLAt., I' Otl6 [JIIO If..,., 'l"llInl,,.rwlrrvnOltt,,M.m'tld . "!~~..~~.O O~!C"""I11G."ONINGTI"TO"M 1:1 INC,lJIl( 0 P; fltI AIJIIKl"I,f1l PEAsn', 5 SK\N^ TunE IllUlllOll1t I .2 rA"ENTSORAU'HO'UllDP(nSONBBK1NAlUnE 11UtfIor1l.!ht'..... cl.ny ","(11011 OItlll',",OfmAlocnNrIlUly p1'l~1N'11I 01 nwd",t t.IW""I Ia I~ ur$1,.gMd phr,,,..n 01 ~ 101 :.c.oc:n... Nm t 1M ItqUI" Plrme'" of VCM''''"'''' '*'-1It. ""'" kI m,..1I Of kll'" party lItl'O tcetpl, IIIIgMllnI NJ\'1tt' dlwm.d bItlo. !:'J~JIi,.".IIl~' 011 File O:-Ol-'?!. S,! '.1l1ctur.;~ On File ! SlGflfP DATE 5K'lUro "~TE '" CUR~~N' ~ IUNESS~'I'r~'OR laIr PATIENI H"SHAD 6AUE ORS....IlAR M.lNE6S 116 11"1f6P"'IE~NA9lE 10 WORK IN CUfU~nn OCCUPAllON l' DO' I INJURYt ."'1 A QIVI'IR&TOA1I M'" 1 DO. 'n" ...... 't'l "lot 00 YY . : .:.":' Ill, PAEGNANC't'(lMPI " rRtlI.I 'to , I 17, NAME Of RHERRM) PHVGICIAN OR OlHER SOURCE ". I 0 HUMBER Of" REfERRltro PUV5ICI^N ,Ill UUSPllA1I1AlIONlHHtf p[LA1rO'ocunnUH SERVICES ",M 011 V" ...... DO vv 'ROO TO I II RESERVED fOR LOCAl USE ro OUTSIDE lAl" , CItARGES Om ~ I 'I OIAQt<<)SISORN""UREor IllHESS OR INJURY IRElAIF II(M5t.uon" TOI1EU,.tEBVlINEI + ;2 U'DICAIDR(SUOlotlSStOH cOO< I ORIGINAL REF NO - ., '1 .....,;. OE:! ,:.t:' l ..' - 3 L.:':..:.. . . .- .- 'l PRIQRAUtHORI1ATIONNUMBER . I - ~," , I €,:r~ .~::l . . 8 C 0 , , 0 .. , J . ,,8.t1l'16IOF SERVICETo .IOC. T,.. PROCEDURES, SERVICES. OR SUPPLIES DIAGNOSIS I"o~' r~~~w RESERVED fOR .. .. I rI,~~U~'UI~~~n("1 CooE I CHAnGES EMD coo LOCAL USE ... !Xl VV .... DO VV PT, If I R UNUS r~. . . , " ',.,nt,1 124: I 1234 ~~: .OC , t (#1 ~-:' 1';1/1 !: , , .:..,: :' '" I' I , I , , , , , , I , , . . , . , , . , , , , T I , h z) I , , , , I , , I , -, , , . , , , . ! ~ , <!!. (/1 I~'" , .,1 , , (t . , , , , , , , , : , '/ :',.J . : t.1 . '. , I I ( . , , , , , , , , . : './ & , . I : : , , .,0 I , , : : : , . 2!l FlUfnAlTA)l.ID NUMBER SSN (,,, 2e PAUUH6ACCOUPHNO I u ~CCErl ASSIGIlt..lWP " TOTAL CUAI10E , 119 A...OUtjf PAID 30 BALANCE DUE ,'Il"': ,'. "'. nn 1(,ly,,~qt'l) i ,-, ~~yf Y~i~ ;: bat. I I . < .).; I C,OC . ! 5'.00 . . 31 SIGNA TunE or PU'l61CIA',on wrrLIEn 31 NoWE A'IDADORfSSor FACility W1IEflf 6fl1vICl6 W~fU --- )] r""51CIA~~S 5urrllEns9nllflONAUf ADDnESS lIPCOOE: INClLJOINO DEonEES {)f1 c:nEO[NllAlS nENDEI1EDtllolMllhI.,'IOI'l'OI 0<<01 ~rlY?'/{, ell !r,OPRAC TT ~ CLINIC Ilrtl1"wlttll....",'."'.nitool""..'''.. .' ~.y lothtt bI end '" rnIde. Pllllhefl'!Jl/;Jf; ~~ ~ Y>Jf':f; ROA[l " J' I .. l' , ' ': (,Pol. ! ~II.E:, PA 1 ~''='1 ~ 1f1"j,'L.~I.' . I \ld....., II , . '.' / " ~ 1"(; r. fll'''' t., I S'GUIO n~tr rl'" . ... . . " ani" HEALTH INSURANCE CLAIM FORM IArrnovED!V AUACOtJUCll OO"'WICAl SfnVICE ...11 MhI ........" A.It ,..., e..l...... IIOOUIII" PLEASE PRINT OR TYPE , UIlI.lIIt'A I~OO 112 eol ronl.lOWCP I~ FonMRRB I~ .IDIU.........."",.,.. u."" I..... 'Ill" ~II "4IM,...,"" /. " ,....sc " /JNOT /.~~ APLE /IN THIS AREA ^, 'IIIIO""EO OMU W3I UOOI F'f\U(\ENT Ifr-'\ I',l', 80): ..7 HQR~,HI~M. PA 1901\1\ I I Ir"'A HEALTH INSURANCE CLAIM FORM I UIDICAnl U1DICAIU CUAWPUS CHAUPVA QROUP riCA OHlEn I. IfiSUflEUSIU fiUlotOER ,-, twJdlc.'." n ,"'id IJ Ii I$poMOt,SSNI n 'VA'. '} n ~l~hl~~lN n8~;JMNQI:-t 1101 "6NO"~6rl ~_. l ~(,'"!i I' r"'''ll:lll ,,"_..: IUllNlmt ,.,1 NJlme,MddlI Inrttilf ;t ~~.~Al~ su . INSUIlEDSNAUEll.,tU.IM r.,tN.mt.NdIJletndlllj ....':;..IXi~;'I',! ._ ~, HfIIJ',. ",..,.\ I~"~ 0,\' 19 ~q 10111 ",'1 Sfl~'!:' I P"11fN1 6 AOOnESS tNo. SU"II . PATIENt RElAllONSUIP to INSUnED 7 INSURED S ADDRESS tNo. 51...1) ~,1 r,. <;,QU1H ',:If'l'''T ...a...u..o c""o Olt...O ~,1 t::. ~,(lL'TH STREET tlfY ISfAlE . P.'I(NI STATUS tlfY I'STAlE (:(\I~LT~,Lr I P(I ''''9't[A IoIW"",O "''''0 CI~I~LI~,LF. PA 'If' COOl 11flEPIKltlE llndudl At,. Codtl liP COOl. ITElEPltONE (INCLUDE AnEA COOEI ~"')P ('17) .'!1\-..4~Flr., l_r"r1~~::;'n~:;'::;"n I;'Ol:1 I (71~) ;'43-1\'313'\ Ut'lt.L>B NWE ClltIN.me,flrllNI'"t. UldlN !N11I1) to IS PAllEN' BCONOIllOHAElATEO TO l' INSUREDS POlICY OROUPOA f(CANUW8ER 4~7-21 0 . , 0 " , J 0 : PROCEDURES, SERVICES, OR SUrPlIES DIAGNOSIS JjA;1 ,rso RUtnvEorQR rPI~*~ ~,u~~C::~'~'l\(tl' COOE I CUAnGES on hm., I"'" COO LOCAL USE mllTS rl'" , IC"~)I,I , , , , I"',' I , 'H\ no , . , ! , I , , """'('0 I , , , , 0 '1 ,,' Ilr, , I , ,j I '0",(\" I , , /-:;-.. , . ... ., A ~,.; (',n , I.!!, , (61/ ?J ~:? \,,,.,,., I , , , , , :" .,,; ,'n , I " if ">7fl' n I , , ,', ~ I r~ D(' , , I I' ~I'\~'r . OtHl" !HaURID' 'OlleY OR GROUP NUUltR . rWPLOYY'NT? ICURRENT OR PREVIOUSj om [BOO b AutOACCIOfNn PLACE IS'At" , b OlUERINSURlOSOAUOf Blnm &EJt ... . 00 I VY i ,~ 'Ill 1 ~~ 1:\,.. WI I c EuPlOYER S N....E OR 5CltOQl NWE (''''\r=:I~ ~lf: ~', ': I It,'! 1 ~ ~.\.."'-;t'1 d INSURANCE PlAN N......E on pnoonAU NAUE , r.~ Om e omEn ACCIDENt? []m DNa ICd RESERVED Fan LOCAL USE DNa I ..~!iD IACO O. '00"'''00' cOWLI1"0' "ON". '''''00'' 12 rAtlFUl S on AUlltonlf[1l rEnSON S SlOf,Alunr 1.1./fhOf1lt ,he !tlta" ol.ny m.dcJ!l 01 o~,InlOlmallOn I\@C"IUI, to procnl thit NlIt\ I tIIO ,~" P'~mtnl 04 OO,I'nmtnI Mni'''' tlCMllo m,.." 0110 Uw pII1,. k.Ctpls ."lQ"im.,,1 - '.(qn(t'.ur.. ',\" I'lie 0:1",;:-'~4 BlOlltO "hAIEOJCURRf.NT ~ l~lNE5Slr"'I.,mplomlon Wr.I , DO I "tV Iwunv (Accldenll on ~)'t ~ -,\:,' I~ 1 P'UGNAUCYIU,lr, 17 HAUl OF AlFERRIHQ PHYSICIAN anOTHER &oUncE . . DATE Illr PAlIENT HAS HAD SAME on SIMllAn Il~NU;S OIVE flRSl o~ TE W I 00 : VY 17. 10 NUIrrIBER Of RErERRING PttYSICIAN II RESERVED reA lOCAl USE II. DIAGNOSISQANATURE or IlLNESS OR INJURY IRHATE ilEUS I.UOR4 WI1EU2U OYll~4EI ~ , 1[(.11 ,..1l' , I 8 "1...9rJ , L::2.::.' ., .. A r,9tTElllor 6ERVICfTo .... 'ilh Y't' MM DO YY 'I I' , ",i." ",'. ," ", ,'.' , . C PIact T,pe 01 01 , , , , ,,"I: ", :'" ., ''1 : ",I ., . , 1"".: II' , , , '.,. '),.' , '"I , , ' " , , , , ,".'1' d' , , .' " . .. , " . .. , , , I, J:)' I~ , : , , ,...: I' : "(1 " , , ~' I' I~. '''''1 r: &, I.:.. , " n()ERA~ lAlIlO NUUBfn ~.. '17':,'1 d I : " PAIIEN1S AtCOUPH 110 , . '\& . \ ~:... " 65N IIN [-WI I , '.:c ,~ 121 ACCEPI A5SllitjMUjP Ir_\~OI Dl',1 tl~_.m' ''''' b.I(~1 q.~\I:"'I?'=lf?''''' II I Y~40 U HAU[ AUOAll()RtsSOf rAfIlITvWIlLRl6lnVlCl5Wllll- RENDERED III olhfor rtl.n homfl 01 0"0("1 31 BlOfjA1Unt or r..'StCl"'wn t.IJl'NI~R INCLUDING DEO"[[$ on Cn(UltlllAl s llnrtl',rtl.lltlll Il.lflmflnll on ".. '.wll'l. apply 10 Ihtl boI,"" .'. m,.. parll~'(I1.1 r' I' '-'.- " , .', '. I !-i' , '/1 / ,,'I " /1,' >I' .' . ,', Ii 1/, " . ,,; . I~... . " 1&10;4(1) VAlr jArrnovw 1I't' AU" COllPllIl O"U[UICA~ tiERVIC( 111t1 1'" ttr .....1 "'It p"" h' ....... 1100""1" PLEASE PRINr OR TYPE PICA I tHJR PRoonAIA IN itEM 11 I;;;;suo,". OA" Of' .,n," MU . DO VY 01 1" 59 "0 b (up\Qy(n S NAME on 50tOOl NAUE H?\RR"U\ S (',OI'IM I f.,!.",A~Y t INSURANCE NAN flAME on PPCY.ln"y NAUE 11 i! .,. 'I]] 1:'I~'.IrlENl 1 AL d IS IIlERE ANotHER .IEAl Ht BENEFit P~AN' ntES Gl "0 H..... "'I'I,"I1Ilnr1c:nmol~'",,,"'lld 1 1 ,,~;"\iiif'ii"iinll "iiilimll,ro "1: n!'iO" 5 SI('.N^ TunE IllulllOtI,. ,...,.n'l'II' of "lf11oelll tMolW'l," 10 tI~ undI"llQ!\fId ph,'CI&n OI.uppIref 101' '.I~U' dew>t>>d tRtlo. Shll19tllrt' 011 F 11e 5KnjEO 16 UA1ENP"lIEt,I Ut,"ut 10 wonK I"CURnUtT O\.CUPATIOtI UM DO ~Y U~ on VY rRt)t,.1 TO II UOSPt1AlllAIIDt4 nAlE! JlElAlf[J tn cunREN1 SfnvlCES UUDnyv UUOD'YV FROt.A 10 10 OU161DE lAD' 'tltAnoES DYES nNa I I 22 ..'[OICAID RESUBUISSIOH CODE I ORIGINAL REF NO 2] rfUCJR AUHtORtlATlON NUUSER , , :.(.'. Of) I :11 101A~ CttAflO[ I" AUOI.Jtll PAll) )0 BALANCE OUE I ~~(.t~~~1 (1',0(1 l"~0:,()~' 11 I'IIY6K:IA'~ 5 sW'rllER 6 Oil I. "10 "AUE. Al>on[ss lIP COOE ,J'Itt)f4(. I!'Jf.H "I>l f"'lPli Ai IF L'_ I NIC 12:t '(('Ii", f!OI'\D l.rr,_. J'd.!', I:"', J701:j ,'.". "1"""'1" 'II l.'II'. JOm,lllUA 1&00 ,UIG, fOm,lUwCP I~ rOR"'Rn81~ frll<<-MHoc,"'II"Ut u. ..~I.....IlH..~..II'I"I""...1l i ,~SE /"NOT /~TAPLE , IN THIS AREA 1",;l"'II,," r I," I' . -'. (1'.1:':"-"'" ~UI~"ItAt'\. ,. (\ 1 '1\\1\" I 1 I IpIC. HEALTH INSURANCE CLAIM FORM 1 1II0ICARl UlDICA1D CUAM,ua ,tHAMPYA ~~pUP ~lCA OtllEIl I, 1'.5UIlf\J610 HUMOlA l-..'~ ,~ n' ~ HI""'Pl'H,~BLHUHO~.. I 1''''*"''1 Ij'lIHIc.d "I If~.SSH' IVA'.. IJ I IISSHcwlOJ I I {SSNI I 1,1(11 "(,~JO I~r'..~' . ~ :'(::'7 Iln...r IL.t1tMrne,halN''''',MldlNkIIll''1 13 r~~lf~'. \tV n61:-. '''1"' 4 INSUnll>8NAUEll"IN.m..r"IN.n~ u.u.1nll.." I;.I'~." "II~,' :'~"ir' 0'1 !'-' ~,"" ... '1'1"1 ~,(\I'1f- . P"ttENt. AODAl68lNo. 6;;- . ''-'''INI nlLAtlONSUlr to INSURED 1 INSURE 0 8 ADORESS (No. &l'M'1 <,I l:.. ",I~IJ'H "!I,CEl' '""06p>uHOCMlO """'[I ~.I r!. ~1'l'rH :.'~En CitY -laTAli l'AlI[N'SI.,UI CitY ISfAfE (,~l,'.. {~, .,X: I r',', _01 ..."... 0 "'".. [] (f1nl. J ~,l r.: Pf1 ZtPCOOE I tElEPHONE ttndudf Ar,.CodI) liP tooE l'ElfrUONE !INCLUDE AREA COOl I IJ','I~ 1(711 ."\'>-I\~,,", 1-'''n~:'~:;''n~::'~";"[-l \7')\:> I (71'1) ~1\3-1\3(<':i I' OHti" :lla'IN,me'II'IN""'. I loll'AlltNI UU\""uJtu II tNSUIlEOsPOLtCVOROUrorHfCANUIr,IOE.n ~. ,~'r . OT"" ~.URlD I rouev OR DROUP NUtlllR "~~O ..c. 0' 'O.~~I'O.1 c_utlHG' lloN"O ".. 'OA" 12 PA11ENT&OR AUlUORllEO PEnsON B 6IGNA1URl l.uthQua. 1hI I"""Dl Illy meek8l'" O~IInlCllm.I-onN'C.'Uty ::.t:"'''' dam I lito 11CJIf" pa)1fltnl 01 OOwlf","*" biN.... a*"'" 10 myu. 0110 IhI part., .....tttepl,..aqvntnl $if.ll1!l' \If t Or, File 0'.1-12' ~I.I 80'[0 DATE !i'OHm ,. CAlf orCURRENl. ~ tUNE6Slhtl.,mpomlOR 1& Ir PAllEtH "AS HAD 5A...( onsluun IllNl6S L" [1"'f6 r"lEN' UUARI[ TOWOlUt IN(UflIlEtll OCCtJPA11Qt1 ~.' DO' V!. ItlJl'RVlAcddltnllOA QIVEfIRS1DA1E...... I 00, yy ...1.1 00 'tV lAM 00 yy () I ~ ~I"'t' qn rnEGNANCYllUPI ,1"flU to I'. HAW: Of RlFlARIHQ PH't&~lANOA01HIR60unCf '"10 NWllfR Of' REFlnRINO PllvS\CIAN '1 HOSPt1A\IIAT'0t.OA1Ef,FlElA1ro lueu""lN1 SERVlClS ...u on VII MM DO VY 'RoM 10 20 OU1610UAB't ICHAnnn fJvu n"" 1 I t2 MEDICAID nUU8uISSIOH tOOl I ORIGIt~Al REF. NO b OtHEA INSURED II DAtE Of' .'RtH 6E1l WI , DO . YY I .n .,., I ~ r.1~ U " \, . c.IMPl.OYERS HAUE OR SCHOOl NAUE I:'\,\hrfl'."l',\:. ':';'111 ,;r.,.rn' d WSUAANCE f'l.AN NAME OR PRoonA'" NWE . IM'LO'fMfUT' tCURRENT OR PAEYK)USI om 0"" b AutOACCIDlNT' PLACE 15111'1 OVIl 0"", , t OtllEn ACCIOENT't Gm [100 IDd n(SERvED raR LOCAL USE 'n I' "UERVeD fOR LOCAL USE 'I. DIAQNOIIS OR NAtURf Of !UNESS on INJURY IRElA1E "EUS 1.2.3 0114 10 111M 24E By llNEI t , I 1':01,. ~I) , I 1):19-,-08 'j ! I~'.' . . '1JM'1E1BI0f' 6ERV1CE,o ... .-M "tY UM 00 . Ul2.."1..21 B c 0 PIac. 11~ PROCEbunu 6EnvICES OR SUPPliES of of. __ _IE I_~.," Ur-Jlual Cll'tumlt.ncltl VY ; r_py,."',,"J:. 1 utVlIJltR I'" : "':'J,' ,-,',: ",,:,~., " " :'~"'>I.,I I. I . qq',? " ' \ ''''7'\1/)'1'," , ., ''':>10101 I i ':"1"" \''' I: ! p,~ : 0:>,< , .1:.. 1'~'7r"" I: I, "'!" 5SH tIN ,. rAtlENTS ACCOUtU NO II i2~' .,eeEr, ASSlm,uUjI't .--.. .----!. ' 01 V'J1'1 tll~~r. ... bid I l' '1"1'''1'' 'r I,ll I \.1.'\tl')""lQrW YES l~...'I NO 3t 6tONA1unE or rll..51(;11"OR SUN'lLIE.n :U NAME A'lOAD(lRE55 or 'ACllltY WHERE S[nVICESWEn[ INCLUDING monrES on C.REUlU111l 5 R["OEnlO I" OIheIlh." toom. Of (I"nl (I n'I.I, ltoatlh. ll",",,~' on Ill, 1'1.'" .w, 10 It'l'. '" aod .If m.. . PItt IMftoll J" . t: . . .""...... "" . ".11,*/,.'........,..." / I ...il.- 1 I.,o'''u ""t I OIAOt<<JSIS COOE . ., , '" I 0':'; 0" :"11 , (\c:,: fO". \.II Ie , , , , 1 ~ ,':4 , ,~ ~": -, :a "Jl ,"1; :'')1\ .r'" , '"I.".'! ,.., '\~ , , , , . (I l' ':IE I:' ~ (J ~.' , , 1(, J' . (J .' 07 !'),\ , pl..:'j'j 1;'31\ ;, , (.17' '} 1 1 , , I ,I " '. -; :;"1 I' "of' .. ": " flP[RAl ,A)fIO NUU8lR IArrnOVfll It, AUA COUljCI\ OUUf(ll(;lL SERVICE ..11 Mtd '" ......1 A'" '"U e......... IIDOU"'" "~fAS" "RINT OR TV"" rteA ' ' I Ilon.'Il00nAUIU "Et.lll . "'SUREa~ DAtEwOf By'V'1 C'l 1'1 !''J "0 b U,IPlO'f'ER j NAME OR 6CltOOl. HAUl; r1r\R"f1CI\ f, ':'JI'1I11 %f1ny c INSURANCE rLAN tj1UE on pPOOR..... "AuE I I i ... 'Dl PRUDFI~' r "L It IS 1IlU"E ANOIHEnltlALW BENEFit rUN' 1_~1((5 (,] 110 Hp,'''h"",,''rwtrmoPtol'Il,""lIl1d 1.1 Im;ll~r(l s PO ""lltOnl;[1l JlI:nsOf'5 61ltNAtUl1E I MltIIQlIII (Io1_",,,nl oIlM1kAI bfl......." 10 In. undl""O~ ph,'lVIin 01 lupploIIlot .1Irf".'dlW,,*,bttIO* Slgnat'.!rf< 011 File 23 PRKlnAU,HQRI/AtKlN"UMUEn "" , C. .....It I J . tlml'SO RESERVED Fon . cu.nn[s on r"mtt, IUO coo lOCAl USE UNitS rllM 4 'Jo~' ",', j, , , I/; ~l; . (In , , rh IItJl) ^ , 1 ~ O~ , JI.j5p~ , 2<.'.00 , ./ , \6.11C , , ----1': ('Ii"' 21 101Al eHAnOE I" AUQUN1 PAID 30 BALANCE DuE I ~0r: oc,l. ,',: OC' "1(\<,' 00 ]1 "HY6)(11" 6 SUPP' lEns Dlll,ua "AUE. ADDRESS. lIP COllE 'P"'JI'~ , 1;1 '.1 U I CIII f\N'f"lACI Ie n. TNT!: :l,n YOB'" RO{\D (""PL J ~,Lt:. F'f'I 1701 J l'jU. "1 (l,.'('.l '1" r: 'I nn", ron...llCfA l!loa I"tol ronuQWcr ISOQ 'ORMAAB IWlO '''1"_",,,,"''''11'''''1 ow .......... '..11'.....--... fl.I..I....... "",0' I-.'~"-"1 ~~ I'u; ..... ..... , ~8E i NOT i 4APLE (~THI8 AREA r''\Ul'rNT I t P ,l'. 9llX ('? ,tClI\';,IIA:01. ,,, 190<14 R I I IPICA HEALTH INSURANCE CLAIM FO M PICA i: I' ,..OICARt: MlOtCAID tItA...PUS CftAt.lPVIlo GROUP !.lCA. otmn I. lNsum.OSIO NU"'~EI1 IrOOPHOOR"UIN nflr"'1 'n 'n n nltlA~lltldAllr-t'},UIlOr'1 ,,:'~IO ,P"} -! :?O.27 n ""*'" II fltlfdrt..rd II l5p(lntOl'I ISHI IVA'. II I SOIl IS NI I'm r lllll Ha"". hit HI"". ModdIt 1nItl'1 ,~~!!, I oto .. INSUfUI1 5 HA"'E Il.11 Hame 'IfI1 HI"". u.Jdlt 1M"', ...... I ~O , ',!, .. II '1'1 H:VJ~ . , 'fol" ft."I : t"\ 'I 1 ~:1 I', '~I ':oI\I~F. -': .., , P"tllNt. ADORlSS lNo, 6111.11 . PAlIENI RllAtMJNSHlP lOINSUnED 7 INSURED S ADORESS IHo. St'NI, r " ~. """ ITH t,'..rr:T s.oo ~ -...0 c""'O "'''',0 '51 E Sf)I.'TH o:.Tr::~J!T ClfY I 81 All . PAttENt stA'US CI1't StAtE .: ,",I'=:I-:!:.. !: r't' -0 ""'lIedO 011"'0 " M!L 1 '.L ~ r,\ '.COOI I llUPllOHE IIndudt AI.a Codel ZIP CODE 11lLEPltONE CIfiCWOE ARU COOlI 1'0), '. (, ,;.) 2,<' ~"R.f:, Empo1td 0 Fut Time rl Pari '.....n l70'.' (. \;0) 14 ')-1\ ;1("; SIOO-"I Slud~1 . IU.1 H.me. if,l H.mI. MtltdIIlnllllll ID ,...".", .COI<.ITIONR"A".TO II INSURED 8 POlICY Gnoup OR rECA NU"'BER ',:'111' . OtHER INSURED 8 POlICY on Gnoup NUWBER . E"'PlOY"'EHU ICURnENt OR PREVIOUSI . INSUREsa o...tt Of fURT" OU , 0 'tV I 0'" ['lItO l'l: lq l;q "0 '[] j! I b OtHER INSURED 8 D...n OF BIRtft SU b AUlD AteIOEN" PLACE 16ta'" b EUpta'E R 6 NAl.'E on sc"OOI. NAUf I! ... , DO , .. I -n 'nl 0". 0"" ',l~r.:H,~l" ". (.'.'!,.nl';~I\RY ,"'t, . I ;:t') ... I , c EMPLOY!R & NIloME OR SCHOOl "AME e OWER "'CeIDEHI1 c tNSURANCE MAN t4AUE OR JlJlD'JRAU NA"'E II l~I~Fll'" ,~t I": I ,~. t:,,'~1i '.' 13VES 01tO ,'RU[lr ',I' I "", ij d MURAtiCE PLAN N......E OR PROORA", N....E IOct RESERVED fOn LOCAl USE d IS tttERE ANOHiEn !-lEAl W BENEfit Pl...N' Ii Otl. 0'10 It... ".",," h It"" tnm(lIf!lelllO'" 0 II d C, O. '~'1'0"1 COIIP(IlIHO. 110...0 tI.. ''''''"'. . I] lN~\1111 US0I1...ii;unnl,fnJlERSOIIS SIOf4AIURE 1.U1horllll I 12 PATfENtS on AUtUOAllEO rEASONS SIGN...TURE 1 1U\tlot1t1lht tt"'"ot a", rM<ktlOf olht'I'II(lImlllOnnHI'tlAl1 P.1'"",11I ollnf'dlrlll two"I'I", 10 lh, t"w1toIllI1~ phrlwn Of'~ lor ::.t.Ottlt tf1tI dim 111Io ''''''11 pI,lMnI 01 vov-r""*'" btnthll .....'lo m)"'" 0110 the PJIfY MlO ICttpll '"1Q'\mtn1 Uf'W'C'1 dntIt.d bItlo* ':i,~ll..,1 '.\ I. Ul" r.i.1E' O?"t: .~11 s! !'lnatlJr~' r)n File IIGIIED O"TE SICUj[O " "Jll'~ 'M~Re~"l ~ ItlNE&&~,~mIOR 1& Ir PAtlErn HIloS H...US......E OR SIMILAR IllNESS I tfl U"TE\t'tIEty UN.mE to won*, IN CURRENt miCUPA'ION INJURY I,.., l;)IVE FIRSt DAtE M'" , 00 . 'tV IUD n "'Y 'tV "I: )H ;jl\ PRlON...NCYtl...f11 ' j ,n""l to 11 NUl( OF RlnRRING PHYSICIAN OR OIHER SOURCE 17. 10 NuutER or RHERRlNG Ptt'tSICIAN -----ii. flOSP""lllAUOf'I HAtf!, f1Elllo'E(l1ncUnRENI sthVtCES . "'U on "IV LIlA 00 'n' ,- I. II "lMRVED FQA lOCAL USE ro OUf&IOE LAB' . CHARGn n,u nllO I I II DIAGNOSIS OAHAtuREOf ILlNE6SORINJUAV IRELAtEltE"'S 1,2.:lOR4t0I1U,uUB'tlINEI t 22 "'WIC"IO R(SUB"'ISSION CODE L ORIGIN"l RE F NO I I r :l, ...,;.' . , f.' ?' ~)8 23 PRIOR AUtttORtZAltQN HU"'BER r L1..J,~ 4~?~1 . e C 0 E , . " I J . : "JlftEIBIOF 6ERVICETo ..." I,.. PROCEDURES, 6EnvtCES OR SUPPLIES DI"'GNOSIS RESERVED Fan , " " I rDI~~lnUt1~,u~~I:.nc.11 COOE , CUARGES on '11m", EI,l(l cae LOCAL USE ! ....00......00 " PI PCB lFI R UNI'S p~" , I ",'1: "" :.).1 II ~: , , ,\ L.""" I , \ 1 ~ ',I .,,~ ..'n I . ., ~ , , 4"~L A I , ;: U, I , , , , , : , , . In: 07 :"",\ II ': ,,": '~-1 ., " : }.fH"I. j)' \-q-1 1 Qr: rl" ;;"\ I I:l,~", ",~ I I , .~ I (l '/ V 1/1 , , , I :q.1. , .-,..l: ,:}~ , '-10\ I 'en 'v.. t\:l' i")', j'l' - , . . ~ , &,J I , I , l. I , , , j "): '4.1 , ,>',lln I , \ ",~~ ,r.: ...", . (1',' (\', ' '.J~ - .. " : , , , I f , , , , , , ",,: ,: <J.1 ""' I" I , , .'...11 -Of"; I . (\., lOr., ":>>.1- . , ('O! I , ! .....J..1.'" ' : , , , ('_: I . ::. ',: . 4 :.~ ~ I :1,1 > ,.<>:< I" I , :t ,)' ,0(' .' n nOERAl TAX I 0 NUMBER 65H fIN .. "11ENT S ACCOUNT NO I" ~CC'PIA'''OI'Ullll' 2'1 totAL CIl"ROE ,I" AMOUNT PIloIO )0 BAlANCE DUE (,trl I [~i 01 on~ tl!..,"",fi .., balkt , 1 PI' :,,1.\" ~ '1Al'''';::'~'''(' 'tUD,j ~_ ':OI'),...'!), 'J.O~ I ~1!0'.UO -- . --...-.--- :11 SIO~"tURE or PIlY5IClAliOn SUPPliER J2' NAU~ ANU AOOnt SS or fAt:IlI'Y WI4EIl[ GERltltl sWim ]1 pmSlcI"'NS &UPI'LIEn, BILlINGNAM!:.. AOUnESS.IIPCOOE ,"(I UOIIiO monElS OR r,n[tJl"TIALS RfUllEREn III omet """ ttome 01 o"ul a "IIlJNf' II U11", IhatlM .'ltert,.nll 0" Ih. ,.,.... OCCi Ch!ROpnACTIC CLIme M!tfIOthtlbll.nda,.m.GtaPlltlhttZI ! 1 J23 YCRP, ROAD J/'r '/IIItV/ i' 1.'Jt(l,lfJ..I.1 ',ARL.bLC. Pi'll J101:, Iloal". .,It. rilj. 1\ I'.l~~(\ 1 'I ~,. Olll'. c.rrRUv((l By....... r.OUtiC11 ON UUIICAI srllvlCE .111 ..'..., "'cltuIA," P,," e........llOOllllln PLfASf PRINT OR rYPf 'MUller" IMlO 111001 fORUQWCP IMXI fon...nR01iOO 'flllI ~ liAMc.'....U,..1I UM......h.....'"I..~..'IU..I......1l . .....-_.... _....... ..~. -, ... ,lASE A NOT dT APLE IN THIS AREA f'I,lltlf.NT 1" P,O. [l:)X~;' HuRSHt'lM ,I l'W~,1 II IrlCA HEALTH INS RA CEC rOCA I, 1 UtOICARI: W.PICAIU tttAUl'US CUAUf1VA ~~lUUf1 ~~(;A otll[n 1.INSUREUSID NUUOE*' IFon Plloc.',AUIN IIEM ') , n I II I1It~A~11t !dAN IIP'.'U"O ["1, ,1~.ljC':1I3r2"! :>0::':' 'I fIMdIc"'" (~.d II n (~'Of.S,SNJ ,VA'.', is Of I ISBNI jill' , PAUfNT 8 NAME Il.'l NItnt '"1 N.me, YddIe 1nII,.I) I .~.:.',," &P'n'Vl~'t I 6U " lusunEO S NAUE IllSl Njm, F.II Uam. Mddle nhlll H,\I.lf:') . .tH", "!',r. 0': I r~ ,q ... fl r 1'1 ',AHr . PAtIENT'S ADORUS IUo, 61'''11 . rAtlENt RfLA110NSIllr to INsunEO , lNSUREDS ADDRESS lNo, 611"'1 ';01 1'. <;nllTH ~, q;:r: I: 1 "'" [J 6I>ouuO """0 "''''Cl '.:'1 t: . '"OU'TH ~,TREn City IITAll . PAtiENt SIAIUS CIlV BIATE ( IIh'L,! '~L E Pf:o a.rq.[J ....".. 0 "'''''0 "AP.L I s'.r Pf, ZtPCOOE I TELlPHOOE l~ "'I' Code I ZlrCOOE tELEPHONE IINClUDE ARfACODEI ! '11) I ", (71') "4'~-43"'., Employed n 'utItlmtll-' P.rt tlmtn , 17(;'1 " (71;>) 21\?-~3'l~, . .... .. -. 5100.,.,1 Sludent 0 5 NA~E IUI' Hlmt. f.,1 Name, " 10 1:tf'ATlttH 1if;0t4UiliON HlLAll;U 10 It IN5UREDS POlICY GnOUp OR rECA NUMOEA I ~ ,\~f:' , , . OlHER INSURED I POltCY on OROUP NUMBER . EUrlOYU[NI?ICURnENt onPREVIQUSI . tNSUR[n~OAlt(."~'t1lt 6t. I . DYES [j"" <' 1, ,9 r;q "'0 rei b OlIlER INSURED S DAtE Of 81mH SU b AU10 ACCIDENt? PlACEISI.I'1 b EMPLOYER S NA~E on SCHOOl NA~l: I ~j: ry',j Y~", I ..n 'n DYES 0"" , , ':11'\P.Rr\~ ~;!I, ('OIIHl ~',<'f\f," c EMPLOYER 6 NAME on SWOOl. NAME t OTHER ACCIOENn t lN5unANCE 1'1 At4 t4AME on S3nOQAAl,( NAUE ~'" '~.r~"I. ~. ' , I'" t ~ ! '~', C (\ 1(',' 13m 0'''' "RI.'('F.NT 1 ,"II. d INSURANCE PLAN NAUE OR PROORAM NAUE HId RESERVED fmHOCAL ust d IS HunE ANOHlln~E^LtlteENUll I'LAN' 1 r-J II. L:l 110 ".....1l0hlf"11.rdCl'tmp!I'II"'""'9I1d ! ~!__~~~~KOF'O~~~~!O~IC~llIHQI'IONWQ'~"ORM 11 IW;;IJ~r 0 S n'l "IJI,iflnt:EO Plnsou S 51GIlAlURE I.Ulho",. II PAllENt S OR AUlHORIZED PEnsON 5 SIONAtURE ltulhon,lth. r,II". ol."~""'. Of DlhI,.,.,IOIm'hO'" "'K'''''., pn~!t>f01I1 01 mfIdoC.11 twlll""llo 1l1Iunrt,"ogned ph~11CWl OIluppkef tor I to plDC"'... daIm lallo 'lquIII pa1"""' ot pI""",", bI"''''' t>thet 10 m,,,1I O'ID I'" PI",.no tatpll "19Wftt1'tt """1Cf'~ICItt.dbelo. ...... ':'!'iI'H.j' 1'1' :1 nt' rile o~. 1 ~ -", :Hql'c-tul'l!' On File , stOUEO VAtE S~"EO "Jl:1E OF cunn~'" ~ llIN[~S lrlllll.,mptomlon t!rt If PAtl(t4lIh\SUAU SAUEan SI~ILAn IlLhlt'S II" lIAlUP.\1IUH UNAm[ 1U WOllk I" runnEtH OCCUPA'IO" , DO , Y INJURY IActdtrltl OR OIVEflRstDAIE UU : 00, Y'f' 'fRr)lJUM DO 'tV to MIr,l DO Y'f' t " .:'~' "1'\ PREONANeVllMPI '7 NMlE Of ~EfIRIUNQ PHYSICIAN OR OlliER60URCE tl. I D NUMBER Of nEFERIIING rllY51CIAU ~ ltOSPtfALIZAlI{)f40",rf t1rlA1rD tncunR(NI SERVICES u.. on " .... 00 " FROIo< 10 " RESERVED fOR lOCAL USE Xl OUTSIDE LAD' ICIlAROES . Ovu n"o I I i It. DIAGHO$ISOR NA1URE OF IllNESS OR INJURY IRHAtE I1EUS U.30R410IlEU2.[ OYlItlEI t 22 ""[OIeAIO RESU8UlSSION I CODE I ORI(iltIAL REF NO ,U...;..;' 3 I F?:.'1~J6 I 23 PRlOn AutuOntZAllON NUUBER . , :" , ;I ~.-'. ,~ 1~,- ;I A . C 0 . , G " , J . ,,~1[ISIOf SERVICElo r,." "" PROCEDURES. SERVICES. on SUPPLIES OlAGtKl51S REstRVED fOR Qa~1 " roo ,~~~ua~~~'~'rv:"l COO. I CHARGE 9 0f1 film., I~O COS LOCAL USE ..... -00 yy W DO " PI, P U IFI UNitS rlan , , : , >7(.1" I : . 1 )A ''''~ \ '" ' , ,," , , 1'\ ) It.' I , , , , , I , ';:': ; 1 :'.'" '.' , , I , ""I '; , '~('I~' J, 1 , , 1..!'.'1 :~O 1)',1 I .' , , " I , , I I , , , , , 1 , , , , , , , , . , , I , ) '" I , n)!'\/7 , , : , , 11 , : , , ;I . i! I , , J ,...,v , , , , , [..I , , , , , I I,; J , , , , , I , , , , : , , ':.. , . 'I FEDfnAL tAlI 10 NUI.lBER 6SN fiN " rAlIENt GACCOU'" NO -1 ~~f;CEP' "'5S'nW"~" 28 '0'At C!tAROt: I 119 AUOOfll PA:O 30 BALANl:E DUE 1"'111 Ir" OfQl:l'o1 r~r.... dl ;1 ";,:, ~)Il ,I I ", . ~)' 1 "', :'1.',U'?;2'."'/~ 'yES tlO , '~, ()I'I I '.',A, , 31 6tOtIA'URE or PU'fSICI"'f~ on 6urflllEI1 32 NAVE "flO"oont~SOF' AClll'" Wl4Ene MRVIC(S Wlnl 31 J'tlYSICIAIlS 6urpuln6Bll1Iltclt4A~E ADDRESS ZIf'COOE 'J4CLUOIUa DEGREIS on cREtlENllALS nUmfR[D I" Dllt"'lh." Itomt! Of ~"I('J tf(~'r i' n 'I r "PI':'" II tt"'" !till lit, .........1111 0" Ih, ,,~.'" ,. ! l~ r.LIN1" eppI., 10 IhII bI.1'td ItlNd. 1 plrtlh"~ I 1 " 'l IIH.'I'. 1\01"(' '11 .. ,', (I I( .~ t ",.,jd,(,.,~,[..1 1'.Jf."':,--Ul'~I/: ( ,V~I ! '. '_t, '-'i'!, I,OJ J "I()tn.n .' DATE 1'1'" 1 I ~\I ,; '" I, 't", onp. u N LAIM FORM l.lrrRovtD B" AI.lACOUIlCIL 01'4 ~EUIC.lL &EIWICE' eel UId II, Mllk,l A'" "", t..i...... I_mIl" PLEASE PRINT OR TYPE Fonl.l IlU A IMlO 111901 f onl.l owep 'flOO fORI.l nnB 1!lOO "JIll .......&."..,.. OM ....'......11...' .-......1111..1......" ~ASE I NOT ,.'1' STAPLE 11,,:lJ INTHIS'l I. AREA /,!~V .... ....h............ r'R'llll'" r lAI f,.". 1::lXr"""i7 fK'I~' ,H/\~', . 1904,1 I I i"'" HEALTH INSURANCE CLAIM FORM poc, ; , I I "'POC'AO, ~ ".l)lC"O .._~ c....ru. ~~c....pv. ,_. ft~,~~, "A" ~t~~u"o ,\0"'.11 ,. '~~~~)S!el~~:~t'2 .:!U'z i ,11'''''''0011'. ," II.. " 1-""""'.""1 I'......cf "1-1'~ilt'55NII 1,\',"IIt" I-I ,5~CIIIOI n- f~ IU~"'~"""''''f,~'1'''1r. .1""....--'....'1 I' ~'lo'!I" , ~ IE' -1, · .."'Jl1fy,~".."'fI'Ill....~Jl\!'.... --....'1 ""tr ~. I ':'I'~r .'. ~.l: I. u (-1 r r~l 11\...,.. In I..rtl.~' ~ '~~ml'1'. 6'l"r I:E I:: T · P'''E"I RELIl""'SOllP 10 "SU"lU , .'t,"rEO~ ~1lO'!!f.~I~ ~'''2 Tn E r: T ... 0 """"0 Ch.,O """,0 1611\~ · PIl'."'I1~US Clll AF.L 1 SI. r: I 6onglt0 .."... 0 0..,., 0 IIllJ.PI'9!'.'-...."..C~l. /'P,COllL01'._ (";' ;.21\3-IIJ~... ._..~'..,....~P."I....~ JI J I I Stude"l I I SlucMnl I I Hu;.~,.,~,~.ull ,~(, Il,'~~''''' ."......,--.".'1 '.'SPAI,""BCOIlPII""'"ELIllU10 la Ir rAl1[1l1 "AS HAD SAME on 5,UllARIUUlf>S I If. 11"1[6 PA1tFNI UtI"ALE to WORM IN rwmrm occurAllOt1 Olvt 'IR51 DAlE "'U ,00 "" UtA DO W LlI,I 00 YV , , ,nfll.l 10 17. 10 NlNlIlROf' RUfRnINOPItY!iICIAtj -, '" IIOSI"IUlll't10tlO'tu PEl.A'rtl lnCllr1RUH S[R\ltCU . t.I'" (In vOW' Ll... DO ,v ,no.. 10 ~o outSIDE lAR' I CHAAGfS -D". ~ I ~2 U(DICA10R(SueUISSo. cOllE I ORIGINAL R( r NO 2] ""lOR AutttUR'lAllON tfUl,I8En a PAIIENI S ACCOUNI NO 1" teC(PI ASSI014Ur.!~P ... lOtAl CHARm J'" At"IOUm PAtO . 30 GALANCI DUE \If Ii':' "-.n', ~.' 00'(10'" C~1fTt! '..l>4Il~l. ,.r "C' '\ r,' ,..,: 01' , ,. " .. --1.[L ,u IJ~_.n · . - ... ., -'. ,....- :11 tlM.lE MID ^!.JOnr.....fll , M:IlIh' WIlII1[ r.r nV11.l Ii W' '" " l'IIV"'CI^"1; "'/1'1'11' fllj "11 I IIl'j "AlAf AIIUII"i'i 'IPt;Uur: R(NUrnlOl"Olh.. II"n hof1.. Of olloc;.1 tttl(~j" 1.II.~J~(Il-II,Al t ~I. '..L1Nlt ?23 yl'Jf.l1 ,;;rH,!; : A~' 1 1:',1_ ~,f',., ~ 701 :. a 1 ':11'-'11'1 ;11: I "1141 OIll'1 ,omAH(tA I!lOO III to, 'ununWCI"'!lM rOnlAAR81iOO n'IU" .........1011,.... u. ...........'1.'.'.......,.. ".1..'...... Cl1Y (tH':'. 1 ':'. F. ,. cOO( . 1'(01:1 . OHlfRINSURlDS POUC'f on nnOUPMlUBEn . E"'f\QYUlNt7 (CURRENt on rf1[\lIUUS, ovu 0"" b AutO ACCIO(Nt? PLACE ISI.If'1 OVlB 0'10. C oIUERACCtOENI' OVER 0"0 IOd RUIRvro rOR LOCAL USE tI ot}l(n INsunlO 8 OAlf or Btlllll "'.OOIYV I 0-=;"'-;_' "n r Ea,lrIO'f'EII 5 N~a,'E on SCIIOQl N~ME. , I'" '. . .... '91" / ,. . '.."'!'~:. :: ~,.(\r r B.' 'n d tNSt"W,Ct. PlAN N^",'( 011 rnOURAM NAME ..tAU laclC OF 'OMl'''OftI toWLlttHO I ~ONlHO 1'Hit '0"" " rMIl'" son AI IItfomlEU rt"~O"5SI(\NAlUnE 1.u1hont.lhe 1r"".oI.",~IIOfoll"'InIOl"'''l>MfIf't.U.', klpnnnl ~rlf'"' I a110 I~" PI,mtnlGI vo:.,.[V'ItO'll bt"fMI ,hI 10 m,ltl'I 0I101h1 pit1J"Nl 1Ct'r' "'IQf\IN'JlI .. ',': ~~"j '. II I: I:- \,.'~. 1........;'; RIO"tD .. 0'1.., ~S"", A[",! ~ ""[s5 ,..".,"""....'0" ..... """ \ 'tV !,,^'n'f',A.cc"""'IOR I;' I rnEGNANC'1,UAr) ., HALlE 01 RIfE RRING PHYSICIAN OR OIlfE R sounCE OAt[ II RESIRvEDfOA LOCAL USt 11 DtAUNOSI,OR NA1unt I)f ItlNESSon INJUR'f' (RHAl( IIfUS 1.2.:JOR4 lOlTEU;4[ BY LINEI ----, r'. 1 ,',' l:':'" '~~I t , 1--,_ , 1--,_ , .. ~ .~....;,;, IE' D C r hAIEUilor SERVICE, PlIe. I,.. ,om , of " ... nn yy ...... 00 vv 0'" ~ ,. :.~ / I"" ",' . t ' , ':':: ] t1l,:,.t , . , I ,: ;, ~ ..' . , f) .,' 1" :0:) I .. " 1,'; "c , . ),. . '4 : ~ 'L-, P PROCEDURES, SIRvlCES onsurPLI(S ((.pl.." Unu'u.IClfcvm,III"iC'I' rpt,lU"prc I UtVltfl&:a ,QQ21.'? I: i P:O~ , 0IA0140SIS coo. , , i ; f I 1.?:~'! ..'71.'10 I 1.....,., .... .. , 4~L , : , "i")lll I I I I I r . , , , , . . 21 'WERA! 1A. 10 NUUBfn '1\,..1' '::i 7':' . .' 5Sl, (IU rlr-, '1 f;1:i'M 11111I' or rll\"i1U~" fill ';'j,'rllf n III{lU{lflUltlmllUi UII rill III tlllAlS l'fPf1+1,tIlllttlfO ,t."",.nl. on"'f' I.."" .1Vf"1'III..b..'.nd.'II"'.d..I,1,'.'"....tlJlI I 1 '--" I" / '/ ' I ~ ".',1'/"" . I" "'"/1 I ,I \ "1'" .'-~ CIGIltO O"E IAl't'n~Wl() (lY AUAlOl.JtKll otlMlOlCM SlnvlCE ".1 Mid .,..IdIe.I",tsP,." c...,..." 'toolllll" PLEASE PRINT OR TYPE 16"~A 11Ur-,,!,';i)'.2U~'1'~ ~~!! II INsunEDBPOllCyonOUPonr[CANUWO[R . INSURfn.5 UA1j:.Pf Atl\l" 511I ~1""'~",(! "[I -[j b E~'}me ~ N~~~~ff,~~~ rg"\: Ct1tl J 0;. <; AF:'( -' I C 1f4$4n"NFl,.ll"~'jA"'E on ppoon..... ~AME f'llU.lt: ~ Ihl. II IS tIlERE "N01HE.R~[^l1l' BINUlt F\AN' I:]t(s d: uo H......'I'..I.nl'f1Ill'~t."lIlm.f1d 11 1I1~1JIlrO ~ nl' A'IlII()fU"'[ll "I'R<;('" 5 Sl('tI'^lUnE IflIutll/'If'If P.""",,I"'()I~oc""bf'nrl"'lothlltnlitol''O'Wdph''I(''''DlIIUPJlI..,IDI ..""...."',~'Yr~.,t,:i'( ('n File 51('\'4[0 , o .. o on film", u,ms PtI" EUG COB , J . fU5ERvEO'on lOCAl USE 'CUI-nGES 3('." ':' H"OC , 20.0'1 ~~ ";:\" '~f\1 l'D ~ u \. '0 I!cASE JO NOT STAPLE IN THIS AREA AI'llfUWl.UUMtfUllJl UWI F'R',': I!:' IT I.... 1"."0 fDxr.,;> H:lf.::HMI..1\ I '~C,1.1 I I I"IC~ rICA , 1 I I "OICA.. "OtCAtU CUAMPUI CttAWPVA ~~Ipl!I'_ :.!f~. 011I111 1. INsunlUSIU NtlUnfn I'on rnoon"M IN 11IM 11 '0 0 0 ':l.~tt'l:lAH081.t.r.'Od, Ilf:>N(I.H.IS~ "12U21 -, ,.....,. II n fUt*.t'" I' ,~. SSNJ IVA'. I' , 5 f}t I IS J (101 11.'" Hamt fll" "1/1'II. MtGlH tnIll'" I ~~'."H , "nOU'r~ " IN'iunlO & HAUl Il.1l Name. hll Narn. ~ 1NI1fl11 'i"l.'!i . T IN,' 1,.,1 'tfl: ~'~ y,,, H~'U~, . 1 J rJA r~/lI; I ,..T.NT I AOOAE 18 lNo . "'"'1 . PAlIIN' AfLAllONSUIP 10 INSURED 7 INSURE D 8 ADORE 55 INo , Slr..t) !H E. l:-~IIJ "I ,.;r'f.101 ... [j -0 C....O """0 !.1 E. SUUTH ~ TJ~E'F. T CITY I"A" . PAUINT fHAIUS CITY I'TAU ( ARLl '.\L E p~ -0 ""''''0 """0 CARLI ~!..E PI\ '''COOl IIElErtil Itndudl~..CodtI liP COOE I ULEPltONE IINClUOI ARU COOE! . ! ?ll ? (' l,: ;:4)-4J65 E'"CJ'O'"O ''''''''''0 ""''"''0 1701.:.1 ( 711) 243-43B~) Slude'" litudlnl HAt.'IS. lhll_rwnt, f..t PWN.I , .. ,...",.'", tlIHSURED6POlICYOAOUPORflCANUUBIA , II.,..' ,; t'lt: I . OtHER laUREO I PaUCY OR DROUP HUNIER . EUPLOYMENt'tCURRENt OR PREVIOUSI . tNSURt:~DAtt,p'Bln1H ... I om Ll"" 1 .~ '~9 "0 'Cl , , b OTHER INSURED II tJAtf Of' BlnHt s.. b AUtU ACCIDENt? rLACE ISIIl.) b UAPLO'tE R S NAME on 60fOOl NA...E I UU.OOI'tY I"n 'n Om 0"" f.f,RL . flMRA~I~~ C. "1111 ~~~I\RY I c EMr&.O'tlRISNA~[ ORSCIIOOlIlAME c a1HER ACelOf.N" c INsunANCE f'1 AN tlAtAl on Pf1OllR"'" '4AM( " ;,r:'. . ~, 'I: I ....' I' '''-1''11 S~,AF"Y C1'u 0"" :m 't'e~; r J ,\l d 'ISUfWlCli PLAN HAt.I( on rROOIlAU NAUE IOd RESEnvEOfon LOCAL USE d IS .,ltRE'-'. JlIf(nf~EAl1~8ENE:f11 PLAN' I 1~,tS 0,,,, fft'P. ,,'IIIInl't.,.t'I>mnIt>1.II.mll.d , -oimo.c. 0' ,~~~.~~:,~.!' ~O_L._.!!,_O "!.O"M 1:lIN~UII[OS()ll AIIIIWlRl;EOf>l:n!i()lllS SloM,tunE I'ulhnll" I I' PAIlENT 5 011 AU"""',AUZFO rrno;'.),~ 5 SIGNAtURE llUthofll' hi...." 011", ",",II DI oltltt lnto"naloonl'iK"UO~ rntfnf'i. 01 "If'fk'' Wnrlol' to !he "'.'9*lph.IlCIIIICII'upptIIf lor '" puent'" N," 1"'0 ltqAl' pa)1Nr4 01 ~1VIItne tltnlIlIt,..... to "",tie Of to "" petty __ 1CUCJt""lQMIeIl' ~dtlCllbldtwMowr - r. ~ 0;1\ I i"t '.J;', ('I' r--ilt' 0', -0;''' ';4 f,i ~111:\ 1.\:, e Gn I" i Ie SlOIltD OAt[ 51('\'4(0 I4I~1fOfCUAR~N" ~ ILlNE"'lr."":;r:"tOR Illr PA11(UlI1ASHAD SAUE on SIMilAR IlLN155 It. U~tU r""ENt uN"mE TO WORI( IN cunnUlf ~CUPAfIO'I ., 00,...(' v ~ ItUlln't' ccdlnl) ,. QIVE 'IRSl OAlf M" , DO ' vy ......DOn UU Vy ~ 'I .. ',.' f>n[OUAt4C'tllurl : II1fW 10 1Z. HAUl Of REflRRtNO PHYStClAUon otHER &OURCE 17. I D HUUIER Of AlflnRINO rttV61CIAU 1111 UOSJ'lltl.UZAlI()tiO"T(f. RUAlrtllnCunn[Nt S(RVK:U uu on 'tv uu DO V't rnou '0 I' RflfRvtD FOR lOCAl USE ~ OUT61OE1AD' . CHAnGES I CJm ~ I II. DIA0NQ5ISOR NA'URI OF ILlNESSOOINJUR't IRElAtE IlI.US 1,1.)0n.I0I1(",,,1. BVL~EI t ~~ MlOlCAIO RE6UBMISSkJN r ." ", P ,.:' 013 COllE I ORIGINAL REF NO . L.....,:'" " , L..:-:.., ~ u rRtOn AUlHORIZATION NuuBEn , L ";'..... . .:. 41 I ~:?'~. 21 . A . C 0 E , 0 .. I J K ..,~n'61 or 6lRvltE 10 Pllc. '... pROC:~Dunt:~. 5U~~ICE5. OR SUPPLIES OIAGOOSIS RESEnvEoron . iVI VY uu 00 .. .. IE_pit., ~tuI~C::~':I'ICe'1 CODE . CHARon an "...., '110 COB LOCAL UIE .... VY UNitS ..... :' :~ ~ " ::t~ ' .: ., : .~ 4 ~ 199212 I , ~ l;'.l.... ":'0 (00 : I . , ,,',9i(; 10'1 I , 'J ): 1 " : ~. , '.~ ;>'; , , : -:"1 "J , ~ ?~4 q J':', ()I) , - .... . , . , , , 'I ~ , PJ \" ~ ,.f , (I . ~ ,~ :., ~l ,,:. " : >", " "97'.: J 4 I , : ~ ;:'~ 2(J Qr:' , n ' , , . , , i , ,IJI 9o;.'! 12 I , .\.': 1 E': (; c' : " ..., ':Jr, ~ , \ ! 2:~,1 :"'Ct . ')(l I , ~, , ,. . , , : (.~. : 1c;':"=-'/1 ~, J ... , ."11 ; "7'~I() I , 1;.0 3~ 1;_ .0(' " , , . , , , I , , :. i ~ 1':':'u; '. , . '. " 1;7':'14 , 1 ~ ),1 ;'0. C"~ , " ...: 'ff' .... : . . , " fEDERAL tAM I D NUU8ER 55" (It, H PAUlNt 6 ACCooN1 uo I ~7 ~CC[J'l1 A_5SIQljU~P il' 101Al CUAno~ ,I" AlIOUtH rAID )0 IAlANCE DUE nil I ( -1 or vo~ ct.,m! ,.. r~l , ,...' . ii, - IJ,\I IQ~'~I:" ~- ' ~ ..4~, ."),',. !'l. C< , 1 :l'.". on " SIO'4A!Un( or J'l11YSICIA'~ on surPlIER 32 ftAUE ANOADOfIEssnr 'ACIt11YWH(lIf 5f.ftvItESW(II[ 11 rUYSlClA'4S SUPPlI[RS8ILL"fONAUI.AODREIS.,IPCOOE- tHCLUOINO OEORIES on CREOENHAlB RINDEnlO I" Dlhtf than he"" 010"1('1 ~~'lf (kfP.('P::AC T JC CLINIC Ilt.....'lhIlr...I.'.INI'lt,onthtl..,.... "'~IOhtblll.nd'I.mMt.P'ot""'eol' I, :1: ~ "C"". IW,~[) J .,. "/i I ,(,.~..,tAt:, ~ Ar,.... ' ~.~.E. I"A 1701:'1 I 'I..'t " I' ,". ,. '-:-r '1\'1 ~~, II 10lOH'D UAtI I'ltll . nnr. HEALTH INSURANCE CLAIM FORM IAPPROVfO er AUA C0Ut4Cll Off UIOICAl SIRVICE 1111 MId" ....1 A,,, 'UII [........" I_u.m. PLEASE PRINT OR TYPE ronUltOA I~ 11"0, funUOWCJ'lI~ ronMRnB 1&00 ,r1IU. .......""...." UW.....I.......f1III1~..IlII..I........ "'IU""",UUllll"WH~ r PR'.'tll.:NTI (" 1-',1),80.1(,......'17 , :'Jr!~,HA~l, I 1'\ 19':>4<1 I I IPOCA HEALTH INSURANCE CLAIM FORM PocA ' II I, UlPICAAI MfDICAIO CHAMPUS CUAMPVA ~!1?Ur !.~~" OHlln I. INSUIlW SIP NUUO[ n t'on PROORAMINl1EM11 rl I<~A~'" ~AN nB'.UINO ~ 4"tW_i85~-1202/ ,"'] ,.w.cac.','J [] '.....d IJ rl (SponS()I' SSNj rl (VA'" II'S 01 I ,SSNl ,1(11 ISNAMflla'lrume,fll.INllN.ModdIrt """'1 13 ':~.'.ll~n'~R1VJ.'.~IE SEX. r1 . 1',SIIRr05 NAME Ilall Nlml '1IIlNlme, UddIe ntIall HA........I HU, ,..",- 't1:: ';j ~,'~ .. n , Hl\lI~. r 11M RAE It PAtIE:N1IAODRUI\No,61r"ll . PAtllNt RElAUON5111P 101N5Un(0 7 INsunED6ADonE55INo. 6t."II r,l E. -:,(:1) p' ':. I r~ I: ::: ~ ... d -..0 eholdO "'...,1] ":11 E. ~,Ot..'TH STnEET CitY 18'AU . PA1tEN' SIAtUS CI1V 161A~~\ ~ Af\l. t.:- t. F PA -c1 ....""'0 ",....[] rARLltl.E '''COOE I tELEPHONE IIntfudI "'.. Codel liP CooE lElEPltOHE IINCLUOl AREA COOEI , ~7{,l} ('11 24,-4~6S EfT1JIO.edn ,u.ll/ftfn Pll1llln"-l , 1701~ ( :'1.) 24 )-4 '3~ 5 BhJo.nl SI\.KMInt_ . un,,"' IL..I Nlme. ,ul Nlme. MICICN InrIiIlI '0 "PAI"NII eOOOlllON ""A"O 10 II INSUREP8POlICYOROUPOR'ECANUMBER HAUS, T' I~,~ ,;.,....~ . OTHER INSURED 8 POUCY OR nROUP NUMBER . EMrLOYMEN'" (CURRENt on PREVIOUSI a INSURE3A OA1~ Of fliRT" 6.. ! 0'E6 D"o 1: r'i '~"1 "0 ,~ , I b OtllER tHsunED S DAlE or Dlnllt 6.. b Auto ACCIOf.NU PLACE 151111' b IMPLOYER 6 ......UE on SCliOOl NAUE I ... . 00 1 VV I..n 'n 0'" 0"0 ':ARL. tIN~q,\~1\5 C (lt~MI5~,Ar~V , , , , t IMPLOYIR 5 ,.,AUE on SCItOOL NAUE c OHlEn ACCIOfN" t INSURANCE rt AN flAI.IE OR ,.RooRI,I.I NAUE I '~A'~-'. rl<"\r,r;'l,r : " ':('''''1: <'.SAR\' [1". I]"" "RUO..,H I ,',L d INsunAUCE rLAN NAUE un rnOORW NAME lad RlSEn...fPronLOCALUSE d 15 UtEnE A'~OlUE" 'lEAL 'H BENEfit Pt.AN' I rJtEB [:1'''0 ""I"IIII"I,.ndrnmolel.n~"d "!Ao.ue. O! .!,~,!..!.o"' co..., Q.'NO '....O"M , II lfjl,lllll II S nil Alll"ORl;"[1l pf:n'iOtl S 51<>""1URE l.uHlOIll. I II rA1IENt SOR AU1HOrllnO rEnSol'lS 6K1NA1unE I.uthoulllhtlflt...oll", 1TM'Ik. OIolhtl tnll)/m.."on""....~r' .Mt'l...'...otnlfOdocal.....,..,..IIl.tOlh.P.IflMI.lQnPdphy.C1IIIOIIUCJflloetIOl to poe...'" dim 1.110 1""".1 payment 01 "",,'Inmtf\4 btntht. IIthet 10 """. 0110 Iht Plrty .t.olCcap4. I..~I ~IC" onalbtd b111o. bo~. ~,ill"''',I\~' ':'n I'ile O-l-O;!"'9-l Si~llI<Jtul'e On File ; lilOtlEO DAtE SIflUro U~tE or cunnEN1 ~ Illt'ES!irlfll""'glomIOR 1IIr PAIIWI UASHAD 8A"'E on 6IUun Il.LNUiS L 1",tlSJ:.,tIEty UNlRlE lQwonK IN ('unnun OCCUPAIIOt! .1; ~i Y1., IU.lllnYI tvd.nll n ,~ GIVE' nRST (lAIE MU I OU . 'n U D lY U'" 00 'tY pnEOt""CYllUPI ' 1f1()t,! to l' NAME Of AEfIRRlNQPtt'tSlCIANOR01HEn SOURCE 17110 NU...BERorAEFEnRlfmrll'l'SICIAII .1" lKJSJlIl"lll"llnt'D"1[[ PHAlru 'ocunnUH SUWlCfS UI.IOllv'OI J.lUUO'Y'r ,nou '0 l' RESERVED'on LOCAL USE. ~ OtJ1SIDE L~8' I CIlARon I .0"" DNa I I ,1,DIAONOSISORNAlUREOf ILLNESSORINJUny InHAtE ItEUS I,UOO.lOI1EUjiI'E 8YlINEt t " MEDICAID nnuBUISSION C'~1"" t="F) 08 COOE I ORlGlNlL REF NO I.~:"':":' 3L..:.....:....:.. lJ PRIOR AU1UORIIAtlON N\JUSER . I L7~';' ..~ . Ie:?'? 21 . A . e 0 E , a I< , J . rr~nlSI or SERVleElo P~t. I,,,, PROCEDURES, 5ERVICES OR SUPPLIES DIAGtmSIS u~~~ ".u, RESERVED ran of of r.P'~~~~~~~lh('~.","1 coo, ICUAROES r.m.w 'UO co. LOCAL USE .... -nn 'n MU 00 " UNitS PU. e..: " :~, ..\ \.':1: , 1'/' ~ . 9921: I , I 1:!~~ 30,00 ", , , 1 I , I I , O't: , ('1);: ~ L : 1:',1 , , ZO.OO ,~ 1 :f:1t\ ., I Q7012 , , l'~,q . ' , . , , . , 1J n m ",'F1 , I , c<,~ ?'J ::'tl C ,: ;: .~: ')'1 ',l '1921';: , 1~3.1 3Q,OC' , 3 I I , D ~ U LJ I , ".~ : .:~ : :':1 1 .~ ?; , ) '97012 , :20.00 ~ 0, 1 '7'4 , l:!:~ I . , ,t~9212 , C'): , , I , , , ::? r~ : 'f;} fl';: "?'. I ~., 3 , L~?-l 'JO' .0':' . v. , (' ~; o.c;'t. l . '; : ,:/~ ~ t. " I , I , " .1 1 ;?~ll\ :20. ')(1 t . : l' ~ . :. ,', .9701.' , . , "'EDERAl lAll.IO HUUDER .5N IN Ho PAtl(Nt & Accoum tm I ~{CCtrl ASS'Gl4I.1EtH' "I lOTAL C..Anm 1 119 ~MOUfH PAID )0 BAL AlICE DUE ~ I ,; ~~.:,.,,~ .' : 1-'1,1 ~~'iL.I"''!'2': 0',) ] 01 00"" dlltl1~ 'N blt.1 . 1 '.1(1:.0'..' , (),.or I 1 !:>O:.O'J ". [J 1<0 31 SIONAlunE or rU"SICIAuon &UrJltlEn 31 NAUI: A'4O ~O{)RfSS or rAClllt" WltERE 6fnVICt.s W[Rr II PU,"SICIAflS surrLtEn60IlLlt~UAU[. ADDnESS "PCOOE INClUDlflO PEGREES on cnEOEllllAlS RWOERrD I" Olllell'"" I'lom. Of 011"'1 \.fIR'H r.HIROI'~:AC TIr: CLINIC 11 ~"w thtllhe '"1ement. on "" 1t,.I" IlfIOIr 10 "', "and ar. mldt I Plr1lhtlMlf 1 ~ . 'J:!3 '(ORI', ROllO _oft!'/I"I (/ ; ~'(,Y1'';ld~ , (I\RLI ~,L!: . 1"1\ 170 1:~ . It _/ . I (I, .\ \ (',nr"~ 4 ., ~ lonr. 610(,[0 " - OAl{ 1'1'" l>,ppnOVEfl BY AUA COUljCl1 Of. l.lWICAL 6EA...tcE 1 III M'd "'''<<hul A'h P,,,. c..t..." IIDDUI'." PLEASE PRINT OR TYPE ronUllctAIKJO 11nOl rOAUOWCP 1&00 FonURna t&OO '~IU.""""''''',,, UII"'"I~.._ .1.'..lI-.fI.lIl1..t....,1I . ^t'I'IlUVltJOYP UI)lllOOI PR'.I~ t:NT II"I t."" 30X ~ HUP~HAH, ~A 19C4~ I I :rOCA rOCA t UlOICAnt UlOlCAIU CUAUPUS CHA"'PVA Q!'llUr ~IC~, 0111[11 II INSUIUU51D NUtolllln Ifon rnoun,"'.I1N 11(" 'I 'n n n,:\A~"'t\A" ~ t\1~~O 'i~b.~-120,r' :J ,......,." n tufdltl<d '/ ISpott..., S5N'1 IV"'" I' f 5 01 , Q 15' jll'l lllltNe~ r.t1HI",-UoddltI"",.r, ~l~~ &U 'ri . f.SUIt[DSNAUE ILl'INam. "S' N.1Ilf UodtNm~t, !if.L';,. 1\ "'" I ..: '0'.: ~ ~ N n ' H,...Ur,. ~ J r~t, r~flE: I '.'IN" ADOAUllNo II'HII . PAllENt nUA'IONStUP to INSUIlEU 1 INSURID IS ADPnna I~jo . 511"" 51 E, "'.Uld ,,' ,.;f:E' s.ooO.......Oc...O ......[J 0,\ c. ~,l)l'TH '::..~ r<l:li 1 City 151A" . PAtlENl8'A'U5 CitY StAlE C ,..r'L ". '.' L l' p~ -d N.....O ......[J CARLl!1L C PA ,..coo( IIEllrItONEClndudIAr"todtl llr COOl 11ElfP'?E lIUC~.Ul'E AR(ACODE! . 1;(' .. (.'1,~ .A~-4~l8~ ('........0 ''''''''0 P," ''''l-j \7013 ( ,17) .4"3 -4 ~Ob Stud... 6~1_ 1l,,1 '''mt. "t1'a.me.u.:tdltI nllall to ,"PA"'N' I CONOII",""".,," '0 II lfi5UnEOSPOllCvonoUPOR.Il:AUUMB(n '~AI.'C:. . , I '1,~ ~ 1.'" I . D'HER w.1SURID II roue v OR GROUP NlJIIMR . (UPlOYU(Nn ICURRENI on pn(VIOUSI . IHSUnl~DA'Ef"IUJnH 'u I 0'" CJoo J, q '~'9 NO ' 1::1 , b 0IHfn..SUREDSDAlf or Dtnm ,U b AUTO ACCIDENt? PlACEtSI.I'1 b lUMOVERSNAt,lEOR fo(,WOOl HAUl I .... I 00 , YV -~ 'n "Af'L. p(\r'r':,'.:K!:, (,':>I~!o\I !:-MRY , , Om 000 , c EIoIPlOVIR8NAUE URSl:llIXX, NAt,lE c OIltER ACtlOENU c ,usunANC( PI AN ""'ofl on p"oon"... HAUl I ,.,.". r o,r '" l ,I.~' 1 ! ~. ,~. Ah: '1' [)m IJ'IO r'J~UC,E !-.' ; I ,~L ,,'I d 1i5URANCf PLA'f NALI!: on l'noonAU tjAUE ICd nUEI\vEU fon lOCAL USE d IS 1IlEnE ANO'HER IIE^lI'IBENEfll M.AN' I rJ tFS Gun "ljO. I....~"I' ,.,..hl'W'1n1fol. 11_9 II d , ...OIACO 0' '0""."0"1 COlIPLlt... I 110"'"0 ".. '0"" I] "'<;Ufl(USOIIAlJlIl(IW;I(J PLnSOI'I!!t t1iIGllAlUUllllllhol,,, I " PAltENTS OR AU"'Onl1(O PEnSOf" 5 6tONAlURE I.UfIlorl,.1t1f "I.." ol.", !nI'doc" (lI o!hl'IfIIOlll'l'hO"fWI(.nll', ra,nlf'''' ol ~IC.I bfonrl", to "'- unl1for,'Orwd pn,.IC"" 01 lupfNf 101' tel p'0CftI ht tUlm I lItO If'qI....1 parlNnI 01 OChtlMWnl t.lttht, ~ 10 mr"" 0110 I'" parlr -"0 lICC.p!' '''9''''1'"' "","" dtwtbed ~ - :'l';J1I;::l '. < L'I1 Fi l~ V.l-V.;- ;>4 hi 91hlt 1".(1 un Fih I SIGHED OAt( !iIOtUO "~I( or cunnlN1 ~ 1I1'~(S5Ir.'I',mpIomIOR 11 ., PAtlfUl ""5 UA06AUl on 5t101un II un r.s I'" IIAIE!' PAIIUU UN'nllIOWQIl" IIlf.UflnUlt OCCUPAIIOPI . I: ~:.; V'(~I ItU\lflV lAce$1'II1 on A OIVE rlftSI OATE "'1,1 , DO ' 'n ...1,1 DO ,... UI,l on vv pnUiNANCY1Iur, ' . In()lA Ie ..~-_.-....._- - I' NAt.Il 01 REflRRINQ PUY5lCIAU onOIlI(R &oUnCE 17,10 NtJUA(ROJ R(f(nn",QPU'f5ICIAtI ,II fMJSPllAlllAlIc)t,nAlflllIlAlll)tC)(;unnrNl Sr_RYt('[S , ...1,1 on ~y UtA OU yy ,n"" 10 : " RUIR'VED rOR LOCAL USE 10 O\ll610UA8' '[llAnO( s n". noo I I II D1AGNOSIS on NAIUn( Of IllNESS OR INJuny InfLAIE II(US 1.2.:1 on 4 10 IIE"'141 BY UNEI + 12 t.4MtCA10 AE SUBU!SSI()tj I:Jf! :11) Fl'" , .tJ8 C E I ORIOlllAl RE r NO ,L--,_ , L--,_ 2] PRIOR AU'''ORI1AIION IIUtolBEn , L J "",J ~. "~'I'~ ? 1 . ' , . L:-, ' .. A . C 0 , , G It , 0 'fC~flI8IUf 6EnVIl:E10 rllt. '''' rnOC(OURES. SfnYICES. on6UPPll(S UIAGNOSIS um I'!m RUERvforon .. .. ,.p,~:~~";.~UI~~'::rw:.'1 COO, , CHARGE S on f,m", fun coo LOCAL USE ... 00 n NN OIl " UfUI5 ..... t:": _'~; :':'-,\ ., , - " "1 -. ).1, '," ":' I . 1 ,~' :.~ 3('\,0(' , ...... , I I : b .~ [l \~ ~:: :- ~: '~I\ , , , .~~ ., ','-"70: 0 I , I ~ :-., I r,. 00 " -" , .-' I ' , , , , \ , , \ ,\ \ ,;, ~: ",:1; :''1.1 .' ".,: " ~ " ~';"7C.' ~4 I , , :. .~ .- :!<.\.'JO , 3 , I : ~,~: )0 :'.1'1 ,....' . , '1 ) (;1021 '2 I , I , ~' "1 10 ')(' , , , . , ,,- , ~4~ , ,\ " , >.1 1~70'~ I , \ :~ ~,1 :,tl (\':1 I " , , , , . : ""t11: '.: : .~..t ,: 'I , " .' h'>~l'" I , ~ .:' ':l: '1 3(" . ~!.' , , I , . ,.. . l' nOf RAl 'All I 0 NUU8ln SSfi (I" 121 PA flENI & ACl:oulll NO I ~_' tCC(PI ..S,SIG14I.lrUI' " .ot., e".na, ~Jlt ."""., PA'O )(I BAl.ANC( DUE 11 [-I IrYOO. r~"""'" .\' . fJI.' A.t -" . - HAIJ":l~"'l"/8r: - \'(s ~__ ' \ 'I r, .01'1 , '......l,.'( , 1.1!':,O',' ---- -----,- "'""-- " 'OO".'un, Of p"",,:o.'wn 5""'"" n J" ".", ..0 Aonn", Of' .e,," , ,,,,,n, "n"CE5 "'"" ]] rIIYSICIAPlS.5UPNlfRSOI\llIKI'jAM[ A[tonE5S llPCOOE liClUOINO [lfOR(E5 on r:"((I(""'l5 R(NDEREUc"ol~ Ill'" hon..OI 0"0(" ~m~k' r:HIRC+'J,AOIr CLINIC Ilr.rt",NII......'.....rlC'O'1"'.'h.". IiVrlotvlbol...'.",.rIt.p,al1tn.llo1l, ' '.23 YORK rW/~1J , '1 ;"V/'(I/~I(I_, //, {~I<'~I~:.Y?;'1 I ::ARU ~,LE. 1"1"1 \ 701.J I' lr"\n'''I1I1''~. I 610"(0 UAll' rllll . \ '. 011I" HEALTH INSURANCE CLAIM FORM " I IArrnoy(o BY AUA [01.,,,:11 01' UfD'CAI SEnYICE I III IIIId .. lII.doc,IArh '..n c......... '_""1" PLEASE PRINT OR TYPE fOflUHU"lrtOO 111101 ronuowcf"m 'ORURRB l~ '''''11. ........''It....U lIM....I......IlU..~..IIII..I.....' AI'I'IIUVlO ()l,ID gUt UOOI r.II':'I'r.'r::rr.lf\I " . '_'. !lOX'-"7 '.It'H'~,HA~'. ..." l :)~)4 It I r \PICA rICA ' I I. UlDICAAI I.I[OICAIU tUAMPUS CHAMP\lA OllOl!P_ ~[CA Olll(n I. I,.,SU"[U510 NUtr.letn I'on rRoonAM IN lilY II "1-1' n "~;l,'''I'lJoII~ "'.,NO )~( :,.7"1 .~:),~ .,' '] f~I" II n ,""'<<Ad '1 - ISNruOt. SSNI fVA',. II Q I 01101 ,UNI ~ 11(11 . IUS' Ha"" 'III' N.,"- ,II 'I l(tiT 6 Bin HI 0 6(1 .. ~ . INSUfl[O 5 NiuE UIl' N.m. '"sl'I''''' UddIe ""'.all T'N . 'e/" 'Pq ,,v" In 'r Hf\I..'S, 1111(1 r,A~ !-I(,IIC;- . ., .'\ h, ~I' ." 1...1 U r . i"i'ii"iNI SAOOREBS I~. &UNI, . PAIIENI RELAllOOSIUP tOlNsun(o 7 INSURlD6AOOR(SSI"O.&I'HIl ;,1 e:. ;rll." H ; ';lI':;:"f ... [) &pou..O (;1"'0 Olh~[] ~1 E. ~,I)Ul H ~. mE!: ' CitY I BtAIt: . PAIlENI SIAIUS CitY 1&lA~I'\ C Al,l !~.~.~ p,e. -0........0 ""'''I] '~ARL!. C:;U: ,"COOI I IHEPHONlllndudt At" COOtI lIP COOE I Ill(PUONE Il"ClUDE Aq[A COOl 1 1 ~'';.&. .. ( "1;) Z':,;-4J85 I_'''n ,,. ''''11 r" '''''1-1 li"O 1 3 (?1i) :!43-438S Sll.Idtnl SludMl " 5 "At,ll ll'" ".me. f..s'H.me........ htIIll 10 ,..."""aC",.OlllOOnILA"O'O tl tNSURlDBroLICYOnouponr[CANUtr.I8[R f!A\.!5, ~H"l'\ ' ... J .OlHlRIHSURlDSPOUCYOOOROUPHUt.tBlR . EUPIOYMf""ICURnENI on rm VIOUSI . IN5unEUAIlA'bf'lIm!1t 0.. I 1]'1& [')110 1 'J '~,9 uO r 1:'1 --' b OlHER INSURW S OAf( or 81nTlt 01' b AU'OACCIOEN1' PlACF 15IAlfll b lUPlOYlRSUAl,lf Ollf,( ltOOl. HAl,ll' I .... lOO~YY I un 'n [lVlS DNO CI'\RL, O(\R';~'C'~ ~, , :1'~'lI ~''''f\RY , ----~..~- -- c INPunEn 8 "AME OR ~(;"OOl f4Atr.I[ c OHtEnACCIQfNU t It,sunatK[ N At' "AUf on "'IOORlI" NAI,lf. , '.. ~'I 1"=.',. , fJ...,I........ l:ut'H'~! :':I"~Y [j'1S U"O H,U[lnn 1I'L d .,sunANCf PL"" flAME OR PROGRAU "AUE IOd RES[RVEuronlOCAI USf d IS IllEnE AIIOIUER~(Al WflUU,11 PlAN' I [1". IJOIn HI'" '.I,""I.,....lrnmt1fo'."....,lllt .db lAC. 0' 'OAII IUOAI COllPllllHO a I1GHlH<ilH,i1OiiiI I' 1~~(lflAiijii(~lltrt~15~IC.U"'Ul1ll'utI;;"-;;;--. I I' PAIIENI &QRAUlItORtlrnrrn5OH& SIQNAlunf l,uttIOIllI thtlllt... 01,,,,"'''1101 OIlWtIfllOIl"II~I\H"U', p.1~IT'PI" alltlfltl(lll tW'1V'1~, 10 th. llOlWtlog'\fOd ph~lltlln 01 Iupplofl 101 kl ptOC'lU "'" eta"" I lito leqASI pe,rNfIl at OO"II'rwnMI benettls e4f\ll1O ""st' 0110 lhf part,.11O ateept, 'U~ NI''fasdlWClIdt>>lo_ - ,'l (In/'t , ~ '.'1'" Fi It< C'~"O:!"9~ fl'JT1c1t '.IrA (In FIle , SK1fj(O DAn SICi'I[D 1.Jl::~ ~f:~Re~,~~ ~ IiLfl[SStot"S.mptom,OR '1 If PAUtrllUAS 14AD SAUE on 611,11lAh IltNESS I If, U"ES ,,'llffll .,"'AL[ 10 ~oJUII"run"I:1l1 ~.CIIP"'1C't1 ,tUllR., I ttlll."', on (, GIVl FIRst DAlE UM . 00 n f,l1,l OU ,., MU III n '. : .- , rnEONA.,CntUI'I ' fllflt,1 '0 ._-l_~...__.______ ______ -- 17. HAMl Of RlflRRIHQ PIt,SICIAf4 on otHER SOUflCl 17.10 NIN8ERor~l'(nnIPIQPIt'SICI'" . Ifl ItOS""Alll'110tlllll(f PllAtfl1 t(1(Jlllf1l '" Sf RVl('rS , uu un ,... tr.IM un "., ,n()lJ 10 "RUlR\lEO'ORIOCAL USE Xl OU1$IOE LAB' tCllARO(& , Llm CJ'~ I I II DIAONOSISon NA1URE Of Iltf4E5SORIfUUR., ,"ElAI( ItlMS I.UOR4 TOITfM,U O'l"I[1 t '2 f.l(OICAlnhESUBul~SIUN I:f', t ',' r.f';'.' 1)8 __~___~IGI""I ntr NO I L-.'...:. ' 3 L--:..:":'" 2] "1110" AU'lfOllllAIIOf4 UUUDI n ..... ~.,.:a "11 . L:.....2 . L..:.:...:.. ,'. .. A 0 C 0 I , II " -, , J . - rl~I~15Ior &ERVlCf,o r"c. "" PROCEDURES SERvICES OR&uprtllS DIAO'IO$IS Ul~'!i fgO nESEnvrn fnn 00 of of rp I ~~~ Un~sut~~~I~~I~'1'O( nl COllf 'CllARms 'M' ,"",., lun coo lOCAl USE .... vv .... 00 vv , lIIllIS r." " " " , '.' ".' " " I 1~10= -:- I ~ L!:'4 :!(',Ot' , , ' ' I I , , , , I , : , , , , " I nI \0.\ ~ ',fl , , , I. I : ,1) , , . ,\1 , , , 1.f1 ", , J , I : ..' . , , . . , , I , , , , . , 1- - , , .... ,I L , , . iO 10'" ";iiir,, -J" AUOU'" PA,O 10 O""ICI OUI n rUlE RAt ''''10 NUUBUt 65.' EI" H PAIIE'" 5 ACCOUtlt "0 11' _ru.Ef'1 A_SSI{V.I,U 'IT' "1"'.'.." 1 1111 .'<<,,\1 JI ., ~. , 1010011 tt."". '.'b.t~1 , ~ , . ~l, ') U(, 20, l'r: ,I" .... __lL1~,--'.l"~I___ -- .,--------- -------,~~~-- Jt 61(jllAIURf or "ln51(1"'On r,up"lIl:l1 ]1.,'UE A'mAUOf1[~SOf rArlll'''VlIlII~( E,ln...I(If'tWfRr- 1] "II~SI(I'''S SIII'I'llfI151lt1\lffOtIAUE AllllfllSS IlrClJOE lflCIUOlljQ o(nnf[!t on (.nrOl "'IAI 5 Rl'IOER((J I" cnt>., !tI." N111>1 Of 011"'1 UW'f' ,I )1",rtMC r,:" rUNIC lit"'''' '"'' If-. Sl,I"""," Gn If'. ,...'.. , IJ'4lI,loII"SboiIlfld,llmldelp.vllto."oll ,(J 32 :~ .- '~r., 1,'{:(,U ,..,' I (" t(,., Yo!, i - , ) " I I I ' I,.' ,/,' /. ~ . , ': APL 1" p,'~ . ?01 ~ . .. . , .-1 1 'l ~ i 'fl I 'r I I~"rl) (JAIL ! l'lfl' filii. I HEALTH INSURANCE CLAIM FORM IArpnovf 0 e. AMA (OUllL11 OIl ME (>ICAI SfRVlC[ . II' Wid br Mtdocl' Alts ,,," ,....." IIOOU'"'' PLEASE PRINr OR rrPE H1fll,lll"A uno "PIN follUIl'h1 r ,~ follU RRn 'flOO "'11( ......,'&."...11 Ott.-.l~I."""'"I1.t~I.IIU"I.~.t11 ^1'1'IK)~lO CUB OU. UOOI I'JWl'W1Ih P,l.'. O';tX ,7 HGI'SHt\I~. flf, J 'Ivl\ <I 1 1 'POCA HEALTH INSURANCE CLAIM FORM rtCA : : I I "OICAR! ME DtCAIO CHAIolPUS CItAIolPVA. Gnoup HeA OHifn II IHsunltJ 5 10 NUIolUllI ,Ion pnOOnAY1N1111olII ..., '("" I I rl n n "iA~"':lAII ',"LUlla '1':,NI,) ll~~,.: ' !.:~t):;~:1 tUfodlcllttl, '.......d" ,~.SSN/ ,VA'. II'S tJt J Q fSSNJ d~ Tl'UilIDTIiwrIL.iilia.... fool II..... - ....'1 , ~A" I ~t 5" 4 IUsun[OSN"Ut Il.,1 Nam. r."Name. ....,.'""..'1 H,"."'., T /11(' 1','1 'l'l'J: ~O,~ .,.., "n ,f'l ' ,/' ~\r. I 'AlIEN"" ADONIS lNo. S"NI, I PA"tH' REtA'IONS"'P '0 tNSURfO 1 INSURED 8 ADORE IS lNo ' 61''''1 ~I t r.. ~,,)11111 1:.1 Ht~J..:1 ... 0 .......0 C.....O 01""0 ':' L E. ~.C'1.11 ~I !:,T1~r-rq ellY TalAlI . 'AlIfN' &lAWS City ISUIE 1',,1';! ,t';I.r L"l" ......0 "'''''''0 """'0 ':I\RL !",L~ PA liP COOl -'-,fLfPttOHE I~AI..CodII "reo(lt I 'fUPIIONE "NClUDE AnUtOOE, l/') 1 . ( ~'1 .!1\'1-4?13r; l.....r.. n 'u".... n ". '''''1-1 In'J J (711) OZ4 3-I\J8~ SMHlll Sludfonl I' cra.l Ham.. h..ilr...... I 10 '.'''''"I8COIIOII"",n''A''OIO It tNSUmOSrUlIC'IOnouponrfcANUIolOER t, l't.~~. I . O'HIR INSVAlOI POUCY on OROUPNUMlER a (UNOVYEN" ICUAn(H' on pnEvlOUS) . lN5URE~~ UA'~ 81n'H 5U I I OVU 0110 I. ,~'1,9 "0 'Cl I II OlHIR INSUREDS DAIt or bUmt 51' b AUlD ACCIOEN" PlACE ISI.".I b E U,", DYE n S HAUE on '"0100I. "'AUE I "Ii": op.~ vv,,~ 'n O'18 0"0 I fIN?r.., :'1< ~ "(W"ll ~,'.'r'I~Y c tMrtmER 8 NAME on 6CftOOl NAIolE (: 01llER ACClDE.'" [ IUSURANC[ "A"U....[ on JlPoon..u .....I,I[ I P'\I 'n(>,f It.'.. C!'i.I~1 r':'~lflr(' DVlS 0"" r J" 11'1::1'11 ((\1. d INSURANCE PlAN NAMt on PROGnAIol NAUI IOd RUERvUJ lOR LOCAL USE. d 15 'HERE ANO'HE" IIEAl'''OENEFI' PLAN' I I~J1r9 l=' uo n"".lflhllnl,.rwtr,1II'I(llfoI.,,_I.d lifiOiR, OflOOIITnOAI to , 110_ ....,oAM I] li;r..~iAiIiiKilll;[O PlUSOll6 SIO"^'UnE I.Ulhotl'. I " PAlIE'" SOOAIJ1ItOnllEO rEnsous SIOI,AWAE l.uthclII'.Ihe'......ol.'" tnNctlDl o~Ird(ll"'.ltQnl'lftfl".." "'1,,,...,. nl "1fltkIMt_~". to In. unMI.'If'I'd pt!t"''''' 01 ~ lor to peat.... dIlm I lItO I~II pa,mMt 01 fOY9InmtnI t>>ntlllt.... to ,""._ 0110 the pill, . 1lX.fPI' ...~ "''11['' ltItuUd ~ - '!..l!t;tV",'I'I'I' Pl'. lil.. 01"1 i""9~ S! Ll",.l Luri- 011 FilEl DAlE , IKU,EO SI(U,ro U~'f OF CURRENI ~ IllNE8S~"~IOR t5 If PAIIWIItAS !tAU SAUE on M,tllAR IllNfSS II~ UA'E\fAlIENI U"Am[ 10 WOf\1( tUrunnnl1 gfiCUPA'OI , .: llI':i X, ~ !fUlIRVI tntl OlvE FIRST DAlF UY 1 00 ' YY 101 DO 'lY MU vv PREO"AItC't'ILloIr, ' ,nf)t,A 10 -'---- ,- 17 NAUl OF R(FERRIN(] PIt'lSICIA" on OIliER sounCE 17. 10 NUIol8ERor nEfEnAIUO PItVSICI"', 1'" f1USPIIAI11AllOt,ijalr, Pf lA1rn 1()(,lInm", s[nVI((S uu on 'l'Y l.IU 00 'fY I '"OU 10 , II RUERvlD 'OR LOCAL USE XI OI.n610llA8' . (ItAROES lJ'u Oil" 1 I " OIAGNOSISOANAWREOf' IUHESSQAINAlnv IAELA'EnEUS !.2,3OR410IlEIoII4E bVllNEI t 21 UEUICAtOnESUOUtSSIOI' cOO< L OAIG"'AL REF NO "I'I ,'" 'J" " . f)O 1 L.:c..:, _ , L.:-,_ il PRI()ftAUluOnllA1tOUHUUBER . ....." - ,. -.,:, " :y, ~ . L....:,;... . ..... s C I - . n :rm, , , J f,OtlllSlor SEAVICElo ""'. "'" pnoctouRES SfRVICES on surrllts OIAG'IDSIS ~n RESERvlD 'OR "::;.' ~y MU 00 .. .' I ,..p,l~~~~,,:~.u~.;,~~.~anc.'1 COO< ICIl..ROES "n f".....,. lUG COB LOCAL un ... yy UNUS .~" t \ II ~ '~'4 : ,:",.1 .' . ,I ~ , \ 1 l,~,?;: 1,1 , , I ~:"l1 ~O ,':0 , , . l' "I , , \ , . , , '97012 I , 1..'.1: n/j :4" 0"; ", I I , ~ , , 1.!:!1\ ':'0 . ~'\' I -, , , , ,I i1J n I L" I' ',' 1 ~ .. :'., "'1: , '", " ~, l?201" I , J .:' .~'I (:':, C; ~.I I \-' \ 'II', , . ~ ,:;. ~J I.': . . , ,~ ,",j: il~ : "-1,1 ? r. 1?~(),1(1 I 1 ..J? 'I ~,tl, "f) I , . \111: ".1 , /01 (,..,' ': I , "11 J ~, ~ .,,, I '(l I , 1.2"~ 6(l.OU 1 , . 'I. _ ,oS i9r."~'l I) : I ).'11' , (I't: 1.),1 , , , , . :'" 1)'1' .,'.' "1 :< l!';,nIJ ! n 'f()fRAllA11 D NUMBEn fiSH Ell' " "'''"'5ACCO\~F.n''iG''''Ttii'- ,,' '0IA1 CII.nOl I" A""""' ",'0 )0 BALAUCE DUE '1' '.'rH'1" 7-, -L~D- _I OIO'W! cla.m- ...bal~f ~I_"II'"~~:'.HU~_.__ _~Ll..~.~___ ~_ 2~(~ "VI , (\. (l( . ;?I.O: (Ill 31 SlQI~A1UnE or PU,SI(.IAtwn 6urrll[n ]0' NAI.lE AtIOAlmnISS(JI 'A(IlI'" WllfFlE f,Jn~lClSWlI'E n "llySlCtAtIS !;urr'lllRsnllllfiON'Ur ADonESS"PCOOE "4ClllOl'lQ l'EGn(E a on enr(lEfill"lS RENDEREU lit 01"" than hnrn. DI DHll'! \m~'lr .. II J r."'1 "U,Cl 1(' CLINIC t'u"",t11111hto.141,"'.,..IID1\,h.lh.',. -.p, 10 N Wind 1'1 In.de a pal1l{'~.oI) ~ "t23 yr,ph '~l ,,'(1 ~l;;I'I,'1I(L'//. /!:/rl/J" ' (^I~I, !"-,L'. rA 17013 <001;'" '0"'/' ,..,.. ,\l,,'HI'I'1 "', "I, nm'. .A"rnOVfO BV AIolA COUtlnl Of4 UEtJlCAl SEnvlCE 1111 ..Id ~, "dll.1 I,U r,,,. hl"nN IIOD Utll" PLEASE PRINT OR TYPE rORU It!':! A l!lOQ III tol 10I\UOWI.I' I!loa rO"Unn81~ nllll ........"'1'''.'' lht...I....II.III~.flU..I...... ~ 'I~C~,,;)!:~ 'fO,\'Mi: . DTHfR....SURIO&POllCY on OnOUPNUUBfR , b OUtERINSURlP8D"'EOfBlnHl 6U 'T'll: Df"'j V~.q I "n c IMPLO'fER8NAMEOH6CUOOl HAUE tl'll<f'fl':'l. ", :,l'l 'H (, "fir,". d MURAHCE "LAN NAUI: on rmXlRAM HAUl ^,'I'1l0vlUWO U9J1 0001 Pf.'l:('lJI!: ,-,-.. p . C,1. Blr< 1 I lor :~,II!I~I, p/,\ 1'~(l41\ HEALTH INSURANCE CLAIM FORM . lurtO't.lIN'f IcunnENt on rnt:VKXJSI o v.. b AUf 0 AcetOENt? 0"" PlACE 161.'.' 1 I 1 \r..A 1. "OICARE wtPICAIO CU.....PUII CttA...rVA onoup ~~~A OII1[fl ,~ . ~ It(A"It PUlN B'KlUNIl I. ,Utcfic'Ift" rl,Ufdlc.ld " '-ll$porl.c.w, S5N, I . I ,VA'. '1 I I ,UN Ctf 10, l'- '5~N' ~ _ "A''':".' 'HoWl tlltlN.". ~llmt ~"\I{,.ll ~~.'.II I, ~ l,\Tt-&u H~,.I~" III~" 1.'\' 'I'f I. . ',1 .' I "n 'r'1 ,,~AI.W"AOO,~(fl"', .'''1'1 "I: T . PAI"",\ RILAllONSlt,P 'OlN5UIII0 .! 1~. ...1, '''. hlfO......OC.....O """'0 ce~,r:1 J ~,I r. I B1~1 IP~'''N' .'~~US _.. 0 I .......d "''''''0 ~,- \lE1J.Pt+ONE ltndudl AI.. Codel ( i1.\ .21~i-l\.3l'S (_,..~ ,...,....~ P."'....~ J I I Stud,"1 I I Sludeol I I Il... N.me. h,1 fWN, I i 10 ID' I 'rL- [lns ONll, c: OUtEn AcelOfNll DiVES 000 IOd "ISERVIU fOR lOCAL USE . "~~~ 'ACK O"~"UI,QIjiC_lIllHQ II ... '0.... I' rAfll'" son AU'UORll[orEnSQt4 S SIGNAtURE 1.\Itfw)lI" II" ".....ol."r ",,*-'01 olhtll1lO1maloonnKP,U't to pr~."" dim I lito '....1 Plrm-nt 01 ~M\f'lt benllllt Hhtt to mrt" 0110 ItlI pet1, IIWhD acnpI. "'1Q'\IN'l1 - ",!,ql1~t,.". nn r-iltl OI\-lj""1 &IOtl(O ".r,;norcURRENf ~ IlltlfSS 1,..1 Ir"lllomlon , 09.' yY ltul'nylAcctdfol'l'1OR , 1: .. ':" '4" rnEGI4ANCYllUrl 17 NWE or REfERRINCI PttVSICI"" Of\ OIltER sounCE II RIIERVED'on lOC:M. USE PICA trOnrnoon"u '" IllU II 1. INsun(U610 NWOEn H.WI.II."..!" I .:o,a .ijSliiiEii'SN~~ N_\lu;TN'iN,\I-;;-U;u. ""MIl ~,.v.,~ 7 ~lr'''l!A.00Q!~~l'11'i''''~, I~CET I m\51\ TUU"IOfj( IIUCLUOE A"UCOOll (71i) 243"1\:l'J5 It INSURlusrOUCVonOUPOAUCAHUMlllfR city _ U\r~1.l ~,I.r, liP COOE . 170!;J . INsUnrOAOAn or nlnllf " 1~1" t j'~ <,OJ "0 "'''''OVlns".., oft '''1OOl .,., nnRR^(~[ r0~MlS5nRY ... '0 t INSURANCE 1'1 At4 .,AUE OR pnoon'lA HAUE ~'r;lI(\l , IT 1 (Ii. d IS mERE A'4Ol"En~EAI H'BEN(fll PlAN' rl'f(S n UQ 1ft., 'ft""'lh.nrtrnmp!ttl.It"""hd -M''''lfl( l)fi iiiAiiiIK)m;ril"i:n~nu s 5lClfj^lUnc IluthnUI' Jl.11""". nI mNlll'.1 tlfo,...,." 10 Itlf unrtlt'l'O'W'd ph)lIt..n Of lupphPf IOf "rw::..dlKt~bttlo... !Cd qll~t.llr(' 011 F 11 e VAIl' 6K'~jlO 11 tr PA,Iun HAS ttAD SAUE onSI~ll"'" IllNltlS I tt. IIAtrSPUlf'tU U'U'\l[ lOWQRl( .urU"'lulI OCCuPAttotl QIVEn"st DAlE MM : 00 : V'f ,n,....,.l.iU 00 '\IV 10 tAU 00 YV L _____ 17110 NUUBER or RUEnnltrorllYStClAU III UU$PlTAlllAI10UO""11 ~(lA'rtJ fnCI.AntN, SUWlC(5 Ul,I on "tV UU OU ...,. fnou TO PO OUTSIDE lAO" I CllAnolS ~l 12 "'WIt"1[) AE 5U8U155~ COOl l OI1IGIN"l Rlr NO if rR'iCiRIUfttOmli"1iOi4 NUUl1E It " DIAONOS'SonHAIURE or IHNUSOOINJUnv InHAtE ilEUS I uon. toltuun By liNE I ~ '-1",1 '(I .':( '''; '''''E! t ,~.:..:.: 3~.":".J ., . 1 L...:.--....:. .. . A flJ.?:1l1510f 6ERV1tE,o w "M 'tV filM Dll YY I 0": ~~4 :.~" '" ",: ".1: ';at! , , . ':": '.'" :,,11'1 ;"1: ')11 , .~,~ :< l,",11 '),1 :';1'1 ) ,,~ '~ ,\ : _. , .1 , , , , ~"~ ' . '1 1".1," "! ". , ',,'1 . - , , , I \: 1'1\ ' '.)1 ("I: " : ,', 1 " , " I I . ,"" I .,.,~ ~.:,~ 0,,' (I',: ., n 'lOlnAllAIIO HuMorn ---S5H'(II' l , 0 " I ! . OIAUtKlSIS nffi !r601 RESERVED ,on CODE 'CUAROE S Oil film", '''0 COB LOCAL USE UNIIS ...... 1 ~ ~.t n. ,C'l) , : 1 .'!~ 1~ f-,Y; !-... hnr : !~ \~0 \' ! :. .~,' ! t; . t,'f,.' ! ,/ f--' 1 : ' ~ t"; (~r.\ e "'" .. .~'.!.;?1 c 0 lrPf pRoclOUR!6 SEhVK:ES.OR&urrll!6 ol! ,If.lpll~~'UIICII[,,,"!,I.nc.'1 : r.III,,&r'.PC'to I unnlrlrR :. \'~sl~r 1 I " , i ~ , , I.- , ~ '.11_~~tfl: , . , I ?rr."!: 1 1.\ , I r-J , I ~, , ... ....IftJ&;,j , Ii Ii I I I I I I I . I I " I' .. '~c;e':,~ ,.,' t' "" 1[,. e(w' ~ ' , ';:i\,t",ur:.,-O I: ' ""'~ p,' 'h' . , .. . . ~~ ----'----"- - .- 1fa PAllEt'll S ACCOUlII uo 11' tecHt A5')1f\t'MfUP 111 tOtAL CIIAnm J" AUQUut rAIU 30 BALANCE I)OE I OlQ1'lrt {II,"" ..,.bat.1 1~/II,""'~:~____O~~J~i_~~._ _~ .!__"".~, ' , . ",\\~' l~t~ U '.AUf. ANn "Ilum 55 Of fACiliTY Wlilnr Sf nVU:(5 wrnl 11 NI'61CI""5 511f'rtllns OllLIUO .~AU[. AounESS liP COOE nfl'tltn(Olllotlllllthl...ho~OlOUl(fI tr'~~lr,~ II: r....H.,f;,(\( 11{' Cl.INlt" ".' 1 ~'lrW J!ljfl[\ 'AI:L",!.f.I(' l/'.'JJ '( I " It, , II 'I _~ I rill. I "'H'I llLl 31 SIGIl"1UnE or f'1f'l'SICI"',on [.urrltfn ,"C\UO'"O OfnnfES on ell( Ilr "11"'6 tl[.."".....IIht.'II~lt.{Intlllll.'.". 1AJI,IOlhtlbrll 1t1dII,maM I p.l1t Ihltl,"" I ,'1.1, I -""," f . (0', . ,."\'i~',f),.~. . f ". 06 f ,,/ ,'.. I. / 161G1~[u tlAIt 1",' I","'" ,,,rrnov[ODY "t.lAr.OW'Cll uti U[(lIC"l stnv,r.( IIBI Mid br "';'tlt Atlt Pr... t.....,," IlOOm,I" PLEASE PRINT OR TYPE tomJ lK:tA IMla 11'001 ronuowcr ,!too fonURn81!lOO '''IU - .....~..'II".1l OM .....'......,ltlll...-......IIU..'..eMIl AI'I'lluvlUOUB 0111 0001 f.' "'. DI:~lr J,.. P , ' o. fJO;~ ("""\7 H'Ji:':'IIAH, P,\ J '>'04,1 I , Ir.,. HEALTH INSURANCE CLAIM FORM I WOIC"RI. P-o ..OICAlD..,......, CHAWPUS ,,....,CIlAWPVA n~E'~~,-rLAN r-It~~~UNG..-l OHlER I. INSUItEDS 10 NOWOEIt [.'......,."1 If~.d'JI "Sponkv.5SN'1 jIVA,..,) 15SNClflOJ I 1,5SNJ II"ot 1~N~~O&:'.:"'l~~("~" " ..,..... ...., II.. H..... ,,,' H.... ..........'", I' ':~"~' M' V, ., , Ii I' !.'" . 'jN^ I," ~l!! T~ ~....n 'r~l . PAfIlN'" ADORESS lNo, !t'N'1 . PAflENf RELAfOOSIiIP fO tNsunED If, l ". ,;,Ol,lTH "I ~F."-' T .... [1 ......0 c.....O """'0 City IIUAU . PAlltHf SfA1U8 r. IIr<u ~,L r:: PI- Songle[j ....,... 0 """, 0 lIP COOf I tELEPHONE IInduOl At.. CedlI 1 '01' (111;;4 )-,\.38'; E""''''n ~~7n ~::'7n IL..INlrne,flrll I 10lIPAlIlN a c()tj 01 0 DATE SK;NfO II If" PAtlEN1 HAS HAD SAME OR SIMilAR tllNEf'S I'" DAns PAttENT UNAAlE to WORK INCUR"nn OCCUPATK>t1 OIVEflRSfOAlE 104M ~ DO, VY I ,ql'lYl.U,I 00 lV 10 u~ 00 VV 17. 10 NWRER OF REFERnl140rUysICIA" III uUSrtlAI'IAlIQfIUAlff t1[LA'rO 'OCtlnRE,,1 SERVlClS , "'1,1 vn vV UW 00 \'V I rnau '0 l'O OU'SID( LAB' . CHAROES I Om 0-0 I 22 MEDIC"'ID Rf:SUBMISSION CODE I OOlQlNAl REF NO ,] PRIOR AUIHOfU1A,lMJN NUMBER . , 0 It , J . 01AO.10515 I uo~~ I~~~~ RnERvED rOR coo, 'CHAROE 5 UNI1S !'tan ...a COB LOC"'l USE 1 ;:31 1 f; 00 I , , 1,:"'4 J~; . ()(' l .-". , : I'D t:J \' ! , ,', ~~ 'J t\ 1~:. 00 , : ~Er ,1 " l,??4 l~.OO 1 ~ : 1" " 15.0(1 1 ,. , , 1.:"" lr: ,0(' : -l~' ...curl ",ssInWJ!t,p ill TOtAL CHAR, al. ,I" AUOUN' r"'ID I' or OOw1 cl..",r ,.. bat~ I . ~J'\I'~I;:r.'lAr, J~ ' '-10' ','(' , ,~.O~, '10: (l(\ 31 NAUE M4D AoonESS or r "'ellllV Wlitnt SEnvlCE 5 WE R[ ]] NjYSlClAJ, 5 surPlIlA 5 81LLlNO .4"M(. ADDRESS, Z'PCOOE RINOIRIOI".'h..~"homo..."", ~f~~'" nl~,I~'J"f",( l!e CLlNIC :1;') YOm, ~(JAD '.I~Rl.I~.Lr. "^ 1701:- '11 :'8",' , "., I I'ltl' lonr. I I I I I I Ii I I ':-Atit" . OfHlA INSURED S POUey on QROUP NWl(A / . EMflLOYWEHn tCURRENt OR PREVIOUS) o VES l3'"' b AutO ACCIDENt? PLACE ISlal., On. ONO, , c: OWER ACCIDEN" [JVES 000 'Od RESERVf:O fOR LOCAL USE b 01HER INSUND B DAtE or BIRT.. SEll "IjJ: op.~ VY'C.j I ..n 'n t IWPLOYfR6 NAlr.tE on 6t.1OOt N"'ME H",pr t,r :','-, I '::,,,,., ~.: ". "r\"~ d tNSURANC( PlAN NAUl on pnOOR"'W NAME ,.~!"-D~~~. 0' 'OfI~,'~!.O~! <_lI"NO. .OO"'NO 'HI' '01" I' PA1IENT B OR AU1110mlrO r[nsON S 61QNAIURE I.Ulh(wllllhlt "..... oI."r IM'lkIl 01 0""1 WIIOfrtl.tI()" r><<""'w to P'II{ftI" ct.n '_0 '~II Plwmlnt of ptfMltnl blntlll..."., 10 mr..1I 0110 tht patf'r 'Ilfto kUPI' '"1QIWIflI tIItlM' l':',iq",~..\",P I'll F Ilf' 0/,& "17"~'~ SlOtI[D 1..Q~1f: Of CURRlNT ~ IltfllSS Ifllll .wmplomIOf\ ~ ' DO ' y:t. tfUl1nV IAccldrntl OR :1, . ~."r\ rnfm4A.P4CYIU,u', l' HMlE Of A1HRRlOOPHYSICIANOAoUtlR SOURCE '. "'RnVED fOR LOCAL USE II DlADfIDSIB00 NATunr or IlL"ESSORINJURY InELATE I1E...5 1,2,3 on. 10IlE"".E BYIINEI--, r " 1 "'. ~'t>"; C Oil t , " . . . '. .' '., . . , '---._ .. L--._ 1 I ., ,":') , :' .. . ,,~'(ISIOF Sf:RVICf10 ... ";0 yy ...... DtJ vv ('1: ',.'" :'~f1 (,l,f I~": ")41 I B C PIlei TfP' oJ oJ . I t~:'7 .2J o PROCEDURES SERVICES OR surrllfS u l(~~~ UnuIU.1 Cittum".nc..1 cPHU:P"1l I UnnlFll:ft Ii '9rerl (1: ~ :. . ~' (14 :"~'1 011: , . I' : ~l/i : '~'I' a 04: C1 :"'fl ('01' 0" : '~'l :< 958~1 I '" : , 1 '9 '5f.l r. 1 I 10: s s 11 :: I '2' " "... I ' I '<.~! <\.' , J'; ~''', ( 'I' '1", -:. ~..~ ")~,(Ir;l '-1' " FlDER"'l ,...., 0 NtJt"IBEfl 5SN EII1 " PAtiENt B ACeOUtH NO 1'111 (";1.: ('I, . ~,' fi' (IIi; 1,11 , .- o. ",,., ,q5a~d . , . \ ~.,: :\1' :".11 " \, , "4~8~, 1 :)1' .'." :.'I -;, . I, 'I'''''.''').,.,''&: 31 8IGNAlURE or PHYSlClAtwn 5urrllER INCIUOttlO NOREIS on cnEtlEI,I''''lS U n.llf, rh.,1hfI ,'.lrmen11 CII the t,vlIl' , yJaIhl.Wand...m....p.sr1',..'otl, . ~ 1 -- t".. . 'I I . ',I/}Irt,,/}, ~~"Y"l' ,I !ll.lGNto 0""[ IArPROYfO (ty "'U'" CQlJtlCIl Ot4 UrOICAl SlAvlCE .111 IItd " .....1 Art. 't,.. t.II...... IIOOUUI" PLEASE PRINT OR TVPE rICA !! Iron PROORAM", I1UA II . lNSUnED& NAUE IL." Name. Flrll Narne, UddIt nrl&ll ".flMf , IN$URf:DS ADDRESS INo, S1'"11 r;1 E. ~I)'-'Hl STRI!I~T CITY I SlATE "/1m 1 'JU: P/\ liP COOl 11lUrltONE IINCLUDE ARU CODEI 171)1:< (7J:? 2<l3-1\3El!; II INSUREDS pouev DROUPQA fECA NUMBER . ItiSUREB3 DATAn,Of Slnm -0 L "r') V~'1 "0 b EMPlovfR 6 NAUf: on 80tOClil N"'UE 3M,R/'I'hf.. ('O~~lJ':;~,M~Y c INSU~A"'CE rlANNAM( M PJlonnAY NAUE .>RUllf,:,I~l ! 'l. d IS HtERE ANotHER IlHltH eENEfIt PiAN' C]'fES [] un H'.... 1"""nh.ndC'lW'lPlI'II.II~g.d 13 IN~UUEO 5 OIl"'IJIIl()Rl~EO PfnSOfl S SIC'\UAIURE I "UlhOlll. rm~",..11I ol mrooc.1 two""'''"10'~ unMl''O!IId ph}lItlan 01 llIpe>>oer 101 MfYI(II dtwuo t>>tow ~Jy~alur~ Un File ... ,~ , , I )Q (tAlANCE DUf ronuller A IMlO IInol fOOU ower IMlO fORM RRB t!OO .1lIU_........"II"'.1I UII_I__II'I"~.Il'I"I..tHIl AI'I'IIU'VlD OUR 01)1 0001 r ,',\,'I'lNT I'...... r' . I', ft(l:-' ~ :' 1'1"1\<.11.,.... f' '\ 1 '1011'1 II IrK,. HEALTH INSURANCE CLAIM FORM I "'OICAnl MEDICAtO CIlAMPUS CUA"'PVA OROUP ff{;A 0111[11 II IPi5U111USIO NUMOlfl ~ ,~...~ ~, ~,"EA'"'.'A" Bl'lUIj",-n..no A( "", ."" ,,, I ',(, "., If~I"'JI 1'.......d"1 1'~"".5SN' I I,VAf."1 I tSSNOIIOI n ,SSN, ~ 'f 'j '. ~.. __h"- Il"1 Na",- fit! ".roe UoddII kwt..11 I ~~.I.I 1 ~..p11t &U . 1H5URlClS N......E IL.'I Ham. h,1 N.roe U->>t k'lII-atl :ifl',I",. 'I J t,'l' I,,'," '1'11: 'fq y,! ",I r r~ '.,(\11i . PAtllNtSAOORlSSINo, 51'..0 . PAt If Nt nllAllONsulP 10 INSURED 1 INSUREDS Aoon[S5 INo, Sir"" 51 ~, C,O:'lITH ''''':F.t:T ...0.......0 C/ooIdO "'...,0 ':01 F, ~f'l!rH '.>''',I-:ET env IBtAn . f'AtIlNI5IAfUS CIIV SIAlE ,'Ar,1, ! ",I r. ' I Pf .......0: ..."... 0 "'.... 0 "Ar<1. 1 '01 r: Pf, lIP COOl l'lLlrlfOHE IIndudt Al.. CocMI liP COllE tELEPIKlNl:. IINCLUDE ARlA COOEI I"~I (.':,) ?1\3.1\313~, (_..~r"T....,...,p."....~ 17'-'13 (71;') '::t1)"13H~, I I Stuctent I I Sludtnl I I IL'li N."".-'..I el) to 1~f'''lItNT a LUNUIIK)litttL"ltU IU I I INSURED S POllC" QROUPOR fiCA NUMBER tlAtE !.1n'l((J II If PATlUO UA5 UAD SAUl 011 SIUILAn Ill'~["S I If, UAU5 PAIIEUI U"AAl[ 10WOflK INfllnl1[tlf Of,CtJPAltofl GivE rIRS' DATE t.l... ,pO YV U... 00 n UU 00 YV . . Ih'lV 10 , _1..--_______ 11. 10 HUt,lfl(ROf" RUfnRfjQ PlnSICI"'" , III UOS""ALI1AIIOt'lUA1E! Ilfl A'I tl 'lIC\Uln(NI Sf.nvlC(5 UtA ()Jl V't UI,I DO V'f f"OU 10 10 OlllStOf lAB' 'CllAnOES I]yn ONll I I 21 ".rVtCAtD RE5UOUlSSION COOt I QRIM''''l nn NO u f:,(,:~!, .OtHERlNsUREDSf'OLICVQRonOUPNUU8IR . EUN.O"MENn ICURRENI on PREVIOUS, Om C1NO b AUlD ACCIOENU PLACE 15'AI"1 o 'IS 000, , c: 01UE" ACCIO(NI' OYIS ONO tOd IlESEnVEorORlOCALUSE b 01llfRINSUREOSDAllDr OlnTll 6U ....h "1"1 YY,., I ..n · r'1 c EMPLOyER S NAI,IE on 6ClkJQl HAUE r:"~\r.:Ar I' t, ,:I.lt,l, . ,".1",' d INSURANCE PlAN NAUf OR PROOflAU NAUE Rubllm. .OR'U"OA' co....... llHO . .'aNOIO 'NIS .OR" 12 rAHlfH S on AlIlltOOlll 0 rEnsotlS SIGNAtuRE I.Ult\oll,.hl.I....ol.nr mt'M.IOI otht'IItOlmRhfl/lI'l'f'''''''' to porn' 1M c"m 1.lto ,~,I plr~nllll OO""'Ntlenl t.nel.tl.'"'* 10 m,,1tft 0110 I'" p.IIl, .ho 1Ct~, "19"""'"1 t.o. c:.l.,' ". 11 1;1 ,'.... r i ,1~. 04 - J? . '1''1 SIGIlW ..~t( or CURflUH ~ ILL"Es&tr.".,mplon110R DO . ,,)' I"JURy IAwd."l) OR . I.. ..."1 ~.1 PREn'~IH"'fIL...rl t' HMlE Of nrHRRlliO "1"SICIAI4 OR ClUER ftOUnCE '. RESlRVEOfORlOCAl USE 'I OIAUNOSISOR UAtUR[ or ILLtlESSOR tNJUn" InElATE I1lUS 12,JOR "0ItlM,"E B'f'L',EI F~'l 0,"'1 ,','I? ')8 I L.:..-,":: 3 ~. t . I " "", .. .. A 0 C rlJMtElSIOf SERVICE 10 Pl.lu T,po ".~" ~" "'U DO ~ ,I .... H ~' 1 : '..'1 :":~ "11: "1 . ':'1\ " " , . . , 011: 0": Oil :'.,,, "1-' 9/, J ~ . . , ",., ~ 01\ , , '"J": ." ," 1 "., '",'il -, 3 , , , , ,. . ~l" ' ('iI : .~~ 1)(' t",: "'1\ '! , , , ,. (.'(11 ~...' '1 :" " 1,:1': ' ~ ,! ' ~; .' :- . Jl:l';' '" . L:..:..., ,~.. o PROCELJURES 6ERVICES,OR611PPL!ES _ __IE ~~~':! Unu,u...I.C~r~','.nc:.11 C;PI.IlCPC5 I UOOlflER 'r,~t'l: 1 I \ ~,: 9r;('~'1 Ill,: ; '''l~I:'r, 1 I 1": I' ,qSfJ!:.l I.::r): E OI"'UNOSIS COOE t,~ '1 1 :~ :' t; :.: '.~!.J 1:: It, ':,tC',I~"11 I.' 1: -,.... . ~ 1.-' :<</1 " , . eM "'d' "', ~ (',' .'1 ~ "rEVERALUIIO NUUBER l...r"nOvfOBy A.UACOut'C11 OU UEUICAL SERVIC(a Bill Mid bor Utf.c.I AIIt 'It II tI......" lIaun"" PLEASE PRINT OR TYPE rICA I I IFOn PlkJOUA"''''llEMII . If4SUR(O.~ DAtI.or I'lm," "'Cl ~J-l vl.'1 "'0 b E....I'lO"fnSU......~~i.l1 [It\I~~'V: I: ~;: .. '1t.~tw11 ~l.~,(.',f\" ... 'l2J e IflSUR"NCf t'\ "'4 PlAUf on "J'OllR...... NAUE Plt'!'I.'" J (,I d 15 IHERE AN(lIHEfH~EAL'HBENUIl PLAN' t~ltr5 [t~'?____!'.~~~nrtr~f1...'"9.d 11 lu..unru SOil Allllll)llt;'E11".n!iOlIS Slri"^llln[ IIUlhl'lfll. "'1,''''''11 n1l1l1'(k.lt...",'I,,,IOlh. UfldfIl''OllfIdpll~'IC"nDl,up&JI.lIQf Mf\oIC...KlItJlldbfolO... ,IPI:cot.'lfl' UI1 r de I 2] rlllo" AUUlOI1IIA11Ot4 "UUOlR r lO'.0C 0 II , ! um\' ,""U on r,,,,,., '''0 CDS uw1S ...., ! . nESEnVEO ran LOCAL USE ,CUAnm 5 1. r:: ,~.'l\ ,...,r ':r;J ~ \l1i\1 ~~\.l , 1~;, D(' , , 1~. .00 1 ~; . (I() 1 r;. L'(\ ' III lOT AL cll"i1ill ].., AIJ{)U;4irAlu JO BALANCE OUl:. . 'II', 'J~' 0, (J( I Q(". U" __u. n 1'llySK;IAtl S SW'''t If 1I!:o 011111'0 "AU[. AOOR[S5.11" COOE Ht'J/"lf I "tr".IPI;f,! '1(' rL!NIl' 'f.~ -~ '1 C r,", 1(l),V:' !~'Hl"'L.r, 1\,\ 1/('1: ., I ;J' (1'1 '1 :~r. I. rill' . lilll" fOIlIA W, A l!lnO II" 901 rOI1UOWCP IYJl) 'ORunRO lSOO """, ...........1'...." Ow ....1..._ ..111'.-..... 'U.MI...... AI'I'llOVlUOIllB VIM OOUI ~ r'Rut'fIH 1,-.. p .". 1]"'< " 11\'W,HM1, f't'I 1 "/\J1 ~ II IPICA E ricA , i I. utOtCAAt YlOlCAIO CUANPU5 CUANPVA U"OUp -ne 01lUII II ItlSUnE0610 NUMeEfI IJOl\PRUGn"YIN111N II "II 'n nltlA~'''~AN~ '\"NO~Ij')~'12()U n '...."", n ",,*.d IJ 1~0l' I 55"11 ,VA ,. II I S (It 1 155NJ' 1'01 . ,;ll..INamI,'"iName.frIIodINlnltllll IS ~~.1.if~~~ Sf_ . 1t'5unlO S NUll tllSIHIIM '~.I Hlme I.kIdIIlnlll&ll HAU~,. 1 ,(Nt'> ",~[ ~~h: '~., ~~ "II · 11 ",M1l I, PATIENT" ADORESS tNo, &1'"'1 . ,A,tIEN1 RlLA1toN5UIP 1OINsunEO , INSURED 6 ...00nE6S lflo. 1it,"11 ,., E. o:.OlJ1H ',ThE~i 14' rf ......0 c.....O """{] ~,l r:, '"IliJ1H 5'1f,r:;eT :.>- CitY I"AlI . PA1IlN1 S1AtUS CitY -\61...tE rAm 1 \;I.E PI -0 ...,....0 -'0 CARL I f,l.[ PA ZIP eOOl \ 1fllPltONE tlndude AlII Coctll liP COOl 1ELEPUONE llUClUOE. ARlA cODEl . 1/1;1 : (71') 2" 3-4~e!:, Efl1lIoy..tn rua"l1MrJ PI11111Mn , 1IIll J (711) :?-I:l-I\~(lr, Sluclent 61\$nt ~."MR.tu,,"'me. ...pqme-:.......InNllI .0 IS 'ATItNII CONDI/ION 11",,"0 10 II INSURED & POlICY OROUP OR 'U:'" HUMBER ';I'\'1E I ,,01"" INIURlD 6 poueY OR GROOP Nt.MER . ENPlOYNENrr IcunnEN1 on pnEvlOUSI . 1N5un[38 0"1~or blAttl .1> I I om dNO I. ?'; vr.:.,,) "0 '1::1 , b 01HERldOOEDSDA1EOf'IIlnm SEX b AU10 ACCIDENT' PLACE (51"'1 b l.UPlonns HAUE 01\"(.11001. ""Ut I "':: cr'~ VY." I "rt 'r.1 Om ONll , <l ,'1RR ,V I' " C'Jt\HI :,sr,RY c ...,rtOYlR6 HANl on 6Cltool HAUl c: 01llER ACCIDENT' t tNSun-.NQ I'\Atjtj~oon,ul~"UE I r.V'lnr\(\t'~ 1:- '.' ('!'lI'j' I ":i"r,"( [1m ONll PRlID[Nl1AI. d INSURANCE PL.AN HAUE on PRoon"u NANt ICd RE6ERVEO fOO lOCAL USE d IS HURE AN01HEnllEAl1l1 BWl'l11'l"N' I lJ"s 0"0 "..,.1 1~',""hllWtfnm~.tI..m..d , ~,Il!t:~ .ACO D' .0'" 'IFO"I COMPLI,,", . S'D""'D ,... '0"11. 1_' IN~'I.'f U S flU AlllllOfll;lll rllle;Ofl It Slr.UA1tIRE 1 l'lUlhOfll. I l' pA-llE,n B OR ,"UlllOnll(ll rEnSOU S 610HAlunE l.uthof1l.ttoe ,.111" ol"'r ~aI 01 DIN' II'lll)lmlloon "fI<"..rr rl<1,""". ol.......I~'1I'1~' 101'" '''.''IQ~ ph"It~n D1lupp....IOf 10 proc:...'" dtm I aItG I~" parmenl 01 oov-'MIInl btnthll tftI '0 m".. Of 10 Iht ptI1, who ICUJ'I' ,uVfII'M"I '.Meet dlttfltlPd billow - ~ ~ "~-Iil~ I ': {. 1111 rill? (l~ -1.:' -'~I\ C,jYlhll\lI'H Oil File $IOUlD DAtE St(\N(O ".ll:1f or CUA~'N' ~ IIIN[S5'f.c"'I'.~IOR t!llr P"'lIEtH liAS 11AO 5......( OR SIUIl"" II.\Nlt'S Ilr. UAtUi P'TIFNt tJNAmt TOWOIII': IN (UmUIII ~CUrAltotl , co.t 14 tNJLIRV I cldctrII] QIVUIRS10A1E UN: Pl1: ~Y i Im_.."'U 00 n to UU 'tV , , I: " ~ . Pl\lONANCYllU"1 ' J__ __ --------- 11 HAIlE 01 REfIRRING Ptf1SJCIAU on otHER &OUnCE 17. 10 t'UIr,IBfR Of' REn,RRIUO PllYSICIAU . III IKlSflll ~lIlA1K)1' U"1f' PO A" (J 1t) tltnn[tH s[nvl(LS ., . ,,1,1 pn ..,... MIol DO "1' ,- lD II N6ERvtOrOOLOCAlUSE ?O OU1SI[)[ l"'O' I CIl"ROES , D"" ~I I I 21 DlAONOSIS OR NA1URl. Of ILL ;ESS on INJURY IRllAtE lTINa '.2,3 on.. 10 I1IN If( BY lltjEI t il ME OIC...IO Ill' aUIU,IlSSKlI-; Cf.'l . "" f!?q . '.lEI COOl I omOlN"l REF NO , L--,- ' L--,- ZJ rJ1lon AUHtQnllA110N UUI.I8ER . ., " lJ'1'-' . 1 I l-:- ' . ~.'ol .. A B C 0 E . 0 " , 0 ,,9:TEI6Ior SERVICE 10 """ 'II" PROCf,OUR(6 SERVICES OR SUPPlIlS OIAO~SIS Jim [l'~li' RU[nvtD FOR . N1 V't ..... UO 01 01 I "'Pl~::~~~IU'~;~~~I.nc"1 COOf. ICltAnOFS 011 "If'l~r ,"0 COB LOCAl USE .... VV p" P IFI R uNns r~, ",,: ,~," :':1, ( ,~: .,..,: '1.\ . <. ~q:.t'ar1 I ,I .: . ! ~""l 'I \~ ,N' \ , , 1 , q..;.S'l 1.-' ': . ,.1,': : '~.'. 0'11 , <, I 1 .! I'~ J r; ~l{ I l - l.lq '.il , - , , . - , , , 1, . , 'i\' ' , , ',,: '." :"'fJ ~'f I t.: ' '" , i ::d.1j1J \ b \ \', \ " .~l\ ~ ~ .'.)....1 ~ , 1:'. .1..10 . \, . '. .. , ~ ~ \j \, , , 'I': " " , Pqf I:' ,~. : :'1, , " If) J 'J I , ") If .?'J . nt, I ,. , . . . , I ,: , (""I' ,....: , ',. II' " , .'1 , , '~~"1 l I , I :' ~. l' ',I (.)1'1 l I . . ~ , I,. . , .... 'l-:.:~,' 2 I , I : . r , J,"",'l :'f1.I:. .' ' '. ,'I., " , . L ,,"U,Alt';"'O'-' ]"-W~I~"il-- .----- "flOlfW lAllO NUUBln 551, llu :6 rAIl[llt6 ACCooU' uo l~' rC(.trn~;rojl,i(ij,,- 30 BALANCE DuE: Ilrl t 01 ;0_1 UI"". 1.11"1~1 ,\" " 'I "~ '.J" I :'.' ! ""I'~ ( llJ~.Ll"~..u ' 1 'I.' ,ll" , '.P', . 1".0: :", -----......-- ---' ._-- II alQ"'~1unf or Ptt"SICI-''' ('Ill lillf'f'lllR ]1 "AUf Mm All(lRfSSOl f AUll1'f Wtl[nl- 61'IVltlSWlm )1 rllV61ttAtlS fiUl'I'tlln6 E1lt\ 11;<1 NAM1. A.unRE6S 'IrCOllE tNC\UUINO IlfOREES on eRf iii UIlll S R[t;tJ(mO 11101'* t1,.ntl()l'Mpi 0"1('11 U"'" r f. I. .. 1- r lIJlil~I'. 1 11 '~L INIl l'-"""''''''''-'''.~''''''' \ IIJPIyllll,.""n...l'It<tflpoll1lhtt1f'Q1! UI l."l (C'r:1 10; 0 f't"' .' I .Tt/l//"'..../r'U')U'<;IAV..1\' .~: f\ f .: \ 'SI r ' 1-'1\ 1 ;'cn:" I., .. ..I ,:' ,'n,'lt! '1.': I lauto LA t ! !'lllt ' . (jlll'. H AL TH INSURANCE CLAIM FORM ! l"rpnovtOIlY A"'At()IlflClI. UUUlUlCAl5lH__l(( ..II ..tit ..,1I....ul.".'''" r..lI....,.I."..I" PLEASE PRINT OR TVPE 10m.. Uti.. 1'00 11'101 fOnM uwer' 1!t00 .on... RnB ,!tOO '1,.14 ......""....11 w....I.......IlIlU.--." 'IU"..I.fll r-r.:'Jt'r.td :~ r. . ", t.ll.~':~ .' =' 'Il'!'- ;.'-i".1. p,", ~ "If,' ~ '\ I I IPICA HEALTH INSURANCE CLAIM FORM ,U[OlCAnE UEOlC"'U CUAMf'U5 CUAUf'VA OIlOW' ~~LA Olll[ll I. "'5UII[U510 IlUt.AUll1 I~, ,~ n ~ "lAl"'P,AN ~Bl'lUN",-l'i ,,'" 'l~ l'I~I..tJr'" ' l,~O.~;' I ItUHot.""I I,u.ck.tdII n,Spot1.Ot,S5NJ tVArH"1 I 155NOtlOJ I I'SSNI ~ Ii "Alii E1UtlHimi~mtlModdlImm'll 3 ~~.l.I('n!]flflTVJ1~n S(1t 4lUSURl_OSNAME1L.I1H.""htlN.rne,UOJielnll,,11 f.it'lll'.. ll1'" i,,:" ~l; If'1 ~~ ..Ii 'r1,,.,.M~ I PA11EH1SAbonfSSlNo SIIHII I P"1Il'llAELAl'OUSllIPlOINsumu ':' I l:, ~,uUl H '; i Rtf: 1 ... r::J........O c".O ",...[-, ell'" IStAtE . """Ul1MATUS ''.f,'', I ~,t.t' '.Y.-ll 0 "".' [J 6lt1Q1fU' u.tI~ 'IPCOOE I 'lElEPltONE llnd\.lde AI.. Codel 1,'013 ( ;'),) 24.)-r\J.)!:> (.....,..- ,"',....,.., P.rtl..,-, -, I 6Iud.,,' I I Stud,,,, I~ , O,Utn INSUREb6 NAUE lUll N.",., '1111 1'QITlII, MO:JI.lntlll1l 10 ISPAIIENl a COflOll1Qtifl(lATEU TO <',,...'11:' [lATE Sll~ll(tJ l!i Ir PAtlltH lIAS UAD SAUl. 011 SII,IllAnlutll SS I If, tIAII.srAIIFtll tlt~Anu lOWOll1( It.( 1JIH1t'fH O{:CUPA1KVI QIVE rIllSI ('lAIE UU t 011 H MU no \V Ul,I ou yy , Ifl()l,' to 17. 10 "'UuBEn Of' nUtRRlt.O rU'I'!.oIClMl --l"p; itu,;>",UlIlAlI(ltl CI'I[I iiii";.;iii IllcunnttH 5lnvte:rs UU [III ,., UU OU \'v rno.. 10 llO outSIDE \AB' 'tIlAAGES o~~J I u t.t[llu;AI(l n[SUBI,IISSION COVE I MIOINAl h[ r NO 7] rRl()f~ Aut"OllltAtlON NUUUER . OHlER INSURED B POllC\' on OROUP NUMDE" . EUPlO'f1,lEN1' ICUARE'" on rREVIOUSI OYI& CI"O b AUIOACCIDENf1 PLACE 15,,11'1 101m [JIIO c OHifR ACCIPUI1' []Y1S [1"0 IOd f1EsrhvEU'On\OCAl USE .. bOtllEntNSUnWSOAU0f"81Rtll SU . ,': up'! Yr.'~ I "'-l ' r1 t EUPlOYEnS"AUEon SCltOOl U.\UE H(,';Pf,' ,....' 1....~J-i'l.\, .^.I " Ii tNSUnANCE PLAtt NAUE on rnounAU t4AUE RI;'O I'Ctc; D' .o1iiiifORI COWPLlfiHl & IIONIHO 'HII 'ohM II PAllEtH ~on A\JUtnmll,' "FfIliOOG SInllA1unE I lI\1tllO"lfIt", "Ie", cI.ny""'doni 01 otl.., Itlto<m"I>nnN'(I'~U'. to p'oc.,,"" ctI,.." 1.1to 1"lI"" ~Imtnt 01 oowffrvnftfll bentl1t. ,,\hellO mI.... Ot 10 IhI pan, .ho ,{c"'P.!' ,,,,O"",,,,nl btlo. ~.iQII;t'lrr' 1l11rl11.1 Pil'!.J.91j 51011[0 14J;::E (~f~A~~.~: ~ 1I1urSS I'''I-'I-."'fl!onl)on 11U1'", '''CCOli.ntl on rAf Ot4ANCYI\UI'j 17 NAME OJ nEffRRlt4Q PHYSICIAN on OHtln SOURCE II fU.SERVED fOR LOCAl USE II. PIAONOSISon"..tURE or ,,-UlES!) on I~UUny InUAIE IlEUS l,r J OIu to lIEU ~.F Ov I1t'fI E~l 20 rJ~.ca ,L--,_ , L--,_ t .~ . '. . ~.. .. A A C fl.g~,ffISlor SEAVIC[ 10 rNie. "" ., 01 .... nnnUUl)U yy ,~.. it! r~ 'I : 1 :IJIl , I ~. \ ~.j 11 " t ','.i: Il , 01,: , , :.a', 1'11. . , . , (>,.,' , " :'..'1 ':;1 " ,,1 ~ , It" ~ I : :"Jf. ,.", " I , . ., ~, I" :"'6 ('''J . " _A " & , f1-4" ;>t . L..:....:..., o pnocTnunh S[iiV1CES DRsul'r(iii rpt~.~~~ Un~'\J-;"~lr~'~'nc.,~ \'~J~.,,!) ? I I 'it: ~:: I I .: ~ \ -- ' OIA(",llilSIS CO(1r 1'" !Il I ! , , I "~9 ~ 1.2 t "....,,), I ' I. " 1 I't ! . 11 - L : , , '.'''' , , , "'~' 1" I ~ ... ,. ~ " . · ~:'\';";'~l ;~:~~ N;';"'ii:~'.:~I",'-I~~~;5:.i'cd'lfjiO~li;Yl~rl,;;~:,;,:;~jj;~ ~} 1': t. e," ;ll ~~ .__..l1LLJ~'~~'~~~ 'I FJ \~_,______l1J ~~~~., jj"!_:~~~~',..~_ 3t !iflVlA1!Jnf or PU\SIUA'4 on tuN'PHl . ]jI "Avr Atlll A(I(11l1 r.s 01 I AeIL Ill' WIIIII[ ~1I1\,1l I S WI m IIIUlI(11tm lIlnnH s on UH (I("II.4t5 I npm'"' (1111 on_. thllf~ ho~ Of 011""1 tl t.'t,I, lh..1 ,h. "..I,,,,,..., on tl,p,p.p". . .Wllolht.boII.'1fl.'.JI'I......1>4fltl'.".ull )i1 :.l' ,J /:4 f" ~, , ,,.'1/"",)(1' /.,' ".. i loll U UA1J .Arrnuv(tlflv AUAUlI.lt,Ul 0" IJlUILAt !;('h'lll.lltt M'd br ...,1 Alh P''', h't..,," 110011111" PLEASE PRINT OR TrPE rICA ; I IH.mpnoonA...tNllU,l'1 7 IUSUJUD& ADDRESS INo, 611..11 !;l E, ~,Ul.llH G1H::.n Is IA t[ 1"1\ lIPCOO[ 11HEPIK)tj[ IINClUP( AmA COU[I 17Q):' (11,) ;!43-1\~ll', I'INsunEP5POl.IC\'onOUPOnr(CAHUU"En CltV ,'ARl !..,[ [ . INsuntrL~ DAr!.Or f\lRIU ""J 1. '11" 'l'!j9 6IX .[j "0 11 turlO'l'f:nSflAMr OnSCI4lX.ll.NAUl '.t"ntlf,',I', ~ QIII'! .;~./lI\Y c IUSI/nu,r;E rlA', "AVE on ""()I1nAI.4 '4AU[ "'1\\'[1'1-11 [,"l. d 1<; IIIEnE ...i.4oHffnl~FAlWRiNii'I l'lAN' J~l!~J:l~~?-. ,,~. ,.I,,1I1!,.I1t1Ctv1101ft1.II_UAd , " 1I1"1,~r (11; P'I /ofIJlflln,;-rll ''In<;(lI, Ii SICiPI^llJf1J: I "Ulhl)lll' J'I.l~""'''' 01 ",fOdori'll hf-,..'I".. to Ih. Ulwtfol.oq'14'd 1>h.!.IC"" 01 IUlIJll"" 101 ..rwU'''''ICI~tMllo''' (H1II,'lUl'E' On File . .0- rl'i""" , J . Ull'& r~u RESEnvrnton ICIIARGE5 all rill....' '''" COB lOCAL USE UllllS p~" "0 (I'" , :'" ,t'( __ ."f (. t\ ( :\,\'..J \" \ f.) ~) \7 :'() . Oi: ..n .VI) , :'0 ("Ill . 2('. (". . it" ,orAl (:l4Annr - ---[19 I.uoum rAIO- 3OitAl....4ti1ilj[-~ I t r t I . '.." I (I . (, (I 1': a . ')() ..--.--------- 11 "Il,!>I(IAtHi MlI'rl1lnSB'l\I'4nNAM[ ACI[lnESS llPcu[lE ~n~'l' ' '1]f. (1I.'i", "I 11' CL 11'11', l ';" " ""\1', 1:;1")(',(1 I\r.'l 1 ""! r r1(, I....\'~ ~~ .1' ,'pj"1\ ~ 'I' I 1'111' ronr. ! fom"!lffA tbOO ll~ 001 fO'UAOWCP 1\00 rom..nnp IfIoOO flU..,......'.,,,,,,,,, UM ..,~1..._fl.1I..__I.. 1141..1....111.. n'.'~E :~~~ DO NOT ",:)1 , STAPLEh / IN THIS / (J4.l, AREA Dr' AJlPnOVEOOMO OUt 0001 PRUDENT ,'-'" P.O. BO>' :'7 HOR5HAH, PA 19044 TII.ItA HEALTH INSURANCE CLAIM FORM , ll(OItA.(, ~ ~DICA'O.. ~ CHAU'US nC"A"'OA ~r~:"PUlN ~~~~VHO \/O'HIA" 4'~~~sJ~~J2~bo~7 l'UtdIt4I"" I 1'.....dl'l 1,!pwltaISSNI f\'A'''''J~SSNOIKlJ (S$NI -rr,IDJ ',~~'~,~D".:.~Io"H,,,,,"~'N""""_"'~1 , I 61' .-'>l · INSIJ~IQiNAUU"'\'''}'''J'}\~'''','''''''''.'' H!lU'i. T l~/J'\ RAE "e~ ~'l 9" II '11 HAU::'. 1 1 1'1 A HAl:. , r.'I(N" ADOAES~LNO. 61'H!j . . PATIENT AELATKlNSttlP 10INSUREt) 7 INsum.os AoonESS IHo, 61".'1 51 E, SOI,TH STfIEET ...d......Oc....o """,0 51 E. SOllTH STREET cltv I &IA_'~E . PAIIf.N' StATUS CIIY IBTAlE l MH,iHE I Pf .......d "''''''0 """'0 CARLISLE I PA 'I"COOE \'ElEPUONE IIndude AI.. ColMI lIPCOU[ IllUPltoNE l'fiCLUOf A"fACODEt . 1101'l (71:\ .!43-1\3l'le. (_..~ ,...,...._ .'",....~ :7013 (71" 243-1\365 -I I Bluett",-' 16'",,",,'-' I .1 '. 1~."!:"rne.h""""",~tMlIll 10 16PA"EN'BCOHDIIOH~DTo II UIIsunEOBPOlICYOnOUPOR'(CANUUBtA 11"lIe" 1 I N!I 1~1\r. :\0': ,'~ : .....11 ',l/l: .~f: :11; ) & I I " " f " , I' ' "'Il' "')t",' "1 'If'\ ""t.. 1.1' r,.,,.\1.,: 1"''14 -'0 on t 1I_~_.o- .' ~_ ~ I'-.J.._ __...- ... . ,. fED (RAl '''.10 NUf.AOER ItSU ftt.' 1'6 rAIIlN.' S ACCOUNI"O I ;'~1~ ";ccrrt ASS!{jtllAftfT' 21101Al (IlARGE: ~l~ AI.4OUNI PAID 30 DAL""4C( O,UE 1,- fOfOOv1 [I~>m. '"blc~1 ~~~__13D-_~~^,~_1.0q80 II~ m.l1~~__'--_ 150~90 -,--~,O:' l~,(),r'o JI SIOljAlIJnr OF rUY61ClAN nn surrl,r". :II tj......[ AJIO AnDRESS OF fAr.ItIf'l Wlfl:Af 6(FW1C16 WlHE .u f'tBSI[IANS SUPPlll:" S bilLING NAME. AOoRUtS lIP COOl: .ICIUlll.,a OEonffson l:nltJf"tIAI!l RtNll1 RII) III o.t.~ tt.anhomtOl 0"11:11 IrfHtIk\' (H I ROPRAr T I c.' CL 1 ~Il C Ilt""'r Ihl'"'I,,".m',," on 1"1 'hi'" t:I'J.. 1 . - ....~w',~Oltltlb.t..ld.,.rn."'I~.I"...,1 1(' ~23 YOR", f,UAD ":f'j,I),tt"I) /ltlf:Q,'f~1i CARLISLE:. P!I 17013 ,JI "~(I',:...r'.. I 41(180447"1 1&ltli.ro DAft. "I'll . 0 om', . OtHER ...IURED. f"Q.1C't' OR QROUP NUU8ER . l"'PLO'fUENn (CURREN' on PREVIOUSI DYES [jNO b AUfO AtClmN" PLACE 161.1.1 o VIS 0"0 l.J tOUtER ACCIOENn dYES o NIl IOd AE6lRVED fOR LOCAL USE b O'HERINSURfOSO"'lEOf 81RUt 6U ... , 00 . yY 1 .~ I' UI I c EUPlOYER 8 NAUE on SCHOOl NA"'E \nC~, p'np~l"K5 CUMMI5~n~Y 'II d INSURANCE PLAN N......E OR PRooRAU NAUE "DU lACK or ,OIly ..,0111 CO, "OHIHCI ".. '011" " PA"EN' lOR -.UlflOf\llEOPERSOti&SIGN"ruRE leulhGtll.lhtt.....oIlfl' rntCtuIOl Clt''lftnlOlm.lIonnKtUlfr tD preteU IhII dim 111IO leQlJt,l permenl of ptlMM benlltl'..., Ia my," Of to.. pwty tIholCnPl' ...~ - ';,i'~lintlJrfl On Fill! . 05-03-94 SKlNf:D DAlE IS IF PAIllNI H"'S UAOSAMl on6IUUR ILLNESS DIVE fiRS' O"'lE ..... , DO I YY , , 17. 10 NlAt8EROf" REFERRING PHYSICI"'N U.P.~tE Of' CURRE.N' ~ IU.NES9thll'rmPf(lmlOR "1'\ I 00'" VV.. It''UII''''''''''~IOR A . t ;;..., .. F'nEONANeVllMrl ''1 '7 NAMt or REFERRING PHY6CIAN OA Of HER SOURCE " AUEnvED'OOlOCAlUSE '1 OlaONQSISOA N...IURE OF illNESS OR INJURY InfLAIE ItEMS '.UOR. 'OIlEM,4E BY LINE I ---, ~ql ,2C 639.00' I L-,_ . L-,_ I I I ' ~~Q . :"' .~?21 , . A B C I F,glEtllOf SERVICElo Placo '''' PROCEDURES, SERVICES, on SUPPllES DI...GNOSIS .. .. ~P'~~~~'~~Ir::..~.ra'l ... on yv M'" 00 yY CotE q.,: P:' : "11 04: 18: 9~ ~ q9212 I , 12:'>4 , :~ 1\: I!;: '~I\ (;4: 10: q4 .3 . , , , , . "" ~ :".' :q" O~: ;'?O: 91\ :- ,),,: ~'O: '1' 01\' .!'): "4 3 , - , Q7012 I , 1234 , , , 12:'4 , , 1:?34 , Q'1,? 12 I 97012 I "'~ :'1 ~ I ... '. L' 31\ l"rt'nOYltJBy AU" COI.Itlf:11. (If' urlllCAI SERvICE alii "Ill 11, "..1 .", ,.'U, ("I""'" I_m"" PLEASE PRINr OR rrPE Pit' I I '"' tfOnpnOOllAMlNntu'l . INSUREP'.'iO...I1P" 81nHt IlK "":l~ "!~ VS9 "0 ' d b EUPlOyER 6 NAUE on 6CUOOl NAUE CARL. BARRAC~5 COMMISSARY t INSURANCE PlAN NAUE OR PROOn.w NAUE PRl'tlENT IAL d IS "lERl. ANOUIER HEAlIH BENl.rll PLAN? DYES ~NO ....IIlurnto.ndromplel'll.ml.d 13 INSUREDS on AUI"ORI1EO PERSON 66IGN"'rURE I.lltho!tl. PI,"",~ 01 rneck.al be",IIl' 10 hi undII',,*, pI1'lIOIIn Of ~,Ior NfYICM dtwP1 below Slgnalur~ On File Bloum II D"'lESPAIIENl UNABLE lOWORK INCURRENI OCCUPAllON .......OOIYV ...u.OD+VV fROM . I 10. t tl ttOSPII"'lll...tIQN OAIE6fUlAIEO laCURRENI SERVICES t.tMlOO.YV "'M,DD,VY Fnou t, 10" 20 OUISIDE LAB' . CHARGES nvu 0"0 I I '2 MEDIC...ID ntBU8UISSION CooE I OOIGINAL RtF NO '3 PRIOR "'UlltORllAllON NUUBER , o II J . RESERVED fOR LOCAL USE . CH"ROE S on Fam., E COB UNI'S Plan MG '30.00 , , 20,00 , , )0.00 , , ::0,00 , , :'a.l>O ronM 110... 1!lOO IU 901 fOJltA owe.. Iboo fonu fUl8 1600 ..,l............'..'.,.,... lhI "~I....... 'l'I"~j" fl"..I.....M r>I;UCJENT' ' ,-...., P.O. 80, ~7 HORSHA~, PA 19044 ....,. HEALTH INSURANCE CLAIM FORM O""R "lIj,u~EIl.SlII.~U)!.IR1"'O')7 . "PI I1bNU.:.n:H)~-...- . IHSUR~Q6 NAIoIl.Jl.tl.N"ntJIIW.me. M\1dIt hhllj HAUS. TINA "Al.. HAU5. " . 'AlIE"1 AU.Atl()t~StuP '0 INSURED ... [j< .......0 C.....O """,0 . PAIIENt BtATUS .......[j ........ 0 ....., 0 .. NT.N" ADORESS tNo, 6uM'1 51 E. SOUTH STREET T 'v I CARLISLE I. CODE . 17013 stAtE P lEU. PHONE tlndudt AI,. Codel (711 243-4385 Iht' .me. ." HAll!;, I T ItU\ RAE . OTHER ...SUAED 8 Pa.K:Y OR GROUP NUYIER 'I ,. . EMPLOYUUU1lCURRENT OR PREVIOUS) [jOO PLACE ISlIl,) ONO t._.1 " OtHER WSUREO S DAlE Of 8tRTH SEll; *IOO.VV " " c EMPLovER 6 NAME OR SCttcxx. NAME (I'\p\.. gARF:AtI\~, C',)t"MiS~'(\R,( ~ tHSURANCE PLAN NAME OR 'Roon.... HAUl OVES b AUTO ACCIOlNT' DYES c: OUtEn Ar:CIOENt? Om ONO IOd RESERVED ron LOCAl. USE CICO 0 C 0 HI 0 II PATIENt B OR AUtHORIZED PERSOU 8 SlGflA1UR( I euthofIlI h ,..... ol'"y rMlkal Of OI"tllnlll""'lIon Nee"'" 10 proceu... ~irn '"10 '...." Plrmenl 04 ~rr: t.nthtt..... to ,""III or k1'" PI"r IiIt'lI ta::t9l' ..llgI\ITItfIt _ ~,lo;llJal\J\'1l On F e 05-03-14 IQNtO n _ " OAt( OF CURR(N' ~~ ~!:l Yf'4 OAtE " tF rA'IEHT H"'SHAD SAME OR 'NllAR illNESS DIVE 'IAST DAtE ...... I DO , YV . . 4 "NISII"" ._oml OR INJURY IAccidtritl OR A PREGNANCYllUPI 17. HAW OF REFERRING PHYSICIAN OR otHER BOUnCE 17..10 HUMBEROF' REFE.RRINGPHY6ICIAN tI RESERvED roo lOCIll USE '1 01"'00061800 N lURE. OF ILLNESS OR INJunv tRElATE ilEUS 1.2.:' on.'0IfEU24E BY LINE) ---, rr'1.:W ' 831.08 t ,1--,_ .1--,_ "2Q .) .~~.21 I L::..., . '. . A B C 0 ( ,.J/tTEt&IOF IERV1CETo Pilei 'roo ROC DUnES. SERVICES. on U PLIES OIAOOOSIS .. .. tE,pI.in UrNluaIClltum81.rce'l COO< ... y ... 00 vv P '" 0": :~ 1 : ,,'" ~,,: .27: 94 3 99212 1234 (~\~: ::~7: r;4 I)~ :7: 94 :I 97012 12')4 I ')~i: '::2:~4 05 (\'1' 9~ '3 qq:?12 1;>34 . ...1 O~.: (~2 ~ ':''' ,\t':' (12: -<4 J '1701 :! 1.':'4 ',' . . ,. UOERAl fAll 0 NUUBER ISH tlU " ,on,:""., .,~ 31 SIONAfURE OF Pln'SICIA" o1l6lJ"f'lIER INClUOltm [)(ORElS on CREDENTIALS 11~'1.lrth'ltht'l.t.m""lIonl"'I'Y"'" _.'!";, 10 "". belI.1'd .'. "'-d" plf1 tti'~1 t l h_1tJI(f:)(J DtJ)pP;6.,~ ., 11 ACtlPT ASSI(}NMf.t,P '01 toY! dllftll. I" bI(." IIAI.1'l2900 - vII J:1.NIl " NAf,le ...,m AOOF\E~S Of FACIUty WHERE SERVICE S WERE "(NOIREO I" OIhtlltlanhoml 01 o"ul .APPROVED 8v AU. COUNCil ON t,UOICAl 6f:nv.cE. 1.1111 .." &I,....~ Alh P".. tI......M I taD m "" PLEASE PRINT OR TYPE PICA IfOR PROORAM IN IlIM II , tNSURED 8 ADDRESS INo, 61'"11 Sl E. SOUTH STREET cnv CARLISLE STATE PA liP CODE lElEPUONE {INCLUOE AREA COOEI . 17013 ( 71i) 243-1\18E. II INSURED S POltCy GROUP OR FleA NUMBER . INSURER.'iOAtl.PF SlAnt '"01 "!'* Y!,9 , , ... FCl "0 b EIr.lP\OYER S NAUE OR 6CUOCX. NA E C!lRL. BARRACKS COMMISSAR\ c flSUnANCE PLAN NAME OR PROGRAM NAUE PRUDENTI AL d IS IIlERE ANOtHER HEALTH BENEfiT PLAN? Ot'ES [jNO ",.. 1.lulnlo.nd~'Il,,"'.d 13 INSUREDS OR AUTHORIIED PERSON 8 SIGNATURE ItUlI\OfLl' plrlMl1t 01 meckll bI,..I"1 10 !hi undtfliQned pn..'ldIn or .uppI....1ot IItva' drllCI'~betow :>lgr;alu\,(. On FilE' 6IQtlEO 'I DAtU PATIENI UNABLE 10 WORK IN CURRENT OCCUPATION UU,DDI'rY MMlOOIYV FROM I I to I I 'I ltOSPITALtlAtlONDAlfSRfLAltD 10CURREN16ERVICE& MM,DD1VY "''-1, DO 'tV FROM I I 10 I '0 outsiDE LABl . CHARGES 13 pnlQAAU1HQRIZAllONNUMBER F o It OR ,."'... l COB UNIT & PilI" MO . RUfRVEOfOR lOCAL UIl . CHARGE & 30.00 , . 2d.OO 3d.00 , . ?O.OO II tol Al CHARGE 100.00 n AMOUNT PAlO )0 BAlA"CE DUE I O:.OC I IOO:.O~) U PII'f6lCIAt4 B. 6UPPl IE R & 81lllNG NAME, ADURESS. liP COOl tf~~H CHIROPf<f.1.11C CLINIC J2? YOR~, pnl\[1 CIIRLISLE, PA 17013 .11 ()801\1\7~. I'lll' n"r. Iom.A uo A 1 &00 I U 101 fOnUo'Ncr 'flOO ~OOlrAnRB "00 '.ll"-........I.",III u......,........"U......-..,..'I.I..I......~ F'f~UDENT TA- P.U, BO. :>7 HOR5HA!1. PA 1901\ 1\ . "....., .._"..._,....-, I . .~...,M~lIrtI,P~ll SEX IU\U", TINA R!lF. " 't1~ T'~ '1:19 "n r r-1 . PA'tENfIADDRlSlINo.81INtI I,.ATIENTRUAtION5UIPtOINSURED ':>1 E. ~OUIH ..TREET "'d-o"""'o """'0 t CitY laTAtE . PA'IlN' l'AIUS I ((If''.ISLE Po' .......0: -0 """'0 ,.. COO( TfUPUONE I"'" Ate. CodII . 1701 J (711) 243-4385 '-"'n ~~II ~~""n IN.WOl""_,..._,_......, .. ""'''NJO""".mION"n HfI~lc;. TIN/'> IME . OtHER INSUREO.. Pa.~y OR GROUP NUMI€R b otHER INSURED 5 0"1 Of IIA1H SEX ....,00, Y'/ I - I I UI I t EUPlOylR 8 NAME OR SCHOOL NAME ('!In: R(\RR'V I(S COt-lMISS,\RY . EUPLOYUUU' ICURRENT OR PREYKJUS) om C'foo b AUTO"teIDENU PlACE IStall' Om 000 L, .I c OUtER ACCIDEN1'P Om 0"" lOd RESERVED FOR LOCAL USE rn . INSURANCE PLAN tw.IE OR PROGRAM HAUl ....D...C..... .....!~~!,"". c . 11 "AlIENt 800AU1HORIl(DPEnSQNS SIGNAtURE IlUIhorlfalhl '......"'anyrneckllotothtt "'IOlm.llonNC"WY to prot:tM" dam I Mo 11qJt1' PI)'fftM of fO'tI'M""II benellt'...... to,."... Of ta'" pertr lIIho ICaPlt ....grwntnt ~ Slgnalure On File 05-lb-91\ BIONIO _ ____ __ ___ ___ __+_ _"____. D"TE._ _ _ __ "~Tl or9c~uRm..n: ~ illNESS '~r"oml OR " W f'AlIENT HAS ttAD 6AME OR SIUILAR ILlNELS I' "9 T.... INJURV, <lOR A a''''IRSlO''( .... , 00 , VY I ... " PREGNANC't'llUI'I ' , "NAME Of REFEARING PH't'IICIAH OR OTHlR SOURCE 11. I D NUU8ER OF REfERRING f'HY6ICIAN I' RESERVED rOR lOCAl U&( 'I. DIAGNOSIS OR NAWRE OF IllNE6SORlNJURY.IRELATE itEMS '.1.:1 00 t 10 itEM 24E BYllNEI t I !: .'.' "?<) , 839.08 1. ._ :I Lo--._ T I I i~"'~..2 . ~9. 21 I . . B C 0 I r,N:tltSIOf' 5lAvtCf,o ""'" 'roo P"",,!OURu. ..RVICU, OR SU'",lES DIAGNOSIS 01 01 r.Pt~~tuaI~~'~.1'IteI1 .... M vv .... 00 VY coo. O~: tl~\ : "':l.r1 ",..' (I,.,: 91\ ~ 99212 1 , 1234 , . .' , I)~.: (.)f-. : ~;r 41 tl~~ "17012 I , , c.",)! Qc1 3 , 12:34 I , f,) ~'.: f~7 : ~~" ~I~: 09: 0;11\ '3 1 <19211. I , 12'34 , , '1~; ()'~:~" ~I~ 09: "'4 .? ,"17012 I , 1231\ . i u~,: '..'~! I'} 1 , , 95051 11 ! 12:1'1) I O~, 09' 94 :1 S , f:~:~YJ! '11\ 'J!:~ "f(O(RAl fAlIO NUMBER ~ 10<101\.1 "", 1:l31\ t I ?'f A:cCtr" ?A5~SI;QN"'E,.t' rOf govt d. ,an be61 'fES ,NO 3l HA"'f AND ADORE6SOJ fACllltV WII[RE 6ERVICES WiRE RENOlRtDIHOlhel th."horntOt otIul OQ:94 ).'~, ')~.l~C;>1 12: 56N EIN " PAtiENtS ACCOUNt NO nn HAU'~2'~ao 31 SIONAtURE Of PIIV6K:IAN on &UrrllER INC1LJOtNO DfGnEfB on CREDENtiAL S tt r.rtd~ hll thf "a""*'" on Iht ....'.. ~Io"'''''''''' ~ ."......j},t)(' / (I:VM../ ()'. ,t(llJ~'~1 "~"'h D'\" ,ArPROVED BV AMA COUNCIt ON UEVICAl &ERVICE atll .... ." .....1 .,h P,n. t..t...." llOOUl'lrt PLEASE PRINT OR TYPE PIC' rrr (FOR PROORAM IN Itl" 'I 7.INSUREOB AOORE68tNo, St'.." 51 E. SOUTH STR~~T CitY IBTAlE CARLISLE 1 PA ZIP COOl nuPHOHt IINCLUDE AR(A COOl I . 17013 ( 711) 21\3-1\:385 11. INSURED S POlK:Y QROUP OR fiCA HUMBER . INSUnER..~ DA'L..Of IlillH "tit "I9 '59 . I yo tt 1t.lPl.OYER8NAME OR6CttOOl NAME CARL. 8ARRAC~S COMMISSARY .(1 r[!j c INSURANCE PLAN NAME OR pnQGfWI NWI PF:UDENTrAL d IS tHERE ANOtHER HEAlTH IENEFI' PlANl DYES [Joo 'rn.IIIU,"Io.nd~I.llem..-d '3 ,"SURIDSOR AUtHORllEDPERSOHIIIGNATUREI.uthOnll pa~ment 01 meekal ~Iol'lo the u'*trgntd ph.,lOIn or ~ toI --- Signature On File SIGNED II DATU P"IEN' UNAlll( 10WOllllNCURR'N'otCUP"1ON ....IOOIV'I ....001'1'1 FROU,I TO" I' HOSPI'ALllATKJN DATES RELAnD 'aCURRENT 6ERVtCES "',OD,VV .....tDDtY't FAOU liTO I , 20 OU'6IDE lAin 'CHARGES Om noo 1 I .. "'OIC'IO RUUIlIoI'SSION CODE I ORIGiNAl RtF. NO 13 PRIOA AUtHORllAtKJN NUU8En f . RUERVED fOA lOCAL USE a H , CHAROn on f.mIl, COB UNitS Plan [YO 30.00 I zd.oO 1 , . Sd.oO 1 , , 2d.oo \ , . 1!:: .00 , , 1'::.00 11 11 T01AlCUAROE .1" AMOUNtrAID 30 BALANCE DUE I 150:.0011 0:,0'. I 150:,00 u Pttv5K:IAN S. SUPPLIER 6 BillING NAUE. AOORE5S, liP CODE tf~f.f CHIROPRACTIC CLINIC ~.'1 YORK ROAlI CARLISLE, p~ 1701~ 4"Hl041\7o; I rl~4' .., ' .. nnr. ron... ItCrA I~ 11nOl fOOU owcr,MlO ran... nRDI&QO ,IDIU-llM*fIlIt,,,u. u. ".'."",,,'"I''~I''II.I''I'''.''' PRUDl:NU'" P.O. BO\~7 HORSHAM, P^ 1901\4 1 I \''''A HEALTH INSURANCE CLAIM FORM PICA IT! t. UlDICAAl MlDtCAIO CHAMPUI CKAUPVA' ~~OUP fEeA )~O'ItEA " lN5UnEDSID NUMBER IH>RPROORAUINI1EWII 1,-","n_""n'_'SSH, n IV""" n 'lW,'~~NnB):~NIlI'rllO' 4toN0:38S2-120;?l lull fUme. h,l. 11 ~'p~1E SEIl.......ll 4 tHSUnED 8 NAUl Il.,l NatM, h,t N,,,,,, YddlIINh"1 ,t/lUS. lll~l~ RI'IE "(l~ If"! '~9 "n , I'l HAUS. lINA RAt: I PAlaENT'I ADORESS lNo. Sl'"') I PAllENT AELATIQNSIlIP TO IN5UREO 7. INSURED S ADORISS lNo. 61'"11 ':01 L !;OUTH STREEr Bolld'-O"""'O """00 Sl E. SOUTH STRcn T CITY I'SlAtE . PA'IlNT SlAtuS cnv I'StA1E ! ('!Ii'll r~1 r:' P/.4: 0 CAm.ISLE PA .- .... ,,1~ .....u' ...,," OM' 0 ItP COOE I1EUPUONf tlndulM AI.. Co6II liP COOl TELIPHONIIINCLUDE ARU COOl I 1101;1 I (71~ 243-1\305 (.......0 ~~::'n ~~n . 17013 ( 71:) 24:)-4JIIl: . ~ INl.MEtl"INeme,fr'INelN,MOItkViiiij 10llPATlI 11 IHSURED8POlICYGnOUPORFEC.............R HAU~,. 11 NA RflE .01HlRINSUREDSPOUCYOAOROUPNUMlfR . EMPlOYMEN" ICURRENT on rREYKJUS, DYES 000 b AUto ACCIOENn PlACE ISUII' Om 000 1.._..1 t omER ACCIOENt1 ~YES OH" ICd RESERVED FOR LOCAL USE bOlll(RINSUREDSOAtEOFBIRTH SEX ...,00,.. I- . 1 MI I c EMPLOVER IS NAME on SCHOOl. NAUE CflJ~I., r:1f1r.f'!,,'1\ S r;Ot1'-1I S!',,'RY 'n d ~SUR/.NCE PlAN NAME OR pnOORAM NAME ~,,-~..~~~~r.Q.IlT"OliIC_LIIlNO Ir"",,,. II 'AlIENT 8 on AUTHORlllD 'ERION S SIGNATURE IJUthOI.rt ...,...." 'I'l)' ",,*a1 ClI othM lnlOfmahrln ntCffHIJ tlIp'ote.... ~ 111Io ''''''11 ~ ot ptttwntntbtntfU.iltleI to rnyttWOI to lhlpatty -.N 1CdPl1"~ ...... <19I1alurE! UIl FilEl 05-11:>-91\ IIGNIO. ._~.' _____ ____.._...!.~_ '.Jl~tE orC.~R~Nl. ..4 IUNlE&at~~':'f:"loR ~ 1: ~q y.~ t1 ., ~f~~lNCYlu"~1 A 17, NAME or RlFERRlNO PHVSK:IAN OR OTHER &OURCE _ ___ DAtE. _.__ ~ .__ ,t IF PA'IENT UAS HAD SAME OR SII,IUR illNESS GIVE '''S' DATE WM . 00 1 yy , , 17.10 NWBEROF'UFERRINQPHY61CIAN " RESERVED'oo lOCAl USE II. OIAQtfOSISOR NATunE or llLNESSOA INJURY IRELAtE ilEUS 1.1.:JOR.'0IlEUIU BVlINl! t ,E",\.:::0 ,839.00 ,. ._ 3,---._ t ~ ....~. , .~,?21 I I.~." f' A B C 0 F.9:1lISIOf SERVtCE,o Pia" ''''' 'ROCEOURES. SERYICES, OR SUPPLtf.S .. .. :Pf~E.:.':-;' ~ .s:,~~.ra'l ... ..M YY ..... 00 .,., P If! R (I'.,: Of;l')I\ "r' 09191\ .~ S 95851 I ~ , , ~ .' , ()ljl (y~: t~1 O~ 09: "~i\ 3 S 958~,1 I 4 , , f , f'\r,: {i'1IQ/1 O~~ 091 '14 :> S 95851.'1 5 , , s ,,)-:: (\"1"" 1 ()~ 09194 '3 S '~%~.1 1 b , - : of, , . C':: , (,r' 09:9~ J S 95851 I 7 , 0"IQ4 ..' , s . "SUREP'!! DATL.Of BlAlIt SEX ~~ "f~ Y!,9 "0 ' c1 . ("PlOnR S NAU( OR SCHOOl NAU( CARL. BARRACKS COMMISS!lRY c INSURANCE PLAN NAME OR PROOR...... HAUl PRUDENTIAL d IS WERl ANOTHER HEAL lH BENE.FIT PlAN' n YES [J NO . t'f.. 1.IUln 10 and complIl.II.."..-d 13 INSURE08 OA AUTHORIlED PERSONS 81GNA1URE 11\.lttIoIll. P'~"""' ot rnedICIl ~I"I 10 thI urdIfsirtd phytlCian ClI auppIIIllOI -"""~- 51gnuture On File BIONiO 111 D"TUPATIENl UNABLE lOWORk !NCURRENT OCtUPATKlN ....,OO,'tY .....OO,YV rAOM I I 10 I t " HOSPITAlIlATIONO"TFS RUAtED toCURRlN' SEfWICES UM.OD.YV ......,OD.Yy FROM .' 10 I . ro OU'SIDE l.AB' 1 I CHARGES nns 000 I 12 UtDlCAID RUlJ8lr,llSSKlN COOl I ORIGINAL REF. NO 23 PRlORAumORllAllONNUUBER E , 0 N I J . DIAGNOSIS 10~Slt(.u RESERYEDrOR cOO( . CHARGn .m.. EUO COB l.OCAl. U5E UNit S Pian 12JI\ 15.00 , , 12'31\ 15.00 I , . 12.31\ 1'" ,00 . , 12:>.1\ l!>,OO 1 , , ln4 ~ EL 00 I ..$ 958':01 i 8 : ,. PAlIENfSACCOl.IN' NO I' I 1 I 0':,0" ,r.i1 05 091 'Jd ) ,. rEOlRAL lAlllO NUMBER 5SN lItf 1\ 1,:In"1\,1n, r:ln :Jt iIONATUm: or F'UVSlCIA"On t.UPP1IEn 1NC1UOINO OEOA((S on Cn((lft-llIAL8 II c.ml, thllllw ""~"" on rhtI Ifw.'M IIlPY 10"" blI.11d "' tnadI. pal1ll*td I I '--r;Of1lrV /1, J),')' ,f:l/A@, 1...Jo'(" (/. Co- OA'" 12':14 I ~'f "iCCEPf ASSIGN"'''H' tOfgo\l1 dltmJ,...bltJo, HAI./Q;?Q80 YIS R'IlO 32 "AME AND ADORESS or rACIlIIV WJIERE !iERVICESWERE RENOEREO I" o1htillh.n home 01 o"ul IArPAQVrO BV AUA COUNCIL ON MEPICAL SERVICE 1111 MIllI ........ AI1. P"n e....."" '_'"'1" PLEASE PRINT OR TVPE . ~' , , 1 ~L 00 2'1 IOfAL CUAnOE In AMOUNt PAID )Q BALANCE DUE . 90'.0011 O:.OC I 90:.00 ]) rtlY51CIAUS SUPPliERS DillING "AUE. ADDRESS, llPeCOE \fIJrH CHIROPflACTIC CUNIC 321 YOHI\ ROAD CARLISLE, P!I 17013 1'''" 11 0801\ 1\ 7 r,; lonl" ronu ..etA IMlO 111' 801 'ORuowep 1!tOO ,onURRD 1&00 fllIat - .....~""....u Utt......,......'UUI"""""""'''' f1U..I....t11 --, _rrnOV1DOUI 01)1 0001 rRI J(lI!NT' .-" P . (l. 80>. ,;,7 HORSHAM. PA 190411 1 I [PICA HEALTH INSURANCE CLAIM FOR rICA " 1 'W:OlCAnE MEDICAID CHAurus Ctw.lPVA aROUP !Jl.:A 0l1ll11 'I INSUI1EU 51 D NUMBER IFOR PRoonA'" IN liE" 11 In n 0 Itl~Il':aANr-t,"uNOD~ 46N038::'Z-120:27 tlfMfrdlr.""nf~'J (~.SSH' (VAr." fOI'l fSSNJ 1'0, . ""'It,".' D~t_I~ltl".,",. '.'1 n&me. MIOlM 1nltl.11 [' r~'~r ~r1~'Vf.9" .. n 50, r>f '4 INSUR[OS NAU[ Il..1 H.rnt, Fill Namt, t.t.ddl. 1011"'1 '''~l.I(.. THIll I\,\E. HAUS, TINA RA[ I rA'..N1 & ADORESS (No, 81'"11 . PA'IIN' nHA.IONSIUP 10INSURW 7, INSURED S ADORESS lNo, SI'..II S1 .. . fOI:rH STREO hlf d -0 c.....O -0 51 E. SOUTH STRE!:::T City 18.AIE . PATIEN' 5T4tUS CITV I STATE . "Ill ) SLE Pf ......0 ...&1,..0 OoIw'D CARL ISLE PA llPCOOE I THfPHOHE lnus. Aru Codfl llPCOOE I.UEPHONE IINCLUDE AREA COOEI . 170l.1 (71,~ 243-4385 EmpIo'ldn FultlmeO P.rtTIfI'IICl . 17013 ( 711 243-1\385 filudenl Sludffl ,r"u", . E ILIII".me.'."","",MICllNInIll&tl 10 IS rAlIEN... CONOI 1I0 11 INSUREU S POlICy GROUP OR FECA NUMDER I iN,.. RAE . OTHER INSURED & POlICy OR GROUP NUUBER . EMM.O't'UEH'? tCURR[NT OR PREVIOUSI 'INSURE~DA1~BlRm ... Dns Cfoo ~ ':t YS9 "0 'd , , b OTHER INSVRED& DATE OF IIRtH SEX b _UfO ACCIOENn PlACE 151."1 b EUf'lOYEn 6 NoWE on SCttOOl HA.lAE .... , 00 , YY 1 .n 'n Om ONO CflRL. BARHACKS COMt1IS<.:.ARY " " I _ I c nlrLOYEn 6 NAME OR 6CUOOl NAME c OTHEn ACCIOENn c INSURANCE PLAN NAUE OR PRoon.w NAUf r.,'RL, ElI'1R1~~K I\~; (;Or1HI SSAr~Y Cl'1S 000 PRUDENTIAL d, INSURANCE PlAN NAME OR PROGRA'" NoWE IOd RESERVED FOR LOCAL USE d IS THERE ANOIIIER HEALItt BENEFIT PLAN? DYES [1 NO . ,.., 1.lurn 10 .nd tomp.lelt.m II. d ,~~~ .!'~c. _Of' '!'!"'_.~!.O"~ C NIHQ ,....O.W, 13 INSURED S on A.UTHORlZEO PERSON S SIGNA TUnE I."'horll' tJ rATIENf'S OR AU"lORllED PERSONS SIGNATURE l.uIhoIll.1lw ,..... ol.", INCkIl DI olhe' IIlflllmallOnllK.'ury PI,mm or medeal bf;,.l". 10 !he undef"U'lfd ph'lltlIn DltuppIltllot to pottn" dim 111IO 1.....1 PI""'" 01 gO'teuWNnI t.neltll ....10 fII;MIl DI to 1hI PI'" ~ kUpl' '''rgrrnenl Mf'tQ' ctnaM bHl* - Signaturo On File 05-16-'~4 5.gnatur<-' On File SIGNED, -- .----- .-. --.- DAtE 51(1'1[0 t'~IEorCURR\NT: ~ IUNE&S~::'~~lon .' tllf rATIENt "AS IIAO&AlAE on 6lt,1lLARlLNESS 1& OAlESJ;:lIE'YoUNABLE TOWOf1K INeURnENI ~CUPAtlON I' OIlg v 4 ..JUAYI , A QlVE fiRST DAlE .... , CO.vv ,IYY "M.IYV , '-. PR[GNA.NCYILUrl , , '1101oI , , TO , , "NAME Of' R(FERRINO PHYSICiAN OR OHffA 6QlJRCE ".10 HUMBER OF RUERRINQPHVSICIAti II HOSPlr_lIlAtIONDAI[SRELATED IOCURRENT S(RVtCES I,tM I DO , VY MU I DO , VY '1101oI , : 10 , , I' RUERVED fOR lOCAl USE iO OUISIDE lAB' . CHARGES n,ES noo 1 1 II DtAGNOSISOR NA.TURE OF IllNESSOf1 INJURY IRElAtE ITEMS 1,1,30R4 TOltEUZU BY LINEI t 22 "'FoICAID RESUBUI5SlON rr11 ':'(1 83.. .08 cOO( I ORlCilNAL REF - NO .L-,_ ,L.:....:-,_ 13 PRIOR AUTUOJUlA T ION NUUB[R -'.'q .:1 . I 8:)':1 ,21 . L'" . A B C 0 , , 0 II I ! . i r,J]tTEISI or lSfRV~ETD ""'" ',PO PROCfDURU. SERVICES OR SUPPLIES DIAOllOSIS ~ ~:~; RESERVED fOR ol ol ::Pllf~~~IU&~I~'~.","1 COO, . C,jA"O(5 00 'UO coo LOCAl USE ! ... DO YY UU OD yY lMe IF! R UNitS PIon ,,1::-: l'''' : '7~ Or: (\:,1 19 , 12,l4 .: i , , ,,~ 1 S q5f)~1 , 1~.00 I I , 11(.; , I , \''"... : '-11\ ~') r:l f:"': 1!:: .00 . ',lr,: , , 91\ 3 S 9'58">1 1231\ I I , Ill: , I .. r I t' '. ~ : .,,, ~)r.: a'~: ?~ J ~ ~5e~I~, 1 ~~l" 1 ~, ,00 I . ,-,' " , I q":~ 9~18~1 112: , I ( l:~" '"l'-: '1":1: ~" ) S lnl\ 15.00 I . , ": ~'j . I , r~!:851 11.1: , 0 ~, Cj: , 'Jr.~ Q'~: q4 1~: .00 . O":'H 3 5 1234 I , (,t;: ("'J: Q1\ ,,' , 05 09; ':14 J 5 ':I!:\8~1 [1!:: 1231\ 15.00 1 . n FEDERAL TAllO NUUBER 65N EIN " pAIIENI 5 ACCOU'" NO I" rccrr, ~5SIO'IUf.NP 11 TOtAL CHAnOE 1'1 MAouNI PAlO 30 BALAPiCE DUE ,'llr'J\)I\I\'~ nr-l H,\U"'2':180 I r{j 011 go'" Cl.!"flt, IN bole', 90:,00 0, .OC 90:.00 't'(5~_ 1 , 1 31 stQNAlunEOfPtlY5M:IA"OR6UPN.I[n 31 NAME ANOAOORE5SOF '~C'llh'WIlEn[ SrRVI{ESWtnE )] rllvSICIA" 5, SUPPLIER 5 OIlllNO NAMr, ADDRESS. lIP C.ODE INCLUDING DEOnEES on CmOENTIAI 5 RENOEnEDlllott~ 1h."homeOt olin, Y~H CHIROPRACTIC CLlNrC "'~I", ...,... ""_onl\ on... ....... i ~,........"".,...-..,........~ ~ 32:1 YORK ROAD .. ' , /(.J 1/ t1d (j. IJ1}i<J ; C,\RLISLE. PA 17013 , . I 1\1080,11\7~, 10"" ''''N,n oA" rlfl' M lA.rrnovrOIlY A.UACOU"CIL ONUEOICAl 6[RVIC( 1"1 ..W .... ......1 AlII P,.U e......." IImU"I" PLEASE PRINT OR TYPE ronMltCf A. lSOO 112 to) IOnMowcr 1!tOO '0""'R"8 I~ "1''''~''''I''''ttl UN"' ,....... flUU1lI--1" uu......,~ --4_ ._ APPnoVEDOMB oUt 0001 ./ ......, 00 HOT STAPLE IN THIS AREA PRUDENT 1,- P.O. BO>- ";,7 HORSHAM, PA 19041\ T I -II 1.ItA HEALTH S R CE PICA 111'1 ''''DeAnE WOtCAID CUAWPUS CIw.tPVA GROUP HCA I r1~HtEn ,. INSURED 5 10 HUMSEIt If OR PROORAM tN IllWl1 U A ,tt AN ILl( UNO . 46NO:i8S2-1~027 1-"_",,,,-,,-.dlln,_.SSN) nIVAFIO', n Ils~..:;t) 'n',S~) 1'0) It "'.~W"'.... , 1~~~J:'l~~t I ,r>i 4 tNSURED 5 NAMVlIilt Hamt. Fut NarM. UddIe 1nII,,11 HAllS. 1111f1 1~!lE ~ ~ '" ,,"I "n S · , , HAUS. IN!I RAr. I PAt.Nn ADORUI lNo. 61'"'1 . PAtIENt nELAtlOHStttP 1DINSURED 7 INSURED Ii ADDnESS lHo. "'..tl rl E. SOUTH STREET hlfd-...o c.....o 0'''''0 SI E. SOUTH STREET Clly -rtAtI . PAIIINt stAtui CITY I SlATE ':!lRl I~,L.E Pi -D ....,,'"D 0"'''0 CARLISLE PA llPCQOf: -I nUPltoHE lWfude AI.. Codel llPCOOE I TlllPHONlllNCLUDl ARU CODII . 1701'3 (711 24')-438S Empoyld n 'uI TImt n P." tllTlfn , 17013 (71i) 243-1\385 SluM", SluMnl U E Il.iiNim..T.i'iHi""me~inttllll ,. 1S1'AfirnrrCOODlflo.jl\ITAfiDlO II. eNSUREO 6 POLICY GROUP OR fECA HUUBER HAI,J<;, . TINA RAE . OtHER INSURiDS POlICY 00 OROUP HUMBER . EMPLOY"'ENt' ICURnENt OR PREVIOUSl . INSUREB8 DAtt,Of SIATIl 61X om d"" 1; 'l Y~9 "0 'Cl , , bOlttfRllfSURf.DSOAtEOFltlRtIt 6EX b AU,OACCIO(Ntf PLACEISlalel b UAf>L01ER 8 NAUE 00 &CltOCX. N......E ... , 00 0 YV I .n 'n OYIS 0.10 CARL. BARHACKt, COMMI5S!lR'Y " " L-.- J c UIPlO'11"S HAME 00 IiCUOOl NAME c otllER ACCtpENtf c INSURANCE PUN NAUE OR PROORAM NAUE , ,'r.~. . B"RRt>L1(S Ll)!1t1! '" ~.ARY Cfm 0"" PRUDENTIAL d "SURANCl PLAN N......E OR PROORA'" H......E IOd RnERVED FOR LOCAL USE d IS tHERE ANOlIlER HEAl tH BENEfiT PlAN? DYES ONO "..... 'eturn to and c~. II,", II . d CK offoiilfU'O"1 COllP\IIlHO 'NO' '0"" 13 INSURED & OR AUtHORIZED PERSON S SIGNATURE '1IIInon,. " PAtlEN'lOOAUTHOAIlEDPfRSONS SIQtlAtURE llUltlo""lhIltll...oIl1'l,""'II01 D!neIInfOlm.hOnN<<IUI, P',mtnt 01 meGal btlwl"llo '" undII'9*f ph,..,." 01 aupp.11oI to pot"' hi dIim I at1G Itqutll parment 01 fD\'IInmtN bInIhll """" to ""I" 01 to Ih1 piA)'..no ICtIPII..1lgnmtnt NrYal dHcr~ below 110100 Sl?l1alUl'El On File 05-16-94 ~ gnature On File StONED _. ..--.-.. ... .--- -- .- --- - -- -- DAtE . SIGNEO _ -- ".&j,(orcU"Q\N' ~ "NlSS~''''~IOR II IF PAtiENt HAS ttAU SA"E ORS....llAR illNESS " OA"'I.l'.:"''1loUNABlI'OWO,,"'N CUR"'N' llliCUPA~1ON l' oql'l 4 INJURY I -'I A G1Vf 'IRST DATE U"IOOIVY 'In "MIDIY , ... PR(GNANCYILUP) , , 'ROW I I 10 I I '7 NAUE Of REffRRING PHY6K:lAN OR OTttER OOURCE 1,.10. NUMBER OF REf ERRING PHYSICIAN II OOSPllAlllA'1ON D"lES RELATED TOCURRENI SERVICES UY I DO oYV ..... I 00 , YY ,"OU , ~ to , , " RESERVID FDA LOCAl USE 20 OUTSIDE lAB" I CHAROE5 DYIS 0"" I I II. OIAGNQSIS OANAtuRE Of ILlNE5SORtNJUny IRELA'E II(...S I.UOR4 tOllEM24E By LINE I t 21 MEDICAID RESUBMtSSION F.81.~'C 839,08 CODE I ORIGINAl RE'. NO .1-,_ . . 1-,_ 23 PRK>nAUTHQRILAtIOONUMBER 7"'-:' .., .~q.21 I L.:....:..:.. 4 .. A B C 0 ( , 0 H I J K FI~tEISIOf IERVICE,o ...... ',PO Il"ftOCrOURIS. SfRVICES, OR SUPPLIES DIAGNOSIS RESEAVED 'OR ..~ YY MY 00 .. .. D1~E~~~lu&I~,~I~.rnl) COO, . CHAROES OIl hm.t I"G COIl lOCAl USE ... YV CP 11 In UNITS .~" iJL71 OQ:'.l4 O~: 09: 911 ') S QS8S1 1 1(,,: 1234 1~ .00 , , f':t\: t'?: q4 </5851 I 17: 0 O~ 091 q4 3 S 1231\ IS .00 . , , , 95051 I 20: , . ~,~,: {}~: ~.1 O~ 09:41.1 3 S 1234 1~, .00 , ~~-~: 95851 I 21: 0 01',,: 9c1 01=' ()9: Q" '3 S 1231\ 15.00 1 . ' .' , O~,~ U":q,, '~~'851 I 23: , 1 (ic; 09: ~4 '3 ~, 12'34 1~ .00 '). n%8~1 I .24: , "r:: nn; ')1 , cr~ C'I'~: ':){I '5 1234 15,00 1 . 2~ fEDEnAL tAM 10 NUMBlR S5.., (IN 16 PAtiENt SAtCOUNI NO I rl,CCEPIASSIOljUrlIP Z' TOTAL CItAnOE ) 119 AUOUNT PAID )0 BALANCE OUE .., 1 or'I'" I~ '~\ nn H'IU'12'1fJO 01 ool1 I!~t ,.. bI~1 I 90'.00 I O:.O( I '10:.00 'YES ."0 , 31 SIGN"IUnE Of" PIl~SIC1"N on SlJl'PLIER 31 NAUE ANOAOORESSOf rActt.IIY wllEnE SERVICES WEllE U PUYSICIANS, SUPPlllRS BILLING NAME.ADont6S.1IPCOOE INCLU~1f1O OEOREI S on cnlOlflllALS nU4U[nEO III Ol~ !tI.n horn, 01 olluj y~", CHIROPRACTIC CLINIC 11~1,I,thllltwIlI.I~IOI1the".e'l. arP. 10 Ihtt boll and II. m<<te 1 PI'llheoM)! { 32'3 YO~'K ROAD ~-y;( 1;7/M (1.1)vlrr: C~" CAP-LISLE,oA 1701J I:JfU.Wh '"A'E rIP'. 410fi04475 10"., IN U AN CLAIM FORM .ArpnovEO 8Y 1.1.11. COU~4C'" ou U[OICAL SERVICE 1111 M.d ".....1 .,h r".. e..hll"" IImU"I" PLEASE PRINT OR TYPE fonUIfCrAt&oQ llltol fonl.lOWCP I!H>O ,onURRB 1!nO "'II" -...........,,"'.u Ow _~ I~""'".I'I"-",, 'UI..'III....II ..:,,'E DO NOT STAPLE IN THIS AREA APPAO\'lDOMBOIJI 0001 PRllOEN P f""'\ P,O, 80;" 'I HOnSHA~, PA 19041\ I I l'ItA HEALTH INSURANCE CLAIM FORM PiCA I ' I I I. utOICARE "OItAID CIu.uPUI CHA"PVA ~!'~. ~~~!'. In~OHtfn I. INSUREDIIID NUU8EA l'ORPROORAMINm..,) 1-0, .,....,.,~ n ,...., HUllNP'AN~IlMlUNa 4t>N030<.;!-12027 u,lIlJrtlt""'U"...id')1 It~'.a~1 ,VA''''J I 1 ,S5Ji0l101 I I (SSNj ,,01 .. II,r"""'"'."~t_I~.'I"""",~.~rwne.MIdlN.......tl 1;1 ,.~~ 6El ~ 4,INSUREDSNAU~L.'INIn'It,'.tlNtmt,MGHI/1II..tl HilUS. TI N!I RAE "'11 ~ 'f<:! '!>9 "n , I " HAU!.i. TI Nil RAE I PAllENUS ADORns lNo, &'"11 . 'AlIENI RELATIONSUlP TO INSURED ,. INSUREDS ADDRESS lNo. SII"1I <,). l". ~,OIJTH STREET ...d'-o c.....0 """'0 51 E. 50UTH STREET T CITY 1I1AIE . PAltE.H"'AfUS CITY I STAlE I'. flP\ 1~L.t: PI .......d -0......0 CARLISLE 1 PA 'IPCOOI Ilfl'PtlON'I_...."-1 lIPCO\lL IlflIPIION'-lNC.\U~ 'RU_~Q!l~ 17013 1(711 24~-43e5 '-"0 ~~n ~:':'''''D . 17013 ( 71.) ~4.~-4,jl:l. . I 11II~1~.r"I""",""'''''''1 to IlIr"'ll I 0 tl WiSUAEDIPOlICVOROUPOR'ECANUM8ER 1f(,II'O. T TNII RAE . OTHER INSURED I POLICV OR GROUP NUMBER . IWPlQVUEJrf" ICURRENT OR 'REVKkJSI DYES DNO b AUTO ACCIOfNTl PlACE 15..1., OVES ONO, h J e otHER ACCIDENf? [jYES ONO IOd RESERVED FOR LOCAL USE b OTHER INSUREDS DATE OF BIRtH su .... , DO , VY I "r-I ., M1 I '0 e fUPLO'fIR I NAME on SCHOOL riAME (11111.. FlAr~:';!lc K<, (OI'1/H SSIIr/'f It .,.,SURAHCE PLAA NAME OR PRooRAY NAME I' PA'lfN' S on ...un'::~:~~~=SON 8 GIONATURE ,~,. ~ ,...." oI.~Wl::::;~ir. ~OImallOnllK.IlIlr kI pllttU" dIlm I Mo 11lJJI" JlIt1'W"t 01 flM'~"""'" kI """" Of to.. pwty.... ttaPlI IItqwnenl - Si'ilnat.ure On File 05-11>-94 .ICIN'O _"uo, _ _ _. _u .u ""~~" or CUR""N" ~ UNESS 1~"""""1 OR ""'1' DP'l v.y 4 ""'URYI "'100 A ". 0 OJ PREoNANevILMP, I'. HAMI OF "lJIRRINO PHYllClAH OR OlHIA SOURCI ... DAtE 11 IF PAtiENT HAS UAD SA"'E on 81MltAR ILLNUS GIVE 'IRST DAll .... I 00 I VY , . t7. 10 NuuelA Of "IURRING PHYlICIAN tI R(SERVED'OR LOCAL USI 't. OIAONOSISOONAIUREOf ilLNESS OR aruJRV IRELATE ITE"S t.2.3oo4 tOI1E'" '4E BVLINEI----, tOl.20 039,C8, 1 L-,_ , L-,_ T 1'1 n9.:? . I El3~,2: 4 8 C 0 ,~1I111 OF SERVtCETo PlItt TrPI PROC~DURES. SERVICES. on SUPPLlU ... DD VY tAl DO YY 01 01 P.~~~~.~rull 1 (;": p :~4 O~~ 11: Cl4 ') 9'1212 I : 97010 I i 97014 I , DIAGNOSIS COllE 1234 , OS: 11 i 94 OEi 11 i Cll\ 3 1231\ , 0<,: 11 : '~I\ O~ It! ~~Ij ') 1231\ . I I 1 , : . o "f"E.DERAL TArlD NUMBER 1\1 0804 4 7!' . .' , : :. PAlIENl S ACCOUlil NO HAU92900 S5t, (IN do 12f' ACCEPT A~SrSlim,uun' ,...... Td! ,'"biLl) \In NO 3~ NAuE AND AOVRE65 or rAelll'., WHERE SERVlctS WEnE RENDERED III olh" Iha" home 01 ollul 3' SIGNA tunE Of' PUYSK:IA" on SUPNlln INCLUDING DEOREES M CREDEN"AlS II Ctf'lIl, lhal the """,*", on Ih. '.'f~I. ~.IQ "" b1110d .r.~", PlIf1I~.,11 / J/1 J ((JIl ~v tl. O'(qtV.1::J1 IOIClN'O n~ (APPROVlO 1'1' AMA COUNCIL Ofi "'EDICAL SERVICE '.1, ..... " .....1 ",., P'm C.. I.. "". '1001"'1" PLEASE PRINT OR TYPE .lHSunEIHi DATI-Of' IIAl.. MO~ Ufc:r V!,9 , , SEX "0 '0 . '''",OYfR "Aul OIl SCHOOl. ~"". CARL. BARRnCKS COMMISSARY e INSURANCE PLAN NAUE OR pnoon"", HAUE PRUOl'N1IAL d IS tuEnE ANOlUEnHEALTHIENEFIl PLAN? DYES df.K) ,,...f.1Ul"tolf1d~.ltem'.d 13 INSURED I 00 AUHtOnllEO PERSON S StQNAlUnE l.utf\GlllI pe,rnM at fNd<.1 benelll' 10 1M undeIllgned pfIr.lNn ar &uppI...1oI MrYal dna~ btIow 51gnoture On File StONEO " DATU PAtIENT UNABLE lOWORk IN CURRENT OCCUPATION _.OOIVY .....'ODln 'ROM 'I TO I 1 ,. HOIPITA~IZATION OAT(II RELATED TO CURRENT SERVICES ....DD.VV W.OOI'tY 'ROM I. to I I 20 OUTSIDE LAB? ,CHAROES DYES 0"" I I I~. ..., CICAIO RESue"'ISSION CODE I ORlOtNAl. REF - NO ,,, PRIOR AUTHORllATMJH NUMBER , o It J . RUERVED FOR LOCAl US! , CUAROES on r""'r ,un COB UNitS pyn MU 3Q,OO , , 15.00 1 , , 20.0C ' il TOTAL ClIAROE ~ I'" AMOUNT PAID )0 BAlANCE DUE I 61..>:,0011 Q.O( 1 t>5:,OO J] rtfy5ICtAN S SUPP~IER 5 fUlllNO NAUE. AOanESS, liP CODE U~H CHIROPRACTIC tLINIC 323 YORK rWAD C!lRLISLE, pn 1701~ 1\101104475 I rim I nnp, ,on... HC'" 1&00 11'101 ron...OWCp 1&00 ,0nMAnB 1&00 "1l64-~"""'nl ow...~ ,..... "'1" ~.. U'I"I_. ,"'l ... APPROVEOOMl 01)1 0001 PRUDENT- ,-.., P.l). BO>' ,7 HORSHAM. PA 1901\4 1 I \PICA HEALTH INSURANCE ClAI F PICA nTl '1Il0lC_ III00cAl' C....."'S CIWlf'VA ~~!u ~ICA, ot.... II INSURED II 0 HUYlIR l'OR PAOQRAM ,.111" II il'-"''' n,......,'J n ,_...UNJ n (VA'''', n 1Jl~'~~rn"l;J,,'J"Or1 ~IDI 46N03852-12027 t ..'~"'._I",.~,".N_.",,"!,,__J ~~l;'. BIX .. ..SUREO&N.....l tLIIlNwnf.F...NIIM........InoiI..' Hf\lJS. TIN!I RAE ~ ';I 9" n , r?1 SAME . ,AT.NI'1 ADORUS tNo. "'tell . PAT.NT RELAltoHSllIP TOIHSUREO 7, INSURID'S ~ODRUS lHo. 6Ir..11 Sl E. SOllTH E>TREI;,T ... G -0 CNldO """'0 51 E. SOUTH STREET City IITATI . PA'.NIS'.'US ClfY IltATI CARL!SLE PI -[J ........0 """'0 CARLISLE PA lI' COOl TlllPHONll1rdudI AI.. CodII ZIP COOl I TlLIPHOHIIIHCLUPl ARUCOOEI . 17Cll~ ( 71 i) 243-4385 E.........O '..'.....n P.,,,.....O . 17013 (717) 243-4385 SII.IStnt 61udtnt II IU'-,....-, J ,. I . CONU' ,,0 'I. IHSURtD8 POlICY QROUP OR flCAHUMIlR SAME .o'....INIUMO.ra.IC'iORGftOUPM.WIR .EMPlOVMENT? ICURRENT OR Pft(VIOUSI I IHIUR1ae DATti' IIATH IIX I om ~HO ~ c:l v!,9 "0 .~ , , 'OTHlR...SURlDlOAfEOf,IRTH ux , AUTO ACCIDENT? PLACE (511I1' . E"PlOV(. B_.OIl SCHOOl. N.... "t'l~ I!cJ~9 I"n .n: om OND L_..I BARRACKS COM~ISSARY c_IUPtOVlR I HAUl OR ICHCXJl HAME c on~R ~CCIOEHT? c ...,SURANCl PlAN NAUE OR PROGRAM HAWE E1ARRA(,KS COMMl S~,ARV , [1m OND PRUDENTIAL II WlURANCI PLAN NAME OR PAOQRAM HMIE tDd Rl61RV1OfORLOCALUSl d IS THERI ANOTHER HEALTH HN1FIT PLAN? OYfS aND 'm, f"",ntotnd~..m"'d II!'~~"~. C--,.,..,. 13 ....SURED'8 OR ~UTHORIlEO PERSONS SIGNATURE I WhOftI. " 'ATIENT'IOR AUTHORIlIOPIRSON I IKlNATURE 11l.bRI' '" '......01 any rntdlCIIor...llID1mlllOll "..u"'y PI,mtnI ot medcaI btnthlllo" "'*19'Id phyIWI'I Of auppIltf "" :t.-...-,....-P'........----.....,....................--............ IIMCeI dllalbed ~ . Signature On File' , 05-22-94 Signature On Fiie _0 .--- DATE.. ______ . . 81QN[0 .. tt~"~C~NT: ~~~~~l~~'J::T:")OR . ".If PAlIlN' HAl HAD $AMI OR '''U'' I..LNfSS II OA'UJ::'."JoUNAOl~ '0 WORK ",CU!l::.(N''i\liCU'A'1ON Ii 1~ 4 'NlINANCYI'''~1 DIVE ,IIIST DAlE .... I IX> : YV , I Y I I YY ,f'C)UI I '0 II n. NMII Of Mn....N.l PHYltelAN OR O1"R IOUACE "1 to. NUMIl" 01 NfERAINO PHYSICIAN tI, HOI"~IlATIOH OATIS RELATEO TOCUAA.Nt SIRVIC!1 IODIYV W,DOIYV ,ROU I I TO I I " M..RVID'OftUX:ALUlI 10, OUT~DE lAB? . CHARGES nYfS nND I I 11. OIAGNOIIID"NA'URIOF UNlSIOAINJURY. tRlLATlITE'" U.3M' TO~tUI"I'V LlHfl t IJ ~1CA1D ........'11"'" I ORIGINAL REF. NO. ,\ Ee1,~0 . ~~.:.08 13 PRIOR AUTHORIZA'ION NUYlER ..172'1.2 .~~,21 . A . C 0 f f 0 It I J . "M:TEI8lOF .IRVICITo ,.,..,. '''' 'ROC~OU."'SE.VICES, OIl su'Pl.. OIAGNOSIS RESERVED fDA .. of p.~~~~~'::nc-') . CHARGES OR ...... EUG COB lOCAl USE .... "';;; vy .... 00 vV CODE UNITS ..... os: 16 I 91, oS: 161 WI 3 99212 I , 1234 3d.oo , , or: , O~ 16!94 97012 I ! 1231\ zd.oo t 1(, I '~I\ 3 , 99212 I , , 0,:1 1~194 051 16194 3 , 1231\ 3d.oo . , 'Jr;! ,e I "tl O~; 1(11 94 97012 I , , . 3 I 1231\ 2d.oo , i , , , , , , , , , , , ! : I , S , , , , , , ~, I , , .. , , , , I , , . II 'fDfRAL 'AllD NUMeER 66N EIN 21 f'A1I1NT'&ACCOUNt NO 1~ICCf'J1t A5StQNU~ 21 ,QlALCHAnQ[ ~17 AMOUN'PAIO :JO BAlANCE DUI nn DIP! i~a,... I , , )( 1 100:.00 110(>','~ 1'~, HAU92960 YES ~ NO 1 100' ,00 1 O' . 0 ' 31 61Ot,A1URl or rUVSlClAN OR 6UPPLlER 32 HAUl AND ADDRESS or fACllllV WIlERE SERVICES WEnE 3) PHYStCl~N6. SUPPLIER 6 BilLING NAUE. AODRE66.1IP COOE flCLUO'UO DEGREES OR CRfDENttALS RENDERED I" oN! f\ln home 01 offal \f~I.r CHJROPRAC1 Ie t.UNIC tlttttltr"llhll.I.,neollonlhtl,yff.. eppt,- to IhiI Wind "1 midi I PlrtIMfIC'A} :.t~3 "ORK IWt,P I.J!r/,I/~If!j () j3e.f?,~JS1 C~RL! SLE, Pt'l 1701:1 "AT rlU' "10001\" 7~, nllP, M aRM ,APPOOV(O IV AUA COUNCIt. 00 MEDICAl &lAVICE ..II .... .,...... A'" ,,,.. c......." '11>>"111" PLfASf PRINT OR TYPf ronuucrA 1600 111 VOl ,onUOWCP-I&O(l 'ORMn"811O:) '..llu.~",."." u.. -""'........................ ""........ nTlPICA HEALTH INSURANCE CLAIM FORM PICA rrr t. UlOlCARI MlOCAO CHAMPUI CtWI'YA ~f'9.'.!.~ !.~~-!'. :1 ri ~'HIR ,. WSURl061DHUUBER l'OA,AOQIW.IIHIlIU') A. lH elM LUNG 46N038S2-12027 b_'Jn'-'Jnl-'SSN) ntvA''''J n~"~n'ISSNj IIOJ ~,iius:1INA~'AE'_' I ~~9( .. n IU, r)j "INSURED 6 HAUl (Lltl....,.. frat N............... ~ll HAUS, TINA RAE . PAtIlNl'BADORESSINo.6IINlI I. PATIlNT RlLAtlONSHIP TO ~SUnED '.INSUREDS ADORESS tHo. S4rH11 51 E. SOUTH STREET 601 0: Bt>ou..O ChOlO 0lh0<0 51 E. SOUTH STREET CITY I "ATE .. 'ATIlN' 1l41U8 C,ty IITATE Cf\RLI ~LE p,' "'-d -0 0lh0<0 CARLISLE PA IIPCOOE \ llLEPL7;E (1nc:WI Aru CadlI 'IPCOOl I TUEPHONE IINCLUDE AREA COOl) 17012 ( 71 243-4365 E-n '''''''n P..Tlmon . 17013 ( 717) 243-4385 Student Studenl S \"0_,''''_' I 'OIl'A" , >10 'I. "'SURIO" POLtCyGRQUP OR FICA NUUBER HAUS. TINA RAE .OlHERINSUAIOIPOUCYORGAOUPN\A&llA ._ IUPLOYUUtn (CURRENT OR PRlVNJUSI ..IHIURI~DAT~ IIRTH .U OVES Cfoo ~ ~ V!.9 "0 'C1 , , bOTHER MOREO' DAlI C11llAtH SUI b- AUla ACCUHT? PW:( \"'~I b IMP\.OYERlNAUE OR6CHOCl'-NAME ... , UP , YY I .n 'n DYES 0'<0 CARL. BARRACKS COMMISSARY " " L_I c IUPLOYIR I NAME OR8CHOa. NA>>E c. OtHER ACCIPENT? c. INSURANCE PlAN NAWE OR PROGRAM NAME CARL. BARRACKS COMMISSARY [jVES 000 PRUDENTIAL . ..sURANCE ft\.AH ~ Of' PROGRAM NAWE HId NIIRV10 fOR LOCAL USI d," lHIRI AHO~R HEALTH HNEfIT PLAN" n YES ' NO . ,...ltMn to tnd c:ompAet. Mtm' ,iI 1:1 INSURED'S OR AUTHORIZED PERSON I SIGNATURII WtlOnI. 12 PATtlNT"!1 OR AUTHORIZED PI ,,&oN I SIGNA70RE 1-..IhOnl." '....M of .,.,,,,.ul Of Dlhtl ~OIJT\1'" '*'1$IfJ pi""'" of Ndc.II blNhll to.. undIft9nId phJlial" Of wppIrIr tor ::._.. dim 1*"....1 PI"'*" of petrwnenl btnIIIII....1o '""" DI to.. pM)' wtlo ~a palgnmlnl --n- sigllflture On F 11e 06-01-9'l S gnature On File IIQH(O .- ---- DATE __._ .n ._._ -- SIGNED ,- _.__4' -.. . -_.._.- "~TI ~~NT' ~ ..NESS!'''! .=1 OR II IF ,ATIINT HAS HAD IAMI OR SIMILAR LLNnl \I OATEW'~~~ TO WORIl" CUcr.'~T \l&C~'W"" OIVlf,"STOATE .... I DO 1 yy 11 ...~ ,4 ::t~~~kVll"~1 A ' j! fROM I' 10 j I 17. NAME Of" Nf'RRINO PHYStClAHOR OTHER &OURCI ",. I D NUU8EROf REfERRING PHYltClAH II. HOSPItAlIlATtotfOATlI AlLATED TO CURREN' IU'VtCll ....,DD,VY ....,OOjVY fROM I ! 101' fl. ..&lRvED fOR LOCAL. USI 20, OU'SIDf.lAII't . CHARon nm riND I I 'I. DtAGNOfPSOAHAT~ Of IlLHlSSOAWJURY. (RELATE "UliS ,.2.3OO410nIM241 BYLINE) t It ME DICAIO RESUlUISSIOH E01.20 839.08 CODE I QRlOlNALRff.NO , 1--,_ ' . 1--,_ 1:1 PRIOR AUtHORllAltON NUMBER . I :'29.2 . I a3~.21 . . A I C 0 , G II , . 'l9:tltIIOf IERVlClTo POCO TIP' PROCEOURES. 6lAV~EI. OR SUPPLIES DIAGNOSIS RESERVED fDA ~ .. IE",In~~~&I:raa) cOO( . CHAROES OR ,..... IUD COB LOCAL USE .... ~ w .... DO VV UNITS ..... Otl\ ~'.l 19., 0" 2319~ :,:I 99212 I , 123'l 30.00 , " , I" t.~~q 2319'l 23!q4 97012 I ! I O~ 3 1234 20.00 1 , . , , 99212 I , , 0-:: 2'5191\ 08 2'5:94 3 , 1234 30.00 , , 0.' "5' 94 ~7012 I , , ...: ". , O~ 2S1Q4 3 , 1231\ 20.00 1 . 99212 1 , O~'\ 31 191\ O~~ 'n:91\ , , 3 , 1234 30.00 . , t)~,: 31 ! 'l4 OS ::11: <11\ 3~ 97012 I , I ," , 1234 20.00 1 . 2ft noUV...t.....ID NUMBER 6&N tIN ,. PATlENT'S ~CCOUNT NO ~ICCEPl A5SIQNUfN'" 2110tALCHAnOE )'~ AMQUNTPAID 30 BALANCE DUE l1In Ofgovt ri.....bIttll 1 150:,00 1 O:.O( 1 150:.00 1\10,?O.,1\75 HAU92980 'YES NO 31 61GUAlURE or PIlVSlClAfi on 6UPPlIf.n 32 HAUE AND ADDRE6S OF rAe\ltY WHEnE 5ERVICES WERE 33 PttY51CIAN S. 6UPPLlEn 6 BILLING NAME. ADDRf.5S, liP COOl tHCLUDING DEOREE S OR CREDENllALS RENOlnEDI"OIhe1' INnhoml01 o"dl y~~ CHIROPRACTIC CLINIC II r:ertd, 111.1 '" a11'~' on !hIlh"" '"'" tothia blind ,r. rnadll pll1 lheftoll 323 YORK ROAD 060194 CARLISLE, PA 17013 I.","," DA1[ "N' 41080'l1\75 Ion.. -. A.,YHUVIO CUI 01)1 0001 ~~ il~\.E · INTHIS AREA PRUDENT7_ P.O. BO>.' ~7 HORSHAM, ~A 190'l4 T ! {APPROVED IY AMA COUNCIL ON M[DICAl 6ERVtCE &"1 MW lit Mtlkll Ana 'flU c.....It.. lICOIIIII" PLEASE PRINT OR TYPE fonUllcrA lr.oo 111,101 rooI.lOWCP.I600 fOfU,lRRD.llOCI .JJI............AltI"'ftI u. ..........141..........114116..... PlE4SE OOt<<lT STAPLE . INTHIS AREA PRUDEN T I ~I, P.O. 80:'-"",7 HORSHAM. ~A 19044 T ! rTTIPICA HEALTH INS RA C PICA fiT ,. "OICAAI ..OICAIO CHAWPUS CHAUPVA GROUP t~~~. )(OHtER " ~"~~~U!2027 ,fOR PROGR.UIIN IfIU 1) ~ 'n' 'n 0 o'Ml,"II(l....n'LOlUNOri Iu.ctt-""j ~ 'J '~lSSNJ (VAn"J f 01' 15SNI (IOJ '':>. I l'\~W1M'I!'-' I I'~~ ~F 7 " n SIX, rll · "fiI~~~""i"1'''''''''''~"I!'''''--' '~1'.~ ~wg'l!ltH"l'~ '\,"l'REET . p"tanUA1KlNSHlPl0WSUnlO , "t"1"lI!~OO'!M~"'!JTRE:E T . ... -0"""'0 """'0 cehP.LISLE. ISI'l!1~ . ,AlIlN' [jUS Cll't ARLI 5L E I S!A~'" ...... ....,...0 011"'0 '~~013 1'('91'EI~~!!ft1a5 (........n '.......n P........n "~~'1013 I"T1!~i~~.!'ItS~1 61Ulttnt Student ~, , !wwrrtllr'''''' I I. ........,."""u,"o.."."'..u 'u 'l.tHSURE.D.POUCY GROUP OA FICA NUU8IR . OtHER INSURED 8 poue\' on GROUP HlAI8f.n . ."'LOYMEN" tCURRE[1: PREVIOUSI · "SUAIll4iA'fi'}'~'tJ SIX [j OVES .., " "0' , , b OtHER INSURED S DAll Of IIA'H SIX b AutQAtclOfNn P\.ACIIStal., ~~~N'tIWUf~'cOMI1IS5!1RV "',oo.yv I"n 'n DYES 0"" I I , , '~~~'tE~s~XR'l'UltmN~'oMM I 5SARY C OHtER [jENU , ~~mtOll PIlOO.........E VIS 0'" tI INSURANCE PlAN tW.IE OR 'ROOMY NAME tad "l6ERVED fOR lOCAl USE d IS1HlREANOaRHEAl.tHBEHEFI1PLAN'J' DVES NO .t'Hteturnlo.nd~I.".m'.d ."''''.....'O"~C a._'....""'" 13 INSURED&OR AUtHORIlIDPERSOHS6tGt4AtURf I.uthonl' "PAlIWf & on AU1UORI1ED PERSON S 510UAfURE llulhOnll... '..... 01 '"' InIlkal Dr DIhIt lnttJ'm.1ol;ln r'IIC""" ~F""" 01 rn.ctal Mntl.1 to III undIfl9'*l P"111N" or "4JPIrIt lot :::............~~'~ rn~r.'"'tI'I'l"}"rrv-N._"............ ""'U'll'.!'1't'.!~ - """!'! 'O'n'a t u r e On File SIONED . DAlE SIGNED - .... - .'- --_._.- _._- .-.. --.. - - .- - ",imWW'~ 4mt~~t:::'\;r:"10Il A ,. I' PATItNT HAl ttAD SAUE OR .IMILAR ilLNESS 11 DAtES PAtIENT UNABlE TO WORK IH CURnENt g&CUPATION OIY( flAST DATI .... 1 00 1 yy ....IOOI'tY MMI IVY 'I PAEONANeVllUPI ' , 'ROM liTO 1 1 11. HAWE Of" RlfERRINO PHYSICIAN OR otHlR &OUReE 11. I D HUUlIR Oft RlflRRINO PHY61ClAN " HOSPITAlIZATI()ti DAtu RlLAnD TOeURJUNT SERVICES .....OO,YV .....,OO.'YY fROW " TO I . III1lSlAVlD '00 lOCAl us( iO outsIDE W'J' . C..AROES nns n.., I I n D~tll.!!~A'URI OF IlLhE5SOf1INJURV IRHAtE IlEUS u.:lOe~'~I:tr~41 BYLINE) t '2 ~ICAID RUUBUI5510N I ORIGINAl. REf NO , L-,_ . L-,_ , I 729.:Z 839.21 rJ PRIOR AUlttORllAllOH NUMBER 'L- . . A C 0 f a It I J . r,9tTlISIOF SERVICEto ...... '''' PAOC~DURU: 6lRVM?l&. OR SUPPliES DIAONOSIS RESfnVED 'OR .. .. Pl~~~~~~I~'1 coo( . CHARGES 011 fllN, ElIG COB lOCAl US( .... Illl VV .... 00 VV UNllS ...., 06: 06,9~ OE. 0(" 91\ :1 5 99213 I I 123<'1 3~.00 , , , , , , 0';': 0(;0:91\ OE\ 06:9~ 3 970 i.? I , 1234 20.00 . , : , i , , C~": O'~: 94 06: 06:94 3 5 95851 I 1 , 1231\ HI.OO , , , , , llf:o: 06:94 Otl 06'91\ 3 5, 95851 I 2 ! 1234 1e;.00 . ; : : , , O~': 06: ';/. 06' 0(-' 94 3 5 951351 13 ' 1231\ 15,00 s : -: t : , , oe.: 0":94 06: 0(,: 91\ .3. ,& 951351 14 , 1231\ 15.00 I , , 1 n HornAl1All.IP NUMOER 5SN (IN IN PAllENf5ACCOUHI NO 12ftCCl r, ~~~I"Uf f," n tDlAl ellAROE ) ,n ~UOUN' PAID )c 30 BALANCE DUE ^ 1 O',"Ii\i\7~. (-~n HAU929130 01 go'lt [~ t..... badol I 110:.00 't'(S NO 1 110,.00 1 0;.0 :II SIONA1URE or PU~51CIA'4 on GurrUIR 32 NAUE AIm AOOl1165 Of ,ACIlIlY v;uERE SERVICES WERE " rn:;t~ s~~l'IIWA'A'e ~1'tA~n~i'H,OO( I"CLUDINQ OEonus on CREDENtiALS RENDERED lit Olhei' thin home 01 0'11", tlc:~l"''''''tt'II''.I~'''''M''''h'''' )".. YORK ROAD tPP'y kill., blI.rwl'" rNde. plrt IMll'd I ~- 061691\ CARLISLE, PA 1701:< 41C80~~75 I IQNro DAlE PIPI' "Ar. U N E CLAIM FORM IAPPROVED By AU" COUNCil 00 MEDICAL 81RYICE ...., .... '" .....1 Afh ,,,.. C.......M 11I00""1" PLEASE PRINT OR TYPE ,on... IfC'A '\00 11210, 'QfU,IOWCP 1&.00 'OR...nnBI~ ..11"-......."""_ U............I'I.'.......I..III1..I...... - . APPROvtD QUI 01)1 0001 PLE~SE DO NOT STAPLE IN THIS AREA PRUDCNT!I'''. P.O. 80l ~7 HOR~HAH. ~A 19044 -II'I.ItA HEALTH INSURANCE CLAIM 0 PitA rn 1 t. "OICME MlDtCAID CKAUPUS CHAMPv",. (1!'~p ~ICA X01tif.n " 'IIll'M~j&~1II~20~7 If OR PHOQR.....IH IlIM II 1'-""ln,-,'n,..........S5N1 ntvAf"" n1~l~~n'\UN'j"Ori'fOl fw~::>, THITr'n"\l!'N.....,...........' ,3 '~" . "nIEX,r2l · "ffflll't! ~"'ii'rNlr"II"~''''''' ....., , , .{.1'1(~~~,~Uffl Sl(~REET I. 'A'3RlLA1IONSttIP TO INSURED I "'!'1"'\!';OO!M~..!lTREET loll -0 Ch4d0 .....0 Cr~f\L I ~.LE I"~ · PAUIN' dUS CII'l::ARL ISLE I "AJJA - .......0 .....0 '~~Ol'J I 'rYii'I~~~~135 (-n '.-l....n P..l""n "~c'Y"7013 11Il('~~~'If~.!'1l'3~ ~, 51udent 6""""" ( ) T' ~-X Ir"'''. , I.... ....,."""""IQH....llOlO " INSURED S POlK:Y GROUP OR fiCA NUUltR . alHf.A INSURED S POlK:'t' OR OROUP NUYIlA . E""'OYUIIH1 (CURREa: PREVIOUSI . INSU.'l!A i"!lb~''N.'9 Sf' ,Cj o VIS "" , , "0 , , It 01MlRIHSUR10SOAll0FIUR'i &EX b AUTO ACCIOf.Hn PlACE 15111" · '~~~~"1l'A~tfm'g"'cOMMISSAR,( ... I DO I YY ,In 'n DvlS 0"" " " L----l '(.'~~(e~ S ~~~~~~cc'i& H~bHM I SSARY C OlHlR .[JEHU , "fI~WE~t OR Pf1OO......... VIS ONll CI lfiSURAHCE PLAN HAUl OR PROGRAM NAME IOd RESERVED FOR lOCAl USE d IS THERE ANOaRHIAlTHIENlFIf PLAN? 0'1(0 NO "....,,,umtaardcomPtt.ltetn..d .... lACK Of '''''''"1'0IlI ' ,III ,""", 13 INSUREDS 00 AUIltORllED PERSON 5 SIGNATURE I.~. 12 PATIENT 8 on Aut..onllEO PERSON B SIGNATURE Iluthotll.1M '"'M of My meckllOf other lnIarmlllOn nece...., ~rmen4 of rnedcaI benel"l tar. "'"""'19* phrlCllll Of "4lP'" kif :'::'" "''T''gl^'U't'fIl'1'''tJ',~''r'm--: 1D"l"" "ID ......ut'.!'1'f!.'.!~ ............~l'UI'TTaturEl On File .. " 61GN(D _ , n. __. .-.._-_.. , --.-- . OAll ... SIGNED - "~\~"&>1'l"~Nd ~ ~~~~W~,'~~'OR A II IF PAlIENY HAS HAD IAU( OR S....ILAR ILlNESS " OAl(s~"'Nl UNABl~ lOWOllO< INCUQ:'Nl g&CU'A,1QH OM ,IRST DAti .... I 00 I YY lPOIV , IVV I 'REOHANCYllt.lPI ' , FAOUII TO" 17. HAUl or RE'ERRIfofQ rHY6teLAN ooDlttE.R &OURCE 17.10 HUUBEROfREfERRINQPHY&1C1AN II HOSPIfAlllAttOti DAtES RUATED TO CURRENT BEAVteES "',OOIVV "',DO,YV fROM I I to I , ,. RE6(AVEDfOR LOCAL USE , 10 OUTSIDE lAB? 'CHARGES nVEB nNO I I II OIAONOSIS on NAtURE Of IlLNUSORIHJURY,lRELAlEltEUS 1.1.100. TOnEt.l2~E BYLINEI t 22 McJ&teAO RE5U8UI$S1OIi EOl .~~ 839.08 C I OAtGlHAL REF NO I. L-,_ 3 L-,_ 23 PRIOA AU1HORlZAtlON NUUBER t ,,729,;' . I 83~.21 , A , 0 . , 0 H I J . fl~tE(&J Of SERVICEyO -- I... 'IitroClOUREI. SERYICES. OR SUPPUES DIAGNOSIS RESERVED 'OR ";;;;- YY WI 00 .. .. 'PI~~~IUIJ~~'~'I COOt , CHAnGES OR .- (UD COB LOCAl USE WI VV UNitS ..... Of" Ot., 'il\ 1)(, 0(,,, 91\ 3 f, 9!,8S1 I 11: 1234 l~.OO t ' , , , , , C',,'l U6:"'1\ O~ 06: 91\ 3 5 9!,8S1 I 12i 1234 15.00 1 , , , , , , 06- Of,: '1' Ol:~ 0';': 94 3 5 9(,8S1 I 14: 1231\ 15.00 l , , , , ("" 06:"'1\ Ol~ .~6: 94 3 5 9E,8S1 I 15' 1~34 15.00 1 , -: , . , 0',' 0(,: 94 0(1 06; 94 3 5 9E8S1 I 16; 1234 15,.00 " . 3, , Of." Ot,: 91 Ot:~ 0(;,: 94 ,6 9E851'1 17: 1231\ 15.00 1 " 1 , " flOEn"'L '.....0 HUMBER 5~~; 21 '.tlltH 15 ACCOUtU NO l~cCCEP,1rr~''''U4'' ill TOTAL CHA"&E ) I" AMOUNT ()IO )( ~ llAlAN~b~bo 1\10t:"JI\1\7~, HA\J92960 01 00w1 et.. ... badll . 9 ;.00 . ;.0 \'(6 NO 31 tilG"ATURE Of' rllYtilClAIiOR tiurrllEn U NAUE AND AOORESSor rAcn.11Y WIIERE SERVICES WEnE " ~,':~.t~I'A&~!'R'A'~~'tAO~!'f~'itOO( INCIUOING oron[ES on cnEOEli11Alti RE'WEnlOIII Olhtf "-"homeClf o"al Iltlfft,l.th'I""IIIl~'Clf'IIheI""".' 323 YORK ROAD appty to"', b.-.nd ...mIde. pIIt1l,.tot I 061694 CARLISLE. PA 170D 1'~N'n 0'" 410801\475 I rlfl. nnp. F RM I""PROVED By AU" COUNCIL ON U(OIC"lIlERVK:E "" MN lit .....1 a,1I P".. c..~.." Ib'''II" PLEASE PRINT OR TYPE FanU"CFA 1&00 Ilnol roouO'I\'cP 1&00 'QRt.lRnB 1600 I."............,....... u.. .......,...1...........,111..1....... A"IlOVlO COla 01.- P\.EASE DO HoT. 8TAPLE . IN THIS AREA PRUDENTl'" . P,O. 80;~7 HORSHAM, ,A 19044 mlplCA , HEALTH INSURANCE CLAIM FORM PICA IT1- I, ..DICAIll "\llCA1O C......PUS CKAlM'VA !!~~. ~lCA X01HIR .. 'It't:~~I3~! 2027 If OR PROGRAMIH ITEW'1 ~"'n~'ln(-'-1 ntVA",'1 'lUll" ~ n"" J"UN<l r'i t .. 1 IS 1 1001 . I ~",.. ",..~- ,,_......, , · II n Bf", il1 · ~lM ~AW~'tWf"~~~,...... ......, I , .~~'Il~~~~"1I14!"1REf.T . 'A'aRILATIONSUIP 10 tHSURED 7, "!'1'fl'! ~oo~f:M'ttf'!:l T RE E T 10M -0 """0 OOhooD Cj~ARLISLE I.'~)'~ . PATIlHT [JUS C''tARLISLE IS.AI!A _ -0 or. 0 ":~013 'T9l'~~~~135 (~n '~'OMn P~lOMrl '~tDf7013 Il(lEPffl~~~!I'J~ &tucitnt 61udent ( ) .. , ~~~r'''''' , ID ,"IOH ""..,,0 ,g '1.IN$URED'8 poue., GROUP OR fiCA HUY8lR .OTHlRIHIURIOI'OUCYORGROUPNUUIlR . E..PlONE'..' ICURRld= PREYKlUII . "SUR(llA~AlU'.l'~'V.~ su ,eI ovu NO , , liD , , . OTHlRIHIURIOIDAn Of IIRtlt II. b AU10ACCIltNn P\.ACIISWa.) .E~~~~~~~~~~OMMISSAnY ... 1 00 : yy. I "n ' n Ovu ONO L_I C~~'l.~l~'rrxh~~mNt'oMMI 5SARY c- OTHER ACe N" . ~\..""PROO_NAUl [ vU 0'.0 d 1N5URA~1 Pl.AH NAIR OR PAOQRAM NAUE lad "UERYI fOR '-OCAl U5E d IS THEAl ANOI~~ HEAlTH BENEFIT PLAN' DYES NO .....rt"'rnloardc:on'lClltlfltem..d "O,,~,,~!,,!,~COWl.""" ' 1:1 WSUREOSOA AU1HORllEOPIRSON85tGNAfURII.u1honll 'I. ,AtlENT a OR AUtttOAlllD PERSONS 8tGNAtURE I UhOrIl' hi.... ~ an, INfUI 01 "'" WOItI\IIlIOn nKtUlf, piymtnl 01 mtdcaIt.M'"' to" ..".,..... JiI,1OIn 01 auppIIII toI :.c......~I,~rot'~""tI'fI"r'm~.-".................tfll'.!'1~~ -"""!I1'C'Truture On File SIOHfO .__ u._... _ ._"_u_ ..-..... -- .-"- DATE - ._-.. SIGNED .. -- .... ...atl~W1f~ ~~~~~t:::~I~IOIl A 11 . PATIENT HAS HAD SAME OR SIWILAR illNESS II DATI'J::TIlNf UNABlE TOWORKINCURRENt ~UPA'fM GIVE 'IRST DATE .... , DO I n looln ..., ,v I I PAEDNA-NCVll"P) I ' 'ROllI ,I to I I 11. NMIl C1I NflRRlNGPHV&ICIAHOR OTHER &OURCE ".10 NUUlEROfREfERRINOPHV61CIAN II t<<JSPlfAUIATKlHDATES RELATED TO CURRENT 6lRVM;EB ......IDD'VY _IODIVY . fROM I to I I " AfSlRVlD fOR lOCAL UN " OUT8IOlLAI? . CHARGES I nm nNO I II. omlS. !l8"TURE Of R.LNUSOR INJURV, IAELAtE nEM5.I.I,30~ j1,.~ l:tr~4E BV LINE I t 12_ MEDICAtO RESU8MISSION COOl I QRIOWAL REF. NO ,L-._ . L-,_ n ,,,toR AUTHORIZATION NUUBER , . I 729 .2 639.21 'L- . . A C 0 , 0 H I " "it,"lSlor BfRYICE,. "'- ''''' AOCEDURU, &UWtCEB, OR SUPPLIES DIAGHOSIS RlSERvtD fOR .. .. 'p.~~~~~t~encetl CODE . CHARGn OIl ,......, Ella COB lOCAl USE .... ..~ VY .... DO yy UNITS PIon 061 06 1 '~4 06 08, 94 3 99212 I I 1234 30.00 ~ I ' , , I , 06106:94 O~ 06:94 3 97(112 I ! 1234 20.00 . , , 0(,' 13191\ O&. 13194 3 9n12 I' , 1234 30,00 , , , . , 06: 13:94 O~ 13;94 3 9701.2 I I 1234 20,00 , , . i , , , , i I , , , , , : , , . , , I , , , , , , , , ! , , " , , . 1& f(DlRAl fAI I D NlJUBER S;;(~ " ,AflENT'S ACCOUNT NO I~' ~CC(P'A5Slnt.UEU" .. 'O'A'CltARGI J \" AUOUNl ~'D )( .. BA'f6bOUb 1\10e0447!j HAU92960 [jotU'lMO....ba(jl1 I 100:.00 I :.0 I :. 0 VES ..0 :11 SIGNA'URE or rllY5lCIANOR surPLIER 12 NAUE AND ADDRE6S Of r,aCILlfVWHERE 6EnVICE6Wl;nE OJ ~'AN'~r.PPlIlnS.~l~NAW~A001'f~'P'tOOE INCLUOIua mORE f 8 on cnEOfN",aLS RENDERlD I" DIhM f\lnttoml Of oIIut ~ iIROP,A T! C I II twftll,!hI1 1M t'A'tmenl. on 1M ","M 323 YORK ROI\D IWr 10 WIll bII.nd at, midi . PI" I~.oll 061691\ CARLI&LE, PA 17013 I'ION'D nAlE 410804475 I, PIU, ORr. ! .APPnoVED IV ,aUA CClt.INCIl ON UEOICAl SERVte:l....j ... ..,..........'h'f... e......,.. '_IIt1I" PLEASE PRINT OR TYPE rooU ltefA 1&00 IlnOI fORUQWCP IftOO ,onlrAf\RB.lr.oo '~l". .........,,,"", U. .........11..............1111..'...... PLll\SE 00 NOT STAPLE . IN THIS AREA ----- PRUDENT t""I P.O. BO>' ~57 HORSHAM. PA 19044 APPROVED CUI 01>> 0001 PICA rn 'FOR PROQRAU IN illY II TTlpICA HEALTH INSURANCE CLAIM FORM 1. "OIeARI ..DtCAIO CHMIf'U5 CHAWYA ll~_ ~~~~__ otHER ,.INSURl0610 N\.IY8ER .,-""'n'-""ln,_ISSNI n ,vW.,/ n U'~~n'\~}"'ro1-11101 4bNOJ652-12027 '._1"._;".-" I " ~~iif~'Rd"~I~,r'" IU ...SURfDSN...flllol_,'..N....,-.....' HIIIJS. TINA RAE .. "!$~ T959 "n' ,n1 SAI1E I PA'.Nl' ADORED (No. ....., . pA,aNT RELAtIONSHIP YO INSURED 7. "SUREo S ADORns tHo, 5u..1I !,1 E. HII.lTH SrREET 101I0-0"""'0 """0 51 E. SOUTH STHEET T CITV . IltATI . PA11l"1ITATUS cnv I &TA1I ! (:(IRL!. SLE I PA _[}........ 0 """ 0 CARLI E,LE I PA 'IPCOOI lElEPHQNEtn:uteAt.lCoJII lIP COOl \tELEPHOHEllNClUDlAREACOOEI .1701.' 1(71il 243-4385 E-"'n~~n~~n . 17013 (717) 243-4385 '_,U__-:r..._, I 'OIl..'''Nn ........u'o 1I,",SUR'OSI'Ol.ICVOIlOUPOIl'fCANUUIIlR SAME . OTHER flSUAEDI POl!CY OR GAOUP NUIMIlR I b,OTtfER...SUAIOlDA11a1IIATH au ~~ Df9 VS9' I ..n 'n c. tuPLOYl" 8 HAUl OR SCHOO.. NAME 8ARR^C~S COMMISSARY , IN~CI PLAN HAUE OR pROGRAM NAME .. EMPlOVUINT1 ICURRENT OR PREVIOUS) o VfB OJ"" b. AUtO ACCIDENt? PLACE (StIl.) DYES 000 L_J c. otHER ACctOENT1 [3YES 000 IOd REHRVED fOR LOCAL USE 0..... 11 ,AtlEHllOO AUTHORtlEDPlRSON8 8K1NAtURE 11UIlOrtl. the ,.... 01.". medleIlI Of othIf lnformtllOn"''''''' :J::"'''' dIIm. I.. '.........,.." ~ ber-.IIlI.....lo,."... Of 10" pII1y _1CUPIt.1igMlII1t . Si gnature On F 11e' 06-28-94 .', llONlO ._. DATE ..,..n _ .. un__ "~AlE <r..CUIIIlEN': ~ UNUS I'''! '~I OIl II.. .A'.N' HAS _....E OIl SIII\.AR UNESS 1, ...,.d V1.4 INJUIIV, ,,0Il O'VE'lII"OATE .... 100 I 'tV I ...; ~ '-J PRlGNANCYILUP) 17. NAME OF MFIRRINQ..PHYlICIAN ~OlHlR SOURCE '7. 10. NUUlEROf REFERRIHO PHYSICIAN -, ", II MIlRVlDfOR\.OCALUSE 'I. DlAGNOItlOAMA'lIM OF UNlIIOR tNJUftY, tRELAtllTlUS I.UORC TO llfUIU 8Y LINEI-"l . I F.81..20 3 ~?..:?8 t .. I 6'39.21 o ~~OUAEI. 6lRVICEI, OR 6UPPLlES 1(.ptaIn~uaI~~I~aratl t;l9212 I I T I I. I 72'1 .2 . ,,~TfISI Of SERVICf,. ~';;;;VV""OOYY I I 'I I 1 O~, 20'71\ 0& 20'91\ 3 . , .- '''''' .. .. DIAGNOSIS COO( 1231\ ot:i ~()!91\ , , 97012 I , I oa 201')1\ '3 I 1234 I , , :?21 91\ 99212 'I , 06' 22'':''4 O~ '3 , 12:31 3 , , , , 97012 I , . ~"..! 2:: I ..~" 00 22' "11\ :3 I 12.3,\ I I , I I , , I ! , I f, . .' , , I , I , I I , ! , 1 " ffUlRAl ,,.. I 0 NUMBER 8SN ftN "PA!!lNt.ACCOUNT NO I ~;CEPI ,lSSlnt",AF-'ll' r'ln OIQO\1~I....tJ&d,1 1\ 10eO'I~;>S HAU92C'80 YEI . NO 31. 6IOfi"TURE or PII'16)(;1"..,on 6UPP\.IER :u NAME AHD AOORESS OF FACllllV WIlERE SERVICES WERE INCLUDINQ O[OR[ E 8 OR CRfD[NtlA\.S RlHOfREP 1M attw Nn homI 01 ofta) jltef1"r lhallhe ,"t.cNn1lonlhl Ifytt" IRJIrlolMbllndll.mede. p.II1hr.oll , I.~~n OQ28"1~ nm 1",rnOVEP BY AM'" COUNCil 0Ii MEDIC"'\. 5lRVICE ,.., .... ......... A'" ,i... CIII...I.I""" PLEASE PRINT OR TYPE . INSURERS PATMY leu" O~ l~ '/;9 "0 b EMPlOYER 6 NAME OR &CttOO'.. NAME BARRACKS COM~I~SARV c. ,.SURAHCE PlAN NAME OR pAOQfWI NAUE PRUDENTIAL d. IS THERE ANOTHER HEALTH 8ENfflT PLAN? DYES [JJ. NO ......'tlUfn'uNtcorr.-....m..<CI '3 INSUREDS OR ,lUtHORIZED PIA$ONS SIQNAtuRE I MIlhOriII Plrmenl" medal"'''t aD 1M undIt19* ph)'tdln Of """*" tot --- Signature On File 8101iEO ..~_ ___ _ _ . ....___ u --- II DAT('W'~Nolo~$'OWOlll< INculm'~' 'jl%C~P~lf" FROM I I Tall 11, HOSPITAUZATION DAns RlLATfD TOCUARENt 6IRVtc;U .....DOIVy ....'DOI'YY FROM I I TO I I ro OUISI[)E W? I I CHAHOE8 nvu n"" I 22 UEPlCAlD RE6U8UISSIOH COOl I ORKllNALRfF.HO 23 PRIOAAUTHORIlATIONNUUBIA so 'QJ , o H , OR Fam,., EUO COB UNitS Plln " RESERVED FOR LOCAl USE ICHMQE8 3d.co l , , 2C:' 00 , . 30.00 ' , I 20.00 , , , , II totAL CHloRal ,I ,n A>>OUNT PAID 30 BAlANCE DUE I I .._ I I 100'.00 I O!.O, I 100'.00 13 PIlYSICIAN S. SUPPLlEn 5 81lllHO N.....E. ADORESS, IIPCOOE y~~ cHIROPRACTIC CLINIC 323 YORK ROAD CARLISLE. PA 17013 '"" 1\ 1 OElQ417<, '1011.. FORUUCF"1&00 t12.101 fORM OWCp.t&OO fORURRI.I&OO '101"'.......-...''''... u............ 'Iml.........um._.... I ' . I. ~,ptEAS~"l~ '''''-; DO NIIT II' STAPlE I IN THIS ,., AREA 2i' PRUDENT r" P.O. 80:"""'7 HORSHAM. r A l'~OI\4 n IIPICA HEALTH INSURANCE CLAIM FORM PICA lIT , UlDICARI UltHCAKJ CHAUPUS CHIJ,IPVA GROUP flCA) ~~THEn 1. ~~~05Ia~UU8ER tFORPROORAMlNlTlW I. A lH N ILtc; lUHQ 03 ",2-12027 h _.'..1 n ,-" n ,_"', SlNI n ,VA""I n '1l~",~' n',SSN/ ,101 Iii. .1~~,~~,_,~.iNlm., I '''.fII!:"~ SEX, M 4. 1!tUR~6 NAM~I~" N-""I F.'kNlmt. UOdIt InItlall tiAUS. TiNA RAE , ~ ",9 " n F' AS. NA ~A' I 'A'It:NrsAOORf6s~NO ,611"1 . PA1IEN1 RlLAtlONSHIP TO INSURED , IN!UnEO~ Aoonus INo ~~ll"ll Sl E. SOU H 5 REET ... Cf -0 CNldO """"0 1 . SOUT STREET CITY I SlAp~ . P"'If"'T .."'US CitY I STAlE CARLISLE .......0........0 """"0 CARLISLE PA ZPCODf tlUPHONE ltndudl AI.. CoOII ZIP COO~ I TElEPltON71INC\.UOE AREA COOf.I . 17013 ( 71 i) 243-4385 E~td n FuI 'lint n P.1t Tlmtn . 1 013 (71 ) 243-4385 StucMIlt 61"'1 . 9!~,'!.IN5UR!0_.,~~.~ .,.......,....-,_....) 10 hlroulc" IIlICONDnlOH 0 11. IN~URED6POUC.,QAOUPOR flCAHUUB(R HAUo;., TINII AE . OUIER INSURED 6 POlICY OR GROUP HUMBER . E..PlO.....E..n ICURRENT OR PRE '110051 . INSURED'S DA'W IIIATH SOX DYES 000 "8~ 9, Y59 "0 '0 , , b OTHlA INSURED 8 DATIE OF BIRTH 6U b. AUTO ACCKllNT? MClEtSlal.1 b tWPlOyr SHAME OR SCHOOl. HAUE WI , 00 , VY I In Fn OYfS ONll CAR . BARRACKS COMMISSARY ! I III L__I c, EMPlOVER 8 ~Alolh Of' ^c~ NAME C OTHER A[jENT? . ~~tl'5'Emr>ieRPIlOO""NA'" CARL. A R CK COMMISSARY YOI ONO d. INSURANCE PLAN NAME OR PRooR"'" HAUE lOd RESERVED fOR LOCAL USE d IS THERE ANOa~HEAL1HBENEFIT PLAtH O....ES NO '....'ttut"lo.nd~.Il.m..d c. Of '~~~~'O.. C II"""'" T....O.... 13 INSUREDSOR AUlHORIlED PEA50N 66KiNATURE l.uIihOlll. 12. PATlE"T 8 OR AUtHOAIZED PERSONS SIGNATURE I authotU.!tlI,...... Df.rty mtlkll Of olhtllnlOlmlllOnnectua'Y PI.,mtri ot ~ bI,.flll to '" undttlignM ph,1OIn Of suppllt tor :.c.........~ ''''\!U''''''1j'oI'''r'm--~-~ .....""'b~~'.~- -~b'fl'ature On File . :; 9na.: Jr-=, n e . -- .. s.....o , DATE _ SKlNEO._ --, ..--- - -- -- --......,. - - - --0 - - _.n '.~W~R~'1! ~ LlNESS 1~:'J:J::~IOIl A tl. IF PATtENT HAS HAD 6AUE OR 611.11tAA IUNESS 'I DATE6J::TlENr UNABLE rOWORK IHCUn:.ENl ~CUP~IOH INJUnYI II GIVE fIRST 0"'1 ...... I DO : 'IV I DO I YY I, ' PREONANCYIUAPI FROM I I TO I I ". HAUl 01 REFERRINQ PHYSK:IAN ORot..IR SOURCE 17.10. NUUIEROFREFERRlHO PHVSICIAN II HOSPitAliZAtION DATES RELAnO TOCURRIHt SERVICES .... I 00 I YY UW.DO. VY FAOU I I TO , , " AE6IRVlOFORlOCAlU5E to OUtllOE lAB? . CHARGU nyU noo I I ." DtAGNOSISon~AtuREOF lllHUSORINJURV (RELAtE IlEMS I.Uon_ to ItIMZU: BVLINEI t 12 ~CAIO RESU8MISSION l~1 ,~O ' 839.08 I O'UGINAL REF. NO ,. L-,_ ' . L-,_ 1:1 PRIOR AUtHORIZAHON NUMBER 7 ).,";1 .., 839,21 .., .... .L-, 'L-, .. A , C 0 I F G H I J . F OA'(ISIOF SERVICE, PIKa t~ PROCEDURES. 6(.MCES.OR SUPPLIES DIAGNOSIS RESERVED FOR . '::;: y~ 0 01 I~~~~'~.ra'l CODE . CHAROES OR Fa",1Iy EloIO COB LOCAL. USE WI Y .... 00 YY pt IfI R UNitS "'" O~: :?'3 : 94 O~: 28: 94 3 9921~ I , 1'::'4 30..00 , , , 97012 I 1234 , Of.: 2B:94 'Jt': 281 94 3 , 20..00 . , , : , 07101:91\ 07: 01: 94 3 99212 I , 1234 30,,00 . , , 07:01:91 0;'1 01: 94 3 97012 I , 1234 ~~.OO . , , , , , , I , , , , , , , , , , , , , I , . I , , , : , , , .' , , . :rI rEDERAL tAll: 10 NUMBER 65'"' EIN "' PAtiENt S ACCOUNt NO I ;~CcErt ~1~Nutll'" fl tOfAL CHAROE I I" AMOU'H rAID ) 0 )Q BALANCE DUE 41(l~OIl1\7. rtn HAU92960 Ofocwt tIJ 5. ,"NO) I 100:.00 I 0:.0 I 100:.00 VES NO 21 610UAlURe or rltvSICIAN on surrl tER 3Z HAUl AND ADDRESS Of fACility wltERE SERVICES WERE :U PItVSICIAN S. surrLIER S BilLING NAME. ADORESS~IP CODE INClUOI'1O DEGnfUon cmotHlIAl6 RENDERED I" othtllhl<'+ hornt Ot o"dl 0Ul!!~" CHIROPRACTIC eLI I C llrerl,.,~llhtllll""'hl'O'1"''''f'''' 323 YORI{ R'JA:l ~ 10 Itll' "".11d .'. rnalM. P1r11~tot I 0.0194 CAhL ISLE. PA 17013 1'''Nlo 1\10804475 I DAlE fl.". onr. (APPnoVED IV AMA COUNCil ~ t.llQICAl SERVICE &'181 W... "....'1 A,iI Pr... e..I....... IBIIIII,. PLEASE PRINT OR Tr,PE fORUllcrA l~ III tol ronMowCPIPrOO ,onUAhB.t&oo '131"-..........tt,,"1 ' "" .....~fl.It'..-..." tII'"I''''''' Pt.tABE DO!T BTA E INTHB AREA PIW[IENT' ~ J.l,u. UO;~7 HlJnSHAM. t"A 19\14.\ T I II IrlCA HEALTH INSURANCE CLAIM FOR PICA flT '''fOICARI UEOICAIO CHAUPU8 tHAMPYA ~~~':" --:!.~~A 1 ~OlllEn " '4S~~&'!3M"2'~~2027 tfORPROORAWWIII" 'I H A 1H AN BUt lUNG li'_..."n'.......dllnl_....SN1 n /VAF"" n ,l~..l;l, 'n',ss", "01 l'lffl' J" . Il.l!,...T'.r"'IN."",~InIl'all I' .~~N'~JI~'~A'( 61K ,~ . tNJ.URf.t}' NAME lUll NIIM. hil HlmI. tudlI ntaall 1 IN~ rlll!: 'ell: ~ 9.. n , ",A l:. I PA'IEN' 8 ADDnE.ss1No. 611te\1 . PATlEN' RELA1)QNSHlP lOIHSUREO , ..~Ul'O~~'g&\.\.,f.t"'t'TREET ~I E. ~~u H 6TREET hlf Cf -0 -0 """'0 CITY. \S1~'A . PATIENt &lAlUS C"CARLl!:>LE I SlAilA (:",,,_\' ,\.t: .......0........0 """'0 liP COO~ \ 1(l~r~. 1- ....Ji...S liP COOl TElEr~7!'NClllllE ~RIA~~~1 . l/Ul" ( ) 243- 3 5 '-'''n '''''....n P.'"....n . 7013 ( 1) ~1\3- 5 $ludenI 6ludlt"l I '~?Ai'n.IHSU"tlill~l.,U.ll.a" "ami. ,....1 Namt, 'I I I.V.U"...."W ,,0 II INSURED 15 POlICY GROUP OR fICA NUMOlA ~; I'll: .OlHERINSUREDSPa.ICYORGROUPNUt.l8f.R . UIPLOVWEHT? levARtH' OR PREVIOUS) . INSUREr.d DA'~ B1RIU .IK I OVES 0"" 1: 9. ~9 "0 ,~ . , b omER INSURED S DAn Of 1IATr 6Elt 'n b AutO ACClOfHt? PlACE 16111.1 tI EMPLOYER 6 HAUE OR 6CltOOL NAUE ~ I' DP':! v<l\'1 .n OVES 000 BARRACK5 COMtlI SSARY ,! ... L__I ~_ '....PLOYER 6 HAUE OR &CtfOQL HAUE caTHER ACCIO(NU c tNSURANCE PLAH NAME OR pnoon"'" NAME lI\Rn(\CK~ '.lJM~II'.,SI"kY dyES o NIl PRUDENTIAL d tti6UnANCE rLAN NAUE on PROORAM NAME tad RESERVED fOR LOCAL USE d ISTHEnEAHo~nHEALTHSENEFI1P\.AN" DYE6 NO .r....lufn1a.ndtomPtl...."'...d ~~~.!'~~~~.~,o COIIl'LII'" ~ ~U' "''''01''', t3 INSUREDSOR AUTHORllEO PEnSQfj 6 SIGNATURE 1.\Ilhot\l. 12 PAtiENT S on AUT..onlllD rERSON S SIGNAtuRE I tuthOtl,,1ht ,tit... oI.n, f\WdCtl or oIheI.-.IOImlllQn "K""" pI,ment 01 ~..t "'ntltt. to Iht ~llO* ph,~ or auppIIrtf lot :::C"''''' c:,"" ,tI" t""'l pI~nl 01 CIO:!'l'!; beneNt.....1o m"" 0110" r>>rtbwho tott'PI ...~ tefYlCft dtWrt "'low \, ?np u,'e On F e 7-14-94 ~ gnBturo On Fila , SIGNED - ~_n ' ~ u._." .---- -.---- DATE ... ~.- SIGNED .. t4JytE Of CURRENT: ~ IL\.N[SS ~,~IOR " "PATIENT UAS UAD SAME on 6IMI\.AR fL\.NESS II. DATE6.r.ATlE~UNASLE to WORK tN CURRENT ~CUPA11ON l' ~~,' 'tJ1\ ...URVI .., GIVE fiRST DATE MM . DO t "IY ... I I YY ..... I ,YY I ~ -, PREGNANCYlLUPI ' , FROM I t TO t t " HAUE or REFERRIHO PH'stCIAN OR OTHER &OURCE 1'.10 NUUIEAOf REfERRINGPtlYS\CIAN II HOSPITALlZATKlN DATU RELATED TO CURRENT SlRVeU UJr.I,DOI"IY tr.IUIDO,VY FROM I! TO I I " RnERVED FOR LOCAL USE 20 OUTSIDE LAS" I ' CHARGES DYES noo I '1 DlAGNOSIS OR NAtUAl Of tlLNE5SOR INJURY ,RELAn IlEMS I,UOR410111M'US'tLlNEI + '2 tJ68ICAIO R16USUISSlON !.:(lI,,::!U 839.08 C I I ORIGINAL REF NO , L--,_ · L--,- 23 PRIOf1 AutHORIZAtION NUMBER .,.,., ", . I 839.21 . ~.,c . C . 0 " I J . FIB:'1l15IOf &ERVICE1o ...." "po PAOC!fiURU.. SERV~ES. OR SUPPLIES DIAGNOSIS RE6fRVED FOR ..~ YY UM 00 D' DI "DT~~":t~IUI~~I~.nt." cOIlE , C..AnGES OIl r.m"t '''0 COB LOCAl. USE .... yY UNitS ...., ';i: ",.'': :':'1\ ():': 0,,1 ~"^ J 1~'.92 \.. I . 12:',1 I 3~,OO l , . , , 197012 I I , ( -' :~d , , }/; or- 07: ()6i'1-41 '3 , 1:,:11\ 20.00 . , , , , , , , , , .,'" , ~ :"11 0il' 13: 91\ :I '99212 I , 1211\ I 3Q.00 " , , . , J :oq,1 970,1.2 I , , 'J,' : 1 (''''' 1 ;,: 94 '3 1;?3A 20" 00 "' , , . , , , , , I , , , , , : , , , . , , : , , . I , , " , , , , , . r!l F(DERAL "")110 HUMBlR 65N flU " PATIlN16ACCOUNT NO ~tCCEPT f91~1lt,l(f4T' n T01A\.CHAnGE ~n AMOUNT P~10 30 BALANCE DUE " (,,?1)"471:, rln H!lUn980 01 gorl cl.. I 1Mbldo.l 1 100:.00, O:.OC I 100:.00 VES . UO 3' 6lGUAlum: or flllfSCIAtlOn 6urNIEn 32 NAUE 1..10 AOORf5S OF fACility WU[flE LEl1VlCf5W[nE 31 PU'tGlCIA.f &, SUPPLIER S BlllIUG HAIolE. ADORl-SS.IIP CODE ttlCLUOIUQ DEaREES on CREOENTIALS REUOEREDI"Ol~ Ihtn home 01 on"'l tf(1t'~f CHIROPr<!lCT IC CLINIC tl c:.rtll, thlllht ,t.ttm.ml 0tI thf ,...tM iIpJlI, 10 lhll boIt.M '" ",.61. JlAt1IM1'011 :12'3 YORK ROAD , ,,:" r.1.' " 071 ?91\ CARl. I o:.LE . r,~ 17012 I"KlUlU 1\1000ol1\7r;. I DAn rltl' fillP. M T ! IArflRovtOe't AMACOUUCIL OOMEOICAL6fnvlCf: III) "14 bJ "'tloc.IA".",,, c......... IIOOU.'I" PLEASE PRINT OR TVPE ronu tlef A IMlO IU tol ronuowCPIMMJ ronuRno Ir,oo ,lll" ~ .........u..'" o....~I""""UUU........Il.I.._.... .", . . Pl.tASE DO~l SlAP E INTHS AREA PHUDEN r r /I'. P .C', lI0 ""~7 HOR€.H!lM. . A 1904 <I I I IrlCA HEALTH INSURANCE CLAIM FORM PICA ITT , "EDICA"I UlDICAID CltA,lr,lpua CHAUPVA DIloup ~ICA ~OI"'n " 'Il't~1ll8S,jl.l~~l!.lr2027 (fUn PAOO"A'" tN nUl 'I 1'''''*...." n I~llf " r, ,SDontcwl ~J n ,vA f. II N1:~I":;jAN nOIMLUNO (i I I or I 155"11 ,/P) ~ r.tt\~,' ~"T~'II,\N'~,{~""mo -'''''''1 I' , , I \fj~" SI~ · "fj'IWj\~~"'W~~"'rfffl!"mo _....,' , , ..n, , ':ft'.~' U~~\~'f't~ .~~~RE[ r ~'d AELAtlONSHIP tOlN5UnlO , ~'f''lf~OO~b'lJ'flf''~TREET s.lI -"0 c""O 0""0 G"'\I ~1. 1'.1. [' S1~~ 1 PAlIIN:d'US C"l:ARLl SLE. _1S1'~I,~ &note ....1I1t1d 0 0''''0 "~C'f~OI ' I I;"Pl~' 1~~!!~~5 l"tdn ''''limen r."'llntn "~C"1'~013 lIl("~~i~Y/'!!'h^Ji'J!.' Sludtot SlucHol ~ PrWW~su"f~ 1 ?~~'/~l\'l"'mo. "" Nomo,"_ ...... " ,...',U<TSlAJ'lU,,,,,,,,,m,,ulU 11..SUREUSPouc'tonoupoonCANUM8IR . otHfR 'fiSURID S POlICY OR GROUP NUU8ER . lIolPLOYMOU'PccunRENI cmrnEvoosl . ..sunlllaf,A'/i,~B\'Y,~ SIX '0 O'ES CJNIl , , "0 , , b OTllEn INSURED s D"lE or BtnlH SIX b AUto ACCIDENU PlACE 15111') "~rA~e~N'l'tA~ffA'eM''''COMMIS~,ARY .... I 00 I yy '''n 'n Om ONO , , L I , , C EUPl,'r'ER S NA'-Af 'r.' sc,~ U"I,lE c otUERACCIDE~I' , ~'k"tJ15~.f'f 'r~Lon PIlOOII." NA., "N: . ~'I' i ""0,':' l:(lt11'11 ~,'5ARY DyES OliO , d INSURAtieE PLAN NAUE OR rnOOf\A1,l NAME ICd RESERVED 'on LOCAl USE d IS tHERE ANOaR ttEALlIl BENEFIt PLAN' DVES NO ""' "lu,"IO'I1d~I'''''"''d 1II'..!'~~.~, ..OM 'lfO~~ ~u'~"U"NQ 1 ...NINO ".. '.OM, 13 INSUnED S OR AUtHORIZED PERSON 6 SIGNAtURE l.utI'!)lllt 12 PAIIENt 80n AUltfORllEDPERS0N6 SIGNAtURE I IuthoflltIht""'u oI.rlrtllllCkIlOlOtht'IIIIOlm.hOnN<.lwr Plrmtnl of mtdul.,."tllo tn, ~llUrotd pn~lJN" or lupp..r 101 "..-.''1'..... I... l-II PO'"'tl" "'1!"fTE....... ....." m.... ~ "... PO"b")'! !'J~' .~_ ......... ""\,,"'f tJ'frll t u r e On Fill .... ~!~111~ ure 11 e _ _ SIGt<<D. _u . __._.u_" ..-- - -- ~~ . - ..~-- DAte h SIGNED - "J:l!~~ne~~' ~ IUNESSt::r~loR A 1. If PATlUn +tAS "AD SAME OR SIMilAR k.lNESS .1 OA1E\CAIIENl UNABLE to WORM IN cunnUH g&CUPAllON INJURy I nil OIVE 'IRSt DAtI MY I DO , VY U,ODIVY MM. ,VY I ._, PREONANC'r'llMPI , , fROM I I to" 11 HAUE Of RlFERRINOPHVSlClANOAOTHER SOURCE 1,. 10 NUUBERQf REFERRING PttVSICIAN l' UOSPlf,lUIA1K>N DAlES RElAIED lOCURRENI SERVICES "'M I DO I VY MU I DO I YY 'ROU , , 10 , , l' RESERVED fOR LOCAL USE 10 OUISIDE LAB' . CHAROES OYES nNO I I .. .'AONOSIS OllllA'une on'NESS OR INJUny .RII.'( "'''S I.U OR' '0 II'" ,.. BHINII t 2' M(OICAIO RESUBMISSION UlI . ;:0 639. OE: coo, I ORIGINAL REF NO , L--,_ , L--,_ ~.J PRIOR AUlHORIZAtlON NUMOER , /.":'J. _, 639.21 , L-- . '---., . " A B C 0 , 0 It , J . "c&nAIE1SI OF" SERVleEto Plan I,.. PROC~OURES, 6fRVlClS, on SUPPLIES DIAGNOSIS flt\'\., RESERVED too .. ., I~~~ ~'UI~~~I~'I'Q'I COOl . CHARGES OR (UG COB LOCAL USE .... no 'r'Y 'M... 00 yy Pft}i r IF UNIIS r~" ~"'\; : ,:.':' "~" 07: .?2: '~4 3 99212 I , 1234 , 30',00 , , , , , ".." , . : '~1 '}7: .?:?: 94 3 9701: I , 12'?4 20:,00 ., , "'- , , . , : , , , , , , I , , , .. , , , , , , : , , , , , I , , : : , , : - : , . , , , , , I , , , , , , , . I : , , , , . , , , , , , " , ;, 10'" CI:.IIO[ ~i> '''OUNI PAlO", .ALAlle! Olii- . ;5 H()(nAj 'UIO HUUOEA 6a~; H PAlIENI SACCOUNI NO I ~~ reCE,.I "'SSl(i'~I.4Hjf' " I' \('. \ ,", 1 ::'~. H!lU929130 .Jj Of 00.... tt~~~ '" Nt.' v~_ . 50::(I() -'- o:,Ot; I !:.O~ 31 Sl(lPI"wnE or "....Slo.:lMI on SUPPLIER 31 "AUF APmAOOR(SS or fACiliTY WIl[Rl StflvlCES WEllE ]) rIlY!,ICIA', S. SUPPII[ n & BillING NAIr,l[ A[IOnESS III' COUl ....e11101N0 OEGn[Eson cn[O[tHlAl 5 REND[nEOI"~'ff th.ntlomtOl Dflu) (JO"'~~ CHIRO~RM::TIC ell N I C II "ft"r th., IhI II.IlPfYltrll. 00 tht "."11 .pp1,kllf..,blt.f1d"'''''cUI.p.al1lh.,.oIl 32 :~ \'ORK f::OAtJ , 'I.' I. ,..'( OnO~4 CAr,L ISLE, l'{, PO 1:1 1'''N'o 410e044n, I. DAtE "!tl' (HW, T I I (ArrnOVEnnYAUACOUtiCH ,...' . ~,..ALSUWlCE..al M'd .., ....UI A'" "... h"...lt'JOJlUUI PLfiASfi PRINT OR TYPfi roruA'ICrA'ftOO 11'101 ronUOWtf'IMIO 'OmiARD 1&00 "ll" -.......,."...."1 UN 1I"l~ 1_..- Ut.1I .-.fll' '11l..'''....~ .._, '. . . Pl.bSE DONr;T STAP E INTHS AREA PRUDENT' ........ J:'.O, BQ~' ,>7 HORSHAM, PA 19044 A"~HOVlD QUI OUt 0001 T 11.ItA HEALTH INSURANCE CLAIM FORM 'MfDICARf MEDICAID CHAUPUa CHAMPVA o"OUfi ~lCA].....l.l OllilA II "SUREOSIO HUMBER tfOR PROORAWlHlllW 'I If-'I n,-."ln,_...NI n WAF.'I n 'll~'~16IANnB\:~NOI'l"OI 4(,NO",El52-1:::027 ILltIH.mt,rU1H.rne. I I -:'~I~~l~ SU . WiSURED6HAUE(L..IHIIflI.h&IH.me,MIddlIkVl...1 '.'''\)'"'' T I Nt'I fll\f: 'e'1: 1~ ~9 "n , r1 SAM!:: I t'AIENl 8 AOORISS IHo, 51'''11 "'-'I(H' RlLA1KlHSHIP 10 INSURED ,. INSURED 8 AOORlSSlNo ,61'..11 ~,1 r" C.'J\JTIl STREET ...Cl......Oc.....O """'0 51 E. SOUTH STREET T CI1Y IS1All . P"IIlNT &lA1US CITY ! ""t~L1.~.u, PA .......~ "''''''0 0.....0 CAHLISLF. ltfl COOE 11ELEPttOHE IIndudt Ar.. Code, ZIP CODE 1701:' (71'1 243-4385 (_r"'~''''''''-P''''''',-, . 17013 -I I 51U01f1t w I I 51udtnl LJ (Lall Hame, h.. I 10 IS PAll IlTtOH RE SA~\[;' .OlttlR..SUREDIPOltCYOAGROUPNUUIlR I b OTHERtNSURE080ATEOFIIRIH SEX 't'IJ: ~.~ Yi!;'~ I "n F~ c 'UPLonA 6 HAUE OR SCUOOl NAME Q"r~""~s tOMMISS~~Y d ~SURAHCE PLAN NAUE OR PROQRAU HAUE I EUPLOVUENT't (CURRENT OR PREVIOUS) om tjoo b AUTO ACCIOlNU PLACE ISl.I'l om '. 000 I..' c OUtER ACClDENn Cl vu 000 I~ RESERVEPFORLOCALUSE . .~"-~ ..co 00: r~,.~!O."!' ~ 010...0 ,.. FOFIll, II PATIENTS OR AUlHORIZED PEASON 6 StONATURE I......... thI ,...... ot anr ",,*"01 ~ lnlonnlllonlllCeu'", 10 poct" this tlatrn 'aI&o IIQUtIl parment DllO"'rwnanl btnIhIIHhtr to""",, Of lO" party .lOCtpt, 1'1igIWnInt - SI<1I'oilt.ure On File 08-00-94 SIGNED. . .__. __. ~_. _...-__w "t(;n or CURRE.NI ~ ,,'NUS I"" .........., OIl I DD-l 'iT A INJURY 1,,"*011 OR . ~ I "".:f:4' ." PAEONANC'f'llMPI 11 ....Uf OF AErERRlNO PHYSICI..... OR DlmR &OUAt! .__._ ~_ DATE._ _. 'I IF 'A"ENT HAS ..AD SAUE OR SlYll"R ILLNESS OWE 'IRBT DAlE "'U I 00 I 'IV , , ,7aIDHUUBER(WREfERRIHOPHYSLCIAN tI RESERVED FOR LOCAL USE 'I DIAONOSISOR NA1URE Of IlLNUBORINJURv_IRElAIE IffU. 1.UOR' lOITEU24EBvlINEI t ,f,I.<, '(, ,8'39,00 1 l--_._ 3 .- , . . I:" ,:"1,:- .. A ,,~IEISI or SERVtCETo tAU 00 'tv M'" 00 VY r.'.'I~~ll~:'1 ')Il:C~:t')" t . 1 R::l'~. 2\ o PROCEDURES. SERVICES. OR SUPPLIES "_PT~~~UI~~.:nce'l I~qq:?\:? I : 11'1:'010 I E 01..000$11 COOl 8 C P"', I,.. .1 .. '3 3 ~ 1:::2'1 I I 1?'.l'1 ~,n: (I ~ :-:'1- ' , 14 . , f)'I: ('~: 3 nr": n, :.-:11 t'''I~ O~: CJt\ : , , , , ! : . , , , , , : , , . "7011\ I , , II I , , I , , , I , " , 1234 . :: :: ~.. ,. FlorRAl "'Il I P HUMBER 5SN fiN ~'0~0A~7? ~[] JI SIGNA1UAE Of PIl,SICIAN OR surr~If.R INClUDING Of GRr Ell OR cnWrtHlAl& tlt~II,lh'llh"I'I,.,...nl'onltlf'.y.". .Alt, 10 ",,' tltlI.rtd ,'. n~d" paf1Iha'tolI 0'.1(,(,,"'4 " PAIIENI BACCou,..T NO I i'1' "icet,., ASStOW.4UlT' '01 govt t/!~t' '" b'l),1 HAU'nQI30 VIS I '1 NO 32 N4...[ ANOADPRE6S OF 'ACIlI1't' WI1[RE SU~YtCES '(viRE nENDUUDII!"'" lh.nhofN 01 ottul I.,or"o OAIl IAPpnOVEO 8Y AUA COl,JtlCll 00 UEllICAl!llnYICE Itl, Mid bt MMltal Arh ,,,.. t..I...." I_UIII" PLEASE PRINT OR TYPE PitA rrT 1 "AlE I J:'A 11llfPHONE (INCLUDE AREA COOlI (717) ~43-4:~8S II WiSURED B POlICY GROUP OR FECA NUU8f.R . IN&UREn..~ DATLOf' BIRTH "'Cll! '1'~ Vil9 "0 b tt.lP\.OYER 8 NAYE OR SCHOOl.. NAME BARRACKS COMMISSARY SEM F~ c INSURANCE PLAN HAUl OR PROORAU HAUl PRUDENTIAL d IS THIRE ANOTHER HEALTH BEHEfIT PlAN? DyES c?J' NO . ".. fllUfn to.nd compIIt....m lid 1:1IHSURlD'S OR AUTHORIZED PERSOHI SIGNATURE I.UIhoIllt per"""' lit ",,*&1 bentl.. to the "'*'.... pItrIOIn or IUPIMr lot --- 5ignetur~ On Filu SIGNED \I DAns 'A'lEN' UNABlE '0 WOIll< IN CURREN' OCCUPA'ION .......oo,y'i UU.OOIVY FROM I I TO' I tI HQSPITAlIZATIOHDAln RElATED TOCUARENI SERVteU UU,OD.VY WU1OD1'rY FROM " 10' I to OlJl$IOELAB' 'CHARGES nvn nNO I I " MEDICAID RUueloltSSION COOl I ORIGINAL REF NO 23 PRIORAU1HOR1LATIOHNlAIBER F It o RESERVED ,on LOCAL USE Q . CHARGES on r""..,.", COB UNITS flYn dAG 30:.00 , , 15: .00 , , 20.00 2110lAl CHARGE I" AUQUNI PAID 30 BALANCE DUE I i!>5:.'JOI. O:.O( I (",:.00 u rUvStCIAN&. 6UPNIER & 8flllNG NAUE,ADDAESS IIPCOOE ,ftJlN~, C.H I ROPP.IICT IC ':LINIC :t~:. VORl.. "'JMJ CARL1SLr. PA 17013 410801\1\7'" I rltll onr. ,om"ltcr A IfloC) 111 tol 'OOUOWCP1&OO fORlolhR81'OO 'lJIU.......I"'u....u U.....I~'UI...--.f11I..""'__ PL'EA~E ~ .. DONOH. ~ ~ ~~~: IJI -^" AREA ~~1J\ . 1 1 l'lt' HEALTH INSURANCE CLAIM FORM I "fDIt'A( ~DIC'IO..~. CH''''US CH''''V'. ~ ~~*~trl'N ~::':~llNG XUlltI. "'~~!\l~~~~~!.lr2027 tlr&lf6t...."[lI~""1 l,s,.on.lY.ISNJ OWA'.', U f~SN.."iOJ ,0'5SNI nflOJ ',r:' . ,'l,.!-T!'!!!I,.....,U_...."I 1>~II\1i'9"'" '>I . ~~f~~N...l'I."N.....,'."N............""." hll"", I 1,,"\ H!lto ~1: Ip~ ~ .. n , rl .. .,f.'lEljJ..tl\l~rJt'tis"~ 1 P.III~.,..IIONI'trP'O'NSUIIIO "'f'~~ooogMff"~TREET ,.1 E. ~c 5 fiEET "'0"""0 c'''O "''''0 T CItV "'~IA · p,"lNI S[jWI C1T'l.ARL I.o.LE I \ flPI H,I.E p DO\- ~ \I' ~ M'II~ 0"-., l'i'~PI1E'~~~~'j'~5 PRUDENTI"" , P.O. BO:~7 HORSHAM. ...A 123~~ 2~.00 ' I~' ",ceEP', 'iA!ifsS,ltU4Mftfl' II lOTAl CIlARG~otIll" AUOU,..f PAID 30 BAlA,E DUE rOlOO~CI'If~".b't~1 1"t:, 0 0" t "'00 VIS 'NO I 0'" I " ," I '.:>:. 32 NAME AtIOADORESS Of fACI~IlV WllUU 6[nVlt:ES WEnE 3J Ptl't'SICIANS surr'ltERS bilLING NAUE, ADDRESS llPeOO{ AI"O'AIO'".'.....,,_.~."..I OO~IH CHIROPRAC TIC CLINIC 323 YORK ROAD CARLISLE, PA 17013 1\10804475 I rill' onr. Z'PCQIlI.) ~ . I" 1.., (mpared,..., Full TImt,.-, P.rt"ImIr--t I I Studt". I I Sludlnt L I .. ISP'\llNIIC""OI nu ~U Illt' ",me, '..'I mini,....... IMIIII . OY~En INSUREl- OJ POlICY OR QROUP NUMIIER . EMPLOYMEN" ICURREN'~R PREVIOUS' om ONO b AUTO ACCIOlNT' PLACE 161.1., Om ONO I I c OTHERACCIIjIENt? Om ONll Hid nESERYEP ton LOCAL USE b OTHJ" If1SUREQ.& DATE Of' Blnm SEX ulll, lll)'j vy.'~ I .~ ,. UI I , l"~Qvln I N'''l OR IC""PI N'Y' l'f'tr~I:t'IC~' C:. l '...'Mi 11 ':..':,(\RY 'n d INSURA'K:E PLAN NAUE on PROORAM HAUf ,,~!'D"C' D, 'D." '''GAI CDtlP'"_'ING IIlGN'NG'''' 'GAw. I' PATIENT 5 on AU1UOnllED PEnsON S SIONAIURE 11uttlo"" I'" f...." of In, mtekll Ot 0111" In!onn.bon ntc.u." 10 ~""...,..... ,....,....." po,..,~I.,.....'J"'jI~ ....... ......,. m.... ",... ....,,'ItlD "I.... ."....... - ,.g11l11l11ra Unt-lle Vtl-lb-."q slOtno _.___ H __.n _ _ _. __ "O'J"~,CUAIltNI ~ 'INISI"." """"omlOR ilia I p[t.{ 'fYq INJURYIAttldeNIOR .. PAEONANeVllUP! 17 HAllE Of REFERRING PHySICIAN OR OlHER &OUnCE ..., DATE _ __ II IF P~T1EN' HAS HAD SAUE on 61li!llAR ILlNE6S GivE FIRST DATE MU , DO I V\' , , 17. 10 NUMBER Of REFERRING PIlYSICIAN l' RUERYEO FOR LOCAL USE II DIAtl~IUS~.tlA1UREOf IUNE6SORINJURV IRElAIE ilEUS t.2.30n~ TO'flUlUBVlINEI---, ~~l .~O 8J9,Oa, , L-,_ . 1-,_ T ... "" .~ ! Il.:~ .~ . . fllM-TEISIOF SERVICE To MY On VVUt.t 00 VY '."1, r-', " "... "J~ 039,21 'I-, D RCX:~~~~~~, &ERV'!=ES. 00 SUPPLIES t~~~~ UnuIUl,t .~~~S"nttIJ PIlltl:Pcs I MonlFlFR -, . po", .. C '." .. , l DIAGNOSIS COOE - .1~34 , ....,A , 12.31\ I 1231\ I , , I ,'" n, "'" I , , , ., , , . Illl: 1 n: '.'4 , , )~I: 1.0: ':'J4 . , I , O~' illtSl4 -3 -- 97010 'I 't.- . : , , , i)~ --03: 94 3- 9,v. I , C~.': J 0: q4 3 ,99212 I 97010 I 97014 I P! PAflENI 8 ACCOUNT HO HAU92980 08, 1 C': '~4 3 Ilf!~ 1 f) : '~4 ~1f1, I IS fEOEn"L "'Ill 0 NUUBER ,11 '110 1 '17~, 3" .. ~ (:: ~., Ii 65N IN Mn 31 SIGNATURE Of ".f't'SlCIANon SUPPlIER 1t4ClUDINO ('lEGAtES on cnEOENllAlS Ilctr"'I'"'llh"I"',,*,,'O"I~"w"" APP'r 10 this b<II.IlCI... madf. pefllh,ltoll 1."N.11 08Jt,94 "'" (APPROVED By AUA COO'lCll ON UEDICAl SERYICE 'UI ..hi '" ...." A,ts P,." t..I...... IIlJ)UU", PLEASE PRINT OR TYPE 19041\ PIC' 11'1 Iron PROORAM W I1EW \) I I SI'IJA lll(PIlIlI<U'NC'~Dt """ ~OJ>l.I5 (I'll) ,<'I..'-'Utl It. INSURIO 8 POllCV GROUP OA riCA NUUIIR ZIPC.""17013 · ""UIIIll.J~'I&,~B~~ 0 " .. , , · IIlfA~fM~sORE6m{r~'sARY ... '0 - , "~tl'6'{m1'Xlo. '"00.... N'.., d IS TH(RI ANO~R U[AlTH BENE'It PlAN' DyES 0 NO "...."lumlo.l"ldt~I.II.m'.d I' INSUnEOSOR AUTHORIlEOPlRSON&610NA1URE I.uthot.,. pI,menl 01 mtdc.1 bentlll' to !hi undI'JV'Id JlhrSOIn Cll' I~!of ..........~\1I'rature On File. StONED II OAtE&PAfIEN1 UNABlI 10WOAK IN CURREN1OCCUPA1tOH UM,ODI'n UU,OOIYV fROM I I TO" II HOSPI1AlIZAflON OATES RElATED toCURRlN1 6ERVK:E& ......IDDI'n MM1DDlVY FROU I I 10 I I ro OUTSlOE LAB? 'CHARGES Om riND I I 22 UEPICAID RESUBMISSION CODE I ORIGINAL REF NO IJ PRIOR AutlK>RIZATION NUMBER , G .. I uon" 'F~:~: UNitS Plln , J . RESERVED FOR lOCAl USE . CIIAROES EUG COB - ~,-Q() 1 , . r' GO :1:9. J1 , "" ",. ~ 1 , Jq,oo ~ lei.OO rORM lteFA IMler (IUOI rORU ower I~ tORU nnB Ir.oct '''I''-~i\f"...." UtI ..........."'.......-..1....1..'....... '" . PLEA!iE , DONOT · STAPLE IN THIS AREA PRUDENT 1(\', P.O. Bo:M'l HOr,$HAM. A I '~044 T ! 1 I \rICA HEALTH INSURANCE CLAIM FORM 'ICA I rr I "EPICA"I UlDICAIO CHAU'UI tHAW,YA QROUP ~(CA XO'H(R .. 'll'tiI\l~~e!~i~Ilf!2()2l ,fOR PROQRAMIN IIi'" 'I I ~I fLlfck'" II n IUfdlC'od II n ,Sppnt4W. 5SN, n fVA'" " ':l'~1H~AN ""lUNIln, I 5 tJI I" n' ,SSNJ 1101 IW,"'!!" ~ N""'~Il\H'r.r\e' N...._ ""'" , :Vi" ,n 60 ~ 4 ~~~ "AME (La" Name. f.., N.mt. MddIt ""'1111 , ! ' .. I '1,~t'IE~~ ~ Alf,'/Ierl'l'~ SV~'I'HEE T . PA'IE""J RElAtIONSHIP 10 INSURED , "t'fE,\!~OO~bm~"~TRCET hlf d -..0 C"''''O 0"'''0 9.'~ "r I.'~~ . rA'IlHl d'US c"l:ARL ISLE 16lAIJA _, r,1. . ..I.,. ....... .......0 ......0 "~ c'r,o 0 1 .:> 1'(~rl~f 1~~!!~1i5 t.pdn fulttmln p'f11~n IlPc.oo'1.7013 Tm'~flNC'12h ~!.A,f~'S Sh,ldtnt Stude", ( ) i '~~^~~~lN~UnEDI NAUE It..i H.mi. ,.., Hlme. MGtlI kWll, .0 IIPA'''NIS CONOillON RfLA"O '0 t I INSURED I pouc't GROUP oR fleA HUMBER . O}l'ER INSUREO&POlIC't' OR QROU,..IJMIlR . IY'LOVWENTl ICURREd= PREvKlUSI . ,,,ullfll.n..'&..~.\!lt'!j .u IrJ OVIS 00 , , "0 I , , b otltERINSUR[~lIOATlOfIIR'H 6E1l 'n b AU10 ACCIOlNt? PIACEI5l1l'l · Et'fA'm\',\t~sOll~~'sARV ....). ""iI? I.n -,' OVIS ONO ,. .. I ..1 c E",r LOyER 6 NAUf on 6MtOOl. NAME t otHER AC~ENn c ~V~tl'f,'Ef.ff r~l"" '"00"A" NA'" PIIRla.lI<'.S LO ~\l :.S f',R V VU ONO d INSURAtfCE PLAN NAUE on fROGR...M NAME IOd RESERYEO fOR lOCAL USE d IS tHERE ANotHER HE"'ltH BENEflf PL.AN? Om 000 "re. "l\,lf" lo.nd compItl.ll.m'. d ~"~!'C'OI'fO'''''lfO''~V 08110 00., '3 INSUREOBOR ...UIHOOllEDPERSOHS6IGNAtURE I.ulhorll' " PAtiENT SonAU1HORIlEDPERSONS SIONA1URE 1 a.Jthot1I. iN ,....,,01 an,"",*alOl 0.... tnIoll".llOl\ntC.".'Y paymtnl 01 mtdttal bel'll"I' k) N undIl.q1ed ph)',oan cw tuppbtl tor lOP...... .....~.. '....l....." P''''t)' ~ "r'm-M' -... m..... .'..... ""'b'lr~"W"'" -'''~~'fI'ature On File _ ~,\,lna lll"e n e -~ - 1 SIGNED. . ." .-.- DATE .. SIGNED ".i:[I"&ij"OJ'lI ~ .'NUSr""'~'O" ,. If ,A1IENT H.... H"'O 'AME OR SIMILAR IlLNISS II DAll'J:"'TIE~NA'l$ 10 WORK IN CURRINT ~CU'ATION . I' INJURY I Cddtnl) Olvt t:IRIt OA1' tAt I 00 ' yy Mil V ...... I I VV - ! I f'REON...NCYtUAPI . , t:ROM 1 I TO" ". ,,"'ME OF R(f(RRINO PHYSICIAN OR at HER BOURCE ". I D. N\AIIEROf' REfERRING PHySICIAN tl UOSPI''''LIlATION o...ns RELAnD 10 C~RlNT 6ERVICU UM,OO,YY "'IODIV'tf t:ROM I! TO" It RESERVED fOR lOCAL USE 20 outSIDE LAB' I CHARon I nVU nOO I It DIA~NOSIS D.R .NAtuRE or IllNUS OR INJUR'(. IRElA'E nu..s I.U OR 4 to ITEM UE BY liNE) t 2i t.4&8ICAID RUUBMISSION ~Vl .~O 639.08 C E I onlOlNAl REF NO ,1--,- .1--,- U PRtOR AUmORIIA'lON NUMBER I 117:'~.,;; 839,21 . I-- . A B C ( I 0 H I " '10:11111 or StRVICE,o Plac. "" PROC~DURES. SERVICES, OR SUPPLIES DIAONOSIS RESERYED ,an "Do yy .... 00 ~ .. r:p,~~~~!~~~'~'IU'1 cOOl I CHAROU 011 hm_, f"G COB lOCAl. USE .... yy p r In UNits Pia" ("'11: \ l :':)11 "El; 17: 94 3 1 .99214 I , 1;;:34 50:.00 , . Il?7C12 I , . ('Ir:,,: , 7 :'-111 (1(1: 17:94 J . 1234 20:.00 , , . . , , 72010 I , {Ih ~ '_ 7 :'.")4 ~B: 1:': '14 3 c;. , 12')1\ 65:.00 ! . . , 72020 I , , 'p~ 1'" 101j I}OI ~i:~4 '3 1234 S~,OO : .: , . , 72120 I , , (}R ~ 1'7 :"4 On., 17:94 3 S , 1234 60,,00 . \ , ;U1 :"11 1, '~n12 I , , 'J>:l: OR: 211;ql'l " , 1234 30..00 . '!I tEUEnAlt.... 10 HUUSER 5;;1 IN " rAlItNtS AC.c:.OUtjl NO 1-'7 teCH1 AS'iII1N'.UU" u totAL CHARGE ~ it AMOUNt PAID 30 ""Net WE 1H'''O~17':> ,hi HAU92?OO ~OfUO'l'l tl!jt ,"bW-1 , 275:.00 1 o;.oc . ,;7...,;.00 yES L NO 31 SIGNAtURE Of PUYSICIAN OR SUPP\I[R 32 NAME Arm ADonES5 or ,A(1111Y 'WHERE SERVlclS WiRE U f'U'1'61CIAN 6 SUPPLIER Ii Blllllfll NAME. ADonus liP cODE INClUOlua OlORHI OR CR[[1(t,'IA\S RE.NDERED III Olhtftt1."horne01 0"1(.'1 llm~' CHiROPRACTIC tLlNIC llt.'I,lflh'IIhl'I"tm.nll onlh'tP."" .pp1, 101M boI end ,r. ",'M . p.I'llh".oI1 32:' YORK ROAD 090194 CAQU5LE. p" 170D 10"'N'" UAtt 4108041\75 I rill' onp, ! IAPPROVED BY AMA COUNCil C" MEDiCAL SlR~ICE .....1 tahl tIt.....tl ..ft. ,,'" t..I"'''" IIODIM'U, I'lIASI I'II'NT Oil TYI'I rOOM ..erA I~ III tol tofU.. oweI' 1!lOIl fOm" RRB t~ ..H..._.....M....." UtI ......"...... 'l'lt\ ......... 'IU"I""" " , PLEA/lE . DO NOT STAItLE IN THIS AREA PR\JDENTI~ P ,0. BO)! '.7 HOR5HAM. ~A 19044 T I 1 I !PIC. HEALTH INSURANCE CLAIM FORM rIC' ITT I '..OICARI MlOfCAID CHAUPUS CHAUPVA ~~. [~~" I r40Tlllft " ~tN~~M~!!."r2027 ,fOR PROGfW.I lfilUW I. 1'''''''''''/ n,- IJ n ,.........SSNI n WAF" 1/ n '1l~li~:lJ'N II'\~JM'" 'WI 'HM?". '\'m"""'lE"N..... 'I , "ij'4" . ... , ~ . 'gH NAME 1'.1&1 HtIN. hp twnI...... hllIll 'r !I RII "Ij' J: un r 'c!.t'IE~' ~ ~~\m'\?t' "'?'fREE T .. 'At~ RELAtIONSHIP to INSURED 1 ~'i.,~~OO!'JM.r~TREET ... -0"""'0 """'0 ~~Ar.L , '~u 1"1!A . p.'.Nl S1~tUS tl1T:ARLISLE 1."~4" -Ll -"'0 """'0 lIPC~Ol 3 t(~Pi1"1~~!!~b5 l-,.on F..."....n P..'....n lIP~ODtj, 70 13 .\ TlTn?'tC'~~ ~!.',f~'5 6tudtnl 51'*'" ~(\m;: 11..-,".-,-......, ,. IS I . II. "SURED. roLtCY aROUP OR 'ECAHUUBIR . otHER ..SUREO II POlICY OR QROUP NlNIER . IM'tOYMEN" ICURRE& PREVIOUS) · ",SUIllll4 ~~'fi,~ B!lY.~ su '0 I DVU "" "0 ' , , , . &"t":'tJ.!..~~OATfOfB'.'H Sf' ,~ b Auto ACCtOlN" PLACE 151.lel · (~'A'llIf~~~~OIl~rgtAR.( , 'I " I .n OVU 0"" " .. L_.J ~f..'i'm~~SN...(OIl ~\m ~AU( t otHER ACCIOENn '~mID.I"~l OIl PROD.... NAU( ,(of l, U'~ VI it" SAR'( dvu 0"" d IHSUAAJ<<:E PlAH NAUl on PROOR"'" NAME 'Od RESERVED fOR LOCAL USE d IS tHERE AHOaR HEALTH IENEFlT PlAN? ,1YES NO """r.turn 10 ard c:omp6el. Mtm', d .. 0'1. 1 _ "",lltUII 13 INSURE060A AutltORlltDPEASOOaSKlNAtUnE l.uthOl'll' t' PA1IENt & on AUlltORllEDPEASOOS SIGNAtURE lauthol'l" lhe'......oI.nrNCk..Ol otheI' 1nf001l'll1.onn<<"WY P'l'mtftI 01 medcaI......1o '" ur*rs.gned IJhl'soan or auppIlef tor :.t.-."'t."r..I....l-"..'O"~"'r..m--.."'...........""'b-~1..~ IIM:It dtla:Md bt'" On F il.. . pnn ure n e 8- - ~ ~lgnnlure SIGNED .. DAlE 6IGNED "~I~ ""c;:"e~w ~ IllN16S "11I1''''Il10lfl1 OR tl ., PAlIENt HAS HAD SAt.lE OR SIMilAR illNESS 11 CAtlS PATIENT UHAIlE TO WORK IN CURRENT OCCUP~ION INJURY I t*nlIOR QIVE 'IRST OAll ...t.I,OOIVY .....DD.YV "',DOt PREONANCYtlt.l') , , FROM I I TO I I "HAW: OF AlnRRtNO PHYSICIAN OR OtHER sounCE UI 10 HUUlER OF REfERRING '1lY61CIAN 'I HQ5PITALlZAnOND"TlS RELA1EOtOC~RENI6IR\'lClS ....IOO.YV lOO.VY 'ROW I' TO' I 11 "UERVED'CIA lOCAl USE. ro OUT&IOE lAB? . CHARGES nvu n"" I I 11 OIAGNOSIS CIA NAtUAE Of'lllNUSon INJUny InElATE ITEUS t,I,2OR4tontt.lIUeVLINEI ~ n. UEDICAlD Rl6UIMISSION ~nl .~U 839.0G COO< I OAlGlNALREF.NO 11-,_ 3 1..--,_ 13 PRlOAAUlHOAlZATlC>>INUUlER .. ~,..., '"I . I 839,21 . I ' ..' .. . B C 0 I , 0 II , J . '1~1EISI or SERVICETo ..- ''''' PROCEOURES. j(~VICEa. 00 SUPPLIES DIAGNOSIS RESfAVEDFon 01 01 rIIT~~~~~'~.rull COOl , CHARGES OIl F......, .W COB lOCAl USE .... '0:;;; " .... DO VV UNITS PIon U.:al 'Z4 '~Jo1 OG: ~':4: qt\ 3 197012 I , 1211\ 20;.00 t ' , , , , , , , I , , , , I , , , , t , , , , , , , , i' , I , , , , , , , t , , , , , I , , , : , , : ,- , , . , , , , , I , , : , , : , , , . . , , , , , " I , , , , I , , , , 1 "rEDfA"'- lAlIO NUMBER .~;.~ " PATlENtSACCOUNT NO \ dPCEPT ~I?UUEU" 21 toIALC.....AOE ) 129 AUOUNT PAID )c 30 IAlAflCE DUE 1\ I ()J)OI\ 1\ i":, HAU92980 orvo~d& 5MtbKto-I I 20:.00 YES NO I 20:.00. 0:,0 31 SlGUATURr or PHYSIC loll; on 6Urr\ IER 32 NAME AUQ ADDRESS OF rAClll1V WItERE 6En.....CESWEnE 1] PHySICIAN 5_ 5UPp\'IER S BilLING NAME. ADORESS. ZIP COOl .uel UOIUQ IlfOAI.' OR CREUlU'IAl & RENDERED I" Ol.....iNnhomtl Of otl<<1 tJtn'" CHIROPFlACTIC CLINIC tlt.",lrth.tllt'tll.tt~l()fll"'I'..I" _r lo!flll bII .Ad II' maM . pal1 "",tof , 323 YORK Ror,t' 090194 CARLISLE, PA 17013 1,10"," nAl' 41080447r, I rlP~' nnp. .. ! (APPROVEDey A~j, COUUCIl ONUEDlCAl6fR~ICE ...., IIIIt1 ... ......1 art. 'I'" t..,...... '.IMII" PtfASf PRINT OR ryPf ronUIlCfA 1&00 111101 fOOUOWCP 1&00 ,ORURRSti(lO .JlIU-........"lt...'" ""'............IIIIU..........""..I..... (- . ,r-., III I I . ~ t I , I @ i'""'\ ",.... MEDICAL BILL SUMMARY 7YIUI Haus November 13, 1996 80ab ChirQ,raatla C.Dter 02/22/94 02/25/94 02/26/94 02/28/94 03/01/94 03/02/94 03/02/94 03/05/94 03/07/94 03/07/94 03/09/94 03/11/94 03/14/94 03/16/94 03/18/94 03/21/94 03/23/94 03/25/94 03/28/94 03/30/94 04/01/94 04/04/94 04/06/94 04/08/94 04/11/94 04/13/94 04/15/94 04/18/94 04/20/94 04/25/94 04/27/94 05/02/94 05/06/94 05/09/94 05/11/94 05/16/94 05/18/94 OS/23/94 OS/25/94 05/31/94 06/06/94 06/08/94 06/13/94 06/20/94 $ l01701/CLM 485.00 105.00 65.00 380.00 65.00 65.00 195.00 35.00 65.00 195.00 65.00 65.00 65.00 65.00 65.00 50.00 50.00 50.00 65.00 50.00 50.00 560.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 50.00 370.00 65.00 50.00 50.00 50.00 50.00 50.00 200.00 50.00 50.00 50.00 , ' i ') ~ t\", ... 0- -~ ...) G ~ Nl(}-o '..&.. ,.... "'l 8 ~I )j . ~ ~ u d.. 6,. . , , 111 , . i. c ,. , , , ! I Ill! ~ ~~ e~l~~.;;1 E:llll~g;i1!g Q9"'~=R _ ~ = -.. ~ ~~i !C~ ! , . . I ! r41 ~ g - l s :c 8 c, (] co ~ I ~ ~ -.z ~ & ~ ---. ..... 95.099 LAW OFFICES OF DONALD R. DORER 3907 Hlrtzdale Drive, Suite 706 Clmp Hili, PA 17011 Telephone Number: (717) 731-0988 Attomey. tor Defendant, Dlnlel W. Peten, Jr. IN THE COURT OF COMMON PLEAS TINA R.IlAUS, PLAlN11FF CUMBERLAND COUNTY, PENNSYLVANIA VS. No. 95.5461 CIVIL TERM DANIEL W. PETERS. JR., DEnNDANI' CIVIL ACTION - LAW JURY TRIAL DI!MANDED PETrnON FOR APPOINfMENT OF ARBITRATORS TO niB HONORABLB, niB JUDGBS OF niB SAID COURT: Donald R. Dorer, ~ulre respectfully represents that: , counsel for the Defendant In the above action, I. The above-captloned action Is at Issue. 2. The claim of the Plaintiff In the action Is for bodily Injury damages. The following attorneys are Interested In the case as counselor are otherwise disqualified to sit u arbltraton: Donald R. Dorer, Bsqulre, Allorney for Defendant. and Lawrence F. Barone, AllomllY for Plaintiff WHBRBFORB, your petitioner prays your Honorable Court to appoint three (3) arbltraton to whom the case shall be submllled, Respectfully submllled, LAW 0 B: Date: May 22, 1996 LAW OF~ICE8 IRWIN McKNIGHT & HUGHES 1lOClI~'_ IWlCtI,A. _HT.. JAIII. D HIJOHfS ....CCA ~ HIJOHf' WEST POMFRET PROFESSIONAL BUILDING eo WEST POMFRET STREET CARUSLE, PENNSYLVANIA f70f:J.3Z22 (717) 24e.2353 FAX (71 7) 24e~354 IWlOUlS _ 'ltz~flm HAROUl S -. 'R ,'IoW-'NfI __._ ".'NfI _ _'lIcI<NIGHT ".....NfI October 29, 1996 STEPHEN L. BLOOM, ESQUIRE MARTSON, DEARDORFF, WILLIAMS & 0110 10 EAST HIGH STREET CARLISLE, PA 17013 RE: HAUS v. PETERS ARBITRATION Dear Steve: Enclosed please find a copy of Judge Sheely's order removing me and appointing you as an arbitrator fOT the above-captioned matter, Once again. I would like to thank you for filling In on such short notice, Unfortunately, my schedule simply does not pennlt me to serve as an arbitrator In this case. If I can ever return the favor please do not hesitate to give me a call. Thank you 8g8in for YOUT willingness to serve on my behalf. Very t~j,~rs, IRwiN. M GHT & HUGHES ,/ IDH:clc Enc\. / / / I Ja I / (// i'r; C\J (; -, LI) 13 N S P.1.; i.'):i ru -~. ~i': ", 1...):-, Ll.. ,,::" 0 (r n: 'n ...,.1 ;'t,:j ll:IH I ,. . ~ , . f.) -r, ;, I,. lit i.lJ'(j It. (:J (.h~ ""1 ,.: 0 ..J c" tl . , , . elS - If- e!~ ~I!~ e",~~..!;:!~ ~9~~~~~! :S~'" ~t~Ci !~ ~ ~e _ "......r..... 95.099 LAW OFFICES OF DONALD R. DORER 3907 Hartlda" Drive, Suite 706 Camp Bill, PA 17011 Telephone Number: (717) 731.0911 Attorney. for Defendant, Daniel W. Peten, Jr. IN THE COURT OF COMMON PLEAS TINA R. JlAUS, PLAlN11n' CUMBERLAND COUNTY, PENNSYLVANIA VS. No. 95-.5461 CIVIL TERM DANIEL W. PETERS, JR., DEFENDANT CIVIL AcnON . LAw JURY TRIAL DEMANDED CERTIFICATE OF SERVICE Donald R. Dorer, Esquire, hereby certifies that he Is the attorney for the Defendant herein, and that he caused a troe and correct copy of the attached Pluclpc to Atta,,1I Verlf1r..tlon to Answer of Defendant, Daniel W. Peten. Jr.. to Plaintiff's Complaint with New Uattp.f to be served by regular fint class mall upon: Lawrence F. Barone, Esquire Anglno &. Rovner, P.C. 4503 North Front Street Harrisburg, PA 17110 Date: December 4. 1995 i;; I/') F: f - " :'.4 &;! -:r .l..r C)~~; 1E1! .,.. U;;;, -~ "- - , ~k) .....-.. - ,;''$.: ~'.' (/1 ri!!t! - ....... ~ ~!: ~. ~: '" "& -. \' , u. , U lQ .':5 C" u . TINA R. HAUS, PLAINTIFF :IN THE COURT OF COMMON PLEAS OF :CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 9S-!l462 CIVIL TERM CIVIL ACTION - LAW JURY TRIAL DEMANDED DANIEL W. PETERS, JR., DEFENDANT ORDER OF COURT AND NOW, this '1/ ".. day of U.:1; i....- . 1996, in consideration of a contlict which exists for arbitrator James D, Hughes, Esquire, and in funher consideration of Stephen L, Bloom, Esquire, agreeing to serve as an arbitrator in the above.captloned maller, It Is hereby ordered that James D, Hughes, Esquire, is removed and Stephen L. Bloom, Esquire, Is appointed as arbitrator in the above-captioned maller, The arbitrators for the above.captioned mailer will meet for the purpose oftheir appointment Monday, November 4, 1996, beginning at 2:00 P.M, In the 2nd Floor Hearing Room of the Old Courthouse, Carlisle, Pennsylvania, By the coun, 1,,/ ';(/rL,.l~( , . l:! JIWI\. I f1 J, Date: (y~ftk H ,/)'Ic. TRUE COpy FROM Rl:COPtD In TfI~"l1lilny Wllll/Col, I hm!) UIIII) fl,,1 my h.100 and tho) 1011<11 01 ~ill C'lU,t i\1 C;,flUJo, I'a, Tills I..' . t1ay llt'l,t:~+....19. '1(.. , ,J .,e.... (;, IlL l (C<- .JJ''fJ ~oltlonotal'i' . TINA R. mus, PLAINTIFF :IN THE COURT OF COMMON PLEAS OF ICUMBERLAND COUNTY, PENNSYLVANIA NO. 9!-!462 CIVIL TERM CIVIL ACTION . LAW JURY TRIAL DEMANDED Y. DANIEL W. PETERS, JR., DEFENDANT ORDER OF COURT AND NOW, this ,,~ I i;ay of (j ( ('- .).}(. -:'1996, in consideration ofa contllct which exists for ubitrator Jamcs D. Hughes, Esquire, and In further consideration of Stephen L. Bloom, Esquire, agreeing to serve as an ubitrator in the above-captioned matter, It Is hereby ordered that James D, Hughes, Esquire, is removed and Stephcn L, Bloom, Esquire, Is appointed u arbitrator In tho above-captioned matter, The arbitrators for tho above-captioned matter will meet for tho purpose of their appointment Monday, November 4, 1996, beginning at 2:00 P.M, In tho 2nd Floor Hearing Room of the Old Courthouse, Carlislc, Peoosytvania, By the Court, /.~~- Date: {JC (. ;"'( /19,,(; / . TINA R. RAUS, . IN THE COURT OF COMMON PLEAS . I CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff . . . CIVIL ACTION - LAW . v. . . . NO. 95-5462 civil Term . DANIEL W. PETERS, JR. . . Defendant JURY TRIAL DEMANDED PLAINTI..'. R'PLY TO D...KDART'. ... MATT.. 18. No response is necessary. 19. Defendant's averment is a conclusion of law to which no reeponsive pleadinq is required. To the extent the averment may be deemed factual, it is hereby specifically denied. By way of amplification, all of Plaintiff's injuries and damaqes are recoverable in the instant action. The Pennsylvania Motor Vehicle Financial Responsibility Law and Pennsylvania No-Fault Motor Vehicle Insurance Act in no way limits the damaqes Plaintiff may recover herein. WHEREFORE, Plaintiff respectfully requests this Honorable Court to dismiss Defendant's Answer and New Matter and enter jUdqment in her favor aqainst the Defendant. AN~I_~O , ~OVNER, Pj' ---.~ .... ,. .- I La~~nce /' :aro~;'~ ,-I.D. No. 68921 4503 North Front Street Harrisburq, PA 17110 (717) 238-6791 counsel for Plaintiff Datel November 17, 1995 .. COHHONWEALTH OF PENNSYLVANIA I SS. COUNTY OF DAUPHIN I I, LAWRENCE F. BARONE, Esquire, being duly sworn according to law, depo.e, and stat. that I am counsel for Plaintiff, that I a. authorized to make this Affidavit on behalf of .aid Plaintiff and that the fact. .et forth in the foregoing 'LAIIITI"" .I'LI 'l'O DUDDIII'l'" .0 IIl'l"l'D are true and correct to the be.t of .Y knowledge and beli.f. U /--;V;! // - (/t i) LA@.~~ron.,~ Sworn to and subscribed bafore .. this ~~ day of j~\\~W\~ , 1995. ~\u~ 'i ~1lw\Ll Notary Pubi c \ NOlM. : '-(" ( M<<lINO, PlMc ~ L~L!I,;, D. I_I ,;o:nmisslon ,I,IM 75726/KLK v. ~ ) ) ) ) ) \ c_ - OATH I. ft. Court .r COIMD fl... .f C\IIIllrllD' CoIaet,. ....,l".ei. l'lNA II, IIAUH 110.95 - 5 4Jj 2 C I V I L l' 95 I \lAN n:t. W. (,WI'EHH, ,Ill. we '0 loleID1, ev..r (or .frl~) tbat v. vlll .upport, ob.y ... ..f... &Ia. eouUtuUon of tb. Valt.. ltat.. ID' the Coutieutl.. of tbit eo.on- ...lth aD' that.. vlll 'l.ch.r.. the 'uti.. four offic. vith fi..lity. (S t': ',I ('. G Esquire - Chalrmsn , III! , ,. I, ' ~" ) I , . ( "I (" Andrea c""J~'b~ Esquire ~ . 'y:-' ._../~ ~. c.sq;;re !"~"I,h." L, B.""" AVAlD , I' f' l' () w., the UD..r.l.... arbltrator., blvi.. b... 'uly appolDt.d ..d .wOrD (or.fUrM'), uk. the folllNt.. lVardl (IIot.1 If ....... for ..1., .r. avard.d, th.y aball b. ....r.t.l'lt.t...), I. /) . ( 1 . i!.. vt"{ , . (VVVf .ppuCibl.. ) . Arbitrator, dill.Dtl. (IUlart DAma if f\ ~~J*\J ,li,~ Dat. of l.ariDlI D.t. of Avar'l ..--. NOTICE OF ENTRY If''KwAinI.. At c\ ' Now, the ~ I day of ~(\.o,.....,.v>-~ ,19.1.1-, at tJ2:i. .d.H., the above .vard val .nt.r.d UpOD the docket and notice thereof siven by mail to the p.rti.. Dr th.ir attorDIY', Arbitrator.' compe..ation to be pai' upon .ppeal: cC . ~~(), - (f~lI""o.C-J-o C', 7J'~ Prothonotary AJ'l (1,1Q ......, lJ Dep~ By: PlI. No,:95.099 . , (Must be typewrlUen and submlUed In dupllrate.) TO niB PROnlONOTARY OF CUMBERLAND COUNTY: Please list the following case (check one): ( x) for JURY trial at the next tenn of civil court. ( ) for trial without a jury, CAPI10N OF CASB: (Bntlre Caption Must Be Stated In Full) (Check One) , " L: ~~'4 " , "'<1, . . -n II" , J'-j , , I , . I, i , , I ~.iJ - 'l 1"._ ,-' , l) , : ' fl\ " , ':? '. ~ -.. r- ~q I::> --. ( ) Assumpsit ( ) TresJNIss Tina R. Haus, ( x) TresJNIss (Motor Vehicle) (Plaintiff) ( ) vs. (Oth..) Daniel W. Peters, Jr., (D6fendant) The lli.11I11 will be called on Aorll 21. 1997 Trilll commence on M.v 19. 1997 P...'\rial. will be held on ADrll 30. 1997 (Bri.r. ." duo 5 day. b.ru" prw-tri.I.,) (lb. p.ny 11.11", \hI. c... r.r tri.1 011.11 provld. fur1h...i1b . copy or lb. p""Ip. to.1I eoo...I, pUIlU." to 1...1 Rul. 21+\,) No. 9S-S462 Civil 1995 19-21 Indicate the attorney who wl1l try case for the party who flies this praecipe: Donald R. Dorer, Bsquire. Attorney for Defendant. 214 Senale Avenue. Suite S03. Camp 8111. Pennsylvania. 17011: (717) 731-0988. Indicate trial counsel for other parties If known: Lawrence F. Barone. R"QlJlre. Allomey For Plaintiff. 4S03 North Front Street. HarrlsbulJ. PA 17110: C7\71 238-6791. This case Is ready for trial, S1.,.{)!J /1. Print Name: Donald R. Dorer. Bsqulre Allomey for: Defendant Date: March 4. 1997 -,... .' r.;:C~l\' ...U I"r:" 117 I~", lJi~1.t 0:, I...,. I' .!....., ') .iI,..\. III. . . Please see Seclions I and II hereinabove. IV. Defendant is not aware of any significant pre-trial evidentiary issues, v. Defendant will call the following witnesses: I, Plalnliff, Tina Haus (as on cross-examination) 2, Defendant, Daniel W. Peters, Jr. 3, Larry A. Roth, D.C. (by videodepositlon to be scheduled) VI. EXI:II.BITS: I. Vehicle damage photographs 2, Records of Thomas A. Boch, D.C, 3, Repon of Larry A, Roth, D.C., August 1,1994 (attached hereto as Exhibit WB") VII. The Plaintiff's last demand for settlement was in the amount of $10,000.00. Notwithstanding the amitratlon award of 52,000.00, the Defendant's offer 15 $5,000.00, Respectfully submitted, , ACOBS & SABA By: nald R, Dorer, re Attorney for Defendant Idenlificatlon No. 39126 Date: April 24. 1997 El&hlblt A ."....... ... """"'" h'" ~''''Il' (~ /" 0', CI " " BOCH OIIROPRAcnC aJNIC lI23 VcIIk &ad c.w.. PA 17013 T~(7171243~ F..: (7171243-6444 September 18. 1996 Lawrence F. Barooe, Eaq, 4503 North Front Street HanilbUlJ, P A 17110 RE: Tina Haul D.O."" 01129/94 Tina Haus prcsented herlelfto my office on 02122/94. She rclated durins her lnta1cc consultation 'that Ibe bad been Involved In an automobUe accident on 01128/94 and had been seen by another c:blropractor, Dr. lames Whartoo orMechanlcsburs. prior to belns seen in our office. Her entrance complalntl were oock pain. headaches. upper back pain, mid baclc pain. lower baclc pain aDd paresthesia In the left ann and hand, Theae symptoms were worse in the momJnss and were aaaravatod by Jift1n& s1eepJna aDd any type orpbyslca1 activity. . ._~:. ~ . TinA ~ ~~, at tIiat tIni~~ ~~~~~~~ed, wbl~e f~e orno~ welpt and ave;;;ii~t. .' , ~~ ,SjJe ~, ,~. Und~~ ofopiCXl'siiUttatloo'ciueatlons reprdlna her coDClltioo ~ ,I bad ,,~:':~ ~ " ': ~p.~,~eve ~t,~e,\l{~ waa~tlna ber,l)".IIptoms or ~~ b~ 00 my p~t~7~'<!;' ., . )'III'I~encelndea\lJlaWlthlqiW)'c:ueI' ': " ..., . ...,.,.. "'r.,,<,'~h,r-"""" , .' ~ ",:,"J.,!;';:'>!{.\.':~:."''',,~' ". ':",;:::';',,;~.: ,,~:::::,;-:',2 :::.~~ ,: · ::, " ~:' .':,;,::, <> ';",',.: :..:~~;?:,\!~~r';.;~~~';:i::, : . , Her p;eYfou.triUma biato.y \Deluded a brOkeli'ink1ci In 1973mda car/moiori:yele IcCIdiilt In'''' " .' 1987. .'SiitiPca1 blliorY' Wls UmIted to tWo o-aectlORl wblCk were Penormed In 1984 an~ iP16; <..~. .' , On Intake; wberiulted If abO was on any prescription druss, her response was In the neiltive: ~:: ' ' . ... ...;......... . Our fvaml;'.t1on orMs. Hauslncluded x-rays and a physical exam, There was'teodemell to' palpation In the paravertebral muscle at the foUow1nslevcls: c-s to T -I and L-3 to L-S, There was UmIted ranse or motion In the neclc and low back dwins flexion, extension and lateral bendJna. Cervical foramlnal compression test was positive In hyperflexlon and byperextension, The muscles palpated were and judSed to be In mild to moderate spasm at the follow1nSlocatlons: C-I,S T-7,9 and L-3,4,S, Spinal x-rays revealed vertebral subluxation at: C-2. L-3,4.5, and wedSed discs at: C-S,6 T-3,4 T- 5,6 T.II,12 1.-2,3 L-S 8-1. These areas correlated to the patient's symptomatic complaints, Also present on the patient's stltlc lateral cervical x-ray was cervical kyphosis, which Is a cluslc finding In casel of whiplash, Some arthritic chanses were seen at C-4,5.6. The left lateral bendlns x-ray revealed a loss of normal motion blo-mechanlcs In the lower lumbar spine, which a10ns with cervical kyphosis were objective Ilsns of trauma and vertebral subluKatlon, Our dla8ll0sls at that time was whiplash, cervical, thoracic and lumbar spraWslrain and vertebral 'If II " . , '. '", eubluxatlon. Ma Haul wns treated In thll office fi'om 02122/94 to 08124/94 approximately fifty' three times before being released as having reached maximum medical/chiropractic Improvement. Her treatment In our office conallted of ch1ropractlc Iplnal adjustmentl, Interferrentlal eleetriw therapy, hot pacla and Interlegmental traction. At the time of her release. she was still experienclna neck and low blck aymptoml, We continued her care under her group health Insurance from 09/07/94 ,to IJI1619S, trea"tlng her for neck and low back pain for approximately thIrty.eJght more vlsltl, ' ' Molt recently, I was colllulted by Ms, HaUl around May 23rd of this year for treatment for another acute epiaode of neck pain and left 11m and hand pain which resulted from some gardenlna activities. IIIW her I total of S times. WhIle MI. Haul wu bclna treated for her accident of 01/28/94, I advised her to avoid helVY lifting. repeated bending. twilting of her torso and overhead work with her anns and hands. I allo prescribed a home cerviw traction unit for her to use outlide the office to help restore her normal 'lordotic cerviw curve. In my oplnlon, she should follow these guidelines permanently. In my opinion, to I reasonable degree of medical/chiropractic certainty, the Injuries for which I treatod MI. Haul were the direct result of her automobUe accident of 01129/94, The mechanlca of . tho adent described to mo by MI, HaUl were conslltent with our finding of cerviw, thoracic . and IwDbar bVWY in that ber car Was not only hit from the rear but wu apun around, c;rOatIng I .':~~~IOD.~f.~p.~_~.t~~~e,t~l;,b.~Ip'~,~:., ,.I, , ., . ",':!.' '-~',~~l;r....;f)....~'., :..\O:"....~,., ,'.".'-'.. ~... '. .,..,..... :'. . "-.' ~ ...:':~.,:". ...: 4 ..,~.. . ..' '-:. : ::. ...:::.........~.7:~ .,"::". ..~: ':: ':: Tii~:a1edI~ i1ieiatUre thai I liive 'read, iipeclal educational ~~s tblt ~ havelttendecfand my'.::.. ':', . . peiiODil,~pe!ienoe in,trCiilna JiUwy cuel for aImo~ ~ee decadei, I!iOWS that duli to'thli aCit,'..",' " ~ ~~ ~~i fornia as pm of the b~8 ill these. typfof .pra1nl~r~.1qjurie.,a)iiiipt~~c:'~' ': ":," :', "', recur'nilice can coDtlnue for an indefinite period oft\me, '. ' . ,'. .'", , , ".~ ,,:,,,, ',', .' "':',' ': '. ,: .... . . 'It la my f\arth~r opinion, to I ~onable degree ofmodical/chlropractlc certainty, that the, '. ' progno.is !n this cue Is that there will be exacerbatlolll~ for an Indefinlte period of time. ThIs OplnlOD la based on the fact that this patient hn continued to experience tbe bVWY related symptom following almost 100 treatment visit. to our office. Sincerely, ~J~cJ .- Thomn A Boch, D.C, .ore. -. Exhibit B .".1"'.'1'.......",..', !l'" """.II~ @ .- , LARRY A. RuTH, D.C. 3545 RYAN AVE. PHILADELPHIA, PA August 1, 1994 KATHLEEN YABLONSKI, R.N, CLAIMS REVIEW ASSOCIATES 660 AMERICAN AVE, SUITE 103 KING OF PRUSSIA, PA 19406 RE: Tina Rae Haus Claim: 46N0385212027 CRM': 988,760-1 001: 1/28/94 Dear Ms. Yablonski: In reference to your request of July 20,1994 I have reviewed the following records and docu- ments relallng to the above mentioned claimant. , 1. Thomas Boeh, DC SOAP Note 317/94 Treatment Notel 2/22/94.7/1/94 Examination of Travel Card NID Supplemental Report 3/11/94,4/15/94, , 5/18/94, 6/22/94 Conlultatlon 2/22/94 Roentgenolo[llcal Report 2/22/94, 4/4194 Muscle Telt3/2/94, 317/94 ROM Worksheet 2/28194-616194 Chiropractic/Orthopedic/Neurological Examination 2/22/94 , LeUer of Explanation NIO Billing Statementl 2/22/94.5/18/94 2, Application for Benefits/Authorization 4/8194 3. Notice of Loss NIO The records submllled for review indicate that Tina Haus, a 35 year old female, allegedly sus- tained Injuries In a motor vehicle accident dated January 28, 1994, Ms, Haus stated on the Application for Benefits thatehe was struck by another vehicle on an Ice covered road, There Is no Indication Ms, Haus sought or recalved Immediate or emergency care following this Incident. The first Indication of any care sought or received by Ms. Haus was not until February 22, 1994, when she presented to the office of Thomas Boeh, DC. A report dated 317194 reported entrance complaints of neck paln, headaches, upper back pain, mid back paln, lower back pain, pain and paresthesia In the left arm and hand, Examlnallon findings listed on the same report noted palpatory, limited range of motion In the cervical and lumbar spines, and several orthopedic test findings, Radiographic studies appear to be taken on several dates, noling subluxatlons/mlsalignments, and a cervical kyphosis, as well as narrowed disc spaces In the thoracic spine and canal stenosis In several regions, A diagnosis was subsequenlly listed as RE: Tina Rae Haus Page 2 motor vehicle accident, radicular neuralgia, vertebral subluxation complex C2,5,6; T3,4,5,6,11,12; L2,3,4,5, Dr. Boch Instituted a course of care consisting of hoVcold packs, electric stimulntlon, supplies, and mechanical traction, Dates of service have extended through to at least 5/23/94 from the dally records submitted, I am also aware of extensive test procedures performed on the claimant including multiple dates of radiographs (2/22/94, and 4/8/94 for same views), range of motion testing on 21 re- gions (performed on 2/22/94, 4/8/94, and 5/9/94), as well as needle electromyography studies performed on 3/2/94 (upper), and 3f7194 (lower), At his request, Dr, Boch was contacted on 7/29/94 concerning this file, I was informed that treatment is stili being rendered to the neck and lower back on a 1 time per week basis, Dr, Boch further Informed me that symptomatic relief was being rendered, The conversation ended shortly thereafter, Having reviewed Dr, Thomas Boch's records, the following Is In response to your questions, 1. Appropriateness end necessity of all treatment rendered by Thomas Bocll, DC The submitted documentation supports a short course of chiropractic care administered to the clalmant, Tina Haus fOllowing the 1/28/94 MVA, however the length of noted care has not been demonstrated as either appropriate and or necessary for this Incident. Minimal objective findings have been noted over the course of care administered to Ms, Haus, and even according to the treating practltloner, care has been ongoing for symptomatic relief, As also mentioned, Ms, Haus did not Initiate care with this practitioner untIl almost 4 weeks post trauma, with unknown I If any care was received prior to this 2/22/94 date, This would ap- pear to be an Inordinate amount of lime If complaints and conditions were as severe as stated, Taking this Informallon into account, along with the findings presented on evaluation, and the diagnosis listed, a short course of chlropracllc spinal adjustment wllh use of some adjunctive therapies can be construed as appropriate and necessary for the reported alleged injuries of 1/28/94, 2, Appropriateness end necessity of all diagnosllc tesllng done to date, The Initial radiographic evaluation/analysis can be considered Justified as performed on the date of entranca, however the follow-up studlas are not considered appropriate and or neces- sary for the claimant, Tina Haus, The roullne use of repeat x-ra~' studies Is not considered a customary treatment practice or necessary from a chiropractic/medical standpoint for most conditions as determined by accepted radiographic guidelines, Limited repeat sectional radiographs are considered acceptable and necessary from a chiropractic/medical standpoint In the following condillons: documentation of clinical regression, significant re- Injury/exacerbation, suspicion of advancing underlying pathology, periodic monitoring for frac- ture care, periodic monitoring of slonificant underlying spinal mechanical alterallon, periodic monitoring and evaluation of a spinal scoliosis In patients who are receiving appropriate treat- ment and management. Unless a provider can submit clinical documentation which estab- lishes one of the above criteria, the chiropractic/medical necessity for repeat radiation exposure has usually not been established, No criteria has been observed to warrant these additional studies, RE: Tina Rae Haus Page 3 The range of motion teatlng la considered a vital end Integral portion of the examination pro- cedure, It should not be cons Ide rod appropriate and or necessary to perform this test as separate and distinct procedures, constltullng creallve procedural pracllces, Absolutely no Justlficallon has been shown from the documentation presented for the elec- trodlagnostlc evaluations performed under procedure codes 95864 by this praclltloner, for the alleged Injuries sustained by Tina Haus In the 1/28/94 MVA. 3. Was the length of treatment time approprlete? If not, what would be a more appropriate treatment plan? In reviewing the dally notes presented for this review, the subjective complaints show ex- tremely slow response to the care rendered, The notes have been provided through to 5/18/94 noting only a resolullon of headaches during this tlrne period, On an objective basis from these same dally notes, response has been even slower, noting sama treatment areas, with minimal changes over the approximately 35 dates of services during this same time span, In my professional opinion following the review of the records, a course of chiropractic care rendered for a period of up to 8 weeks In duration should have been more than appropriate and sufficient to address the complaints/conditions and diagnosis stemming from the 1/28/94 reported Incident 3, If treatment were appropriate and necessary for the alleged Injuries sustained, a) has mexlmum benefit of treatment been achieved? b) If so, when A course of chiropractic as described In this report, and excluding all diagnostic procedures except for Initial radiographs can be considered appropriate and necessary to address condi- tions aOld complaints stemming from the 1/28/94 MVA for a parlod of up to 8 weeks duration, and dating to 4/18/94. A maximum benefit from the care rendered should have been allalned by that date, It was also noted that a stretching exercise was not Incorporated Into Ms, Haus' routine until 4/1194 by this practitioner, A home stretchlnglflexlblllty exercise program should heve been Initiated Into Ms, Haus' dally activities soon after the Inltlallon of care from this of- fice. Further In-office treatment beyond the 4/18/94 date has not been considered appropriate and or necessary for the reported persistent complaints, without objective findings to warrant extended care, Thank you for the opportunity of reviewing this file, If I can be of any further assistance In this case please do not hesitate to contact my office, As with all reviews of this type, a profes- sional opinion Is expressed, This review was wrlllen without bias to practitioner or patient. Yours for beller health I ~/".&.c. Larry /y'Roth, Doctor of Chiropractic Certified, Independent Chlropracllc (Medical) Examiner Diplomate, American Academy of Pain Management " ' ,~'t \ TINA R. HAUS, plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 95-5462 Civil Term v, DANIEL W, PETERS, JR. Defendant ARBITRATION PLAINTIFF' S PRE-TRIAL IIDInRAHDUJI I. FACTS/LIABILITY On January 28, 1994, Plaintiff Tina R. Haus was driving her car on North Hanover Street in North Middleton Township, Cumberland County, Pennsylvania. The weather conditions that day were icy and foggy. As Ms. Haus approached the Church of God Home on North Hanover Street, the car directly in front of Ms. Haus stopped suddenly causing Ms. Haus to apply her brakes and move to the shoulder of the road. Defendant Daniel W. Peters, Jr" was in the car directly behind Plaintiff Tina Haus. Mr, Peters failed to bring his car to a stop, striking the rear of Ms. Haus's stationary vehicle. Upon impact, Plaintiff Tina Haus's car was knocked forward and spun, causing the vehicle to again collide with the Defendant's vehicle. 111411 /MLM II . DAMAGES Ms. Haus sustained a cervical, thoracic and lumbar sprain/strain, vertebral subluxation at C2-LS, cervical disk injury and thoracic disk injury. III. STATEMENT AS TO PRINCIPAL ISSUES OF LIABILITY AND DAMAGES The principal issues in this case are whether the Defendant Daniel W. Peters, Jr. is liable for causing the accident of January 28, 1994, and the amount of damagEs Tina Haus is entitled to recover. IV. SUMMARY OF LEGAL ISSUES There are no legal issues regarding the admissibility of testimony, exhibits, or other matters are anticipated. V. WITNESSES 1. Plaintiff Tina Haus 2. Defendant Daniel W, Peters, Jr., as on cross-examination 3. Mr. John Walker 4, Thomas A, Boeh, M,D. Plaintiff will supplement this list, if necessary, in a reasonable time prior to trial. ~j ,.. ".,-" . ;,..,.'" ,. VI. ~XHIBITS 1. Photographs of accident site 2, Diagram of accident site plaintiff will supplement this list, if necessary, in a reasonable time prior to trial. VII. CURRENT STATUS OF SETTLEMENT NEGOTIATIONS plaintiff has demanded $10,000 to settle this matter. The Defendant has offered $5,000. o &; ROVNER~' /' , r. La rence F. aarone, Esqu re I,D. No. 68921 4503 North Front Street Harrisburg, PA 17110 (717) 238-6791 counsel for plaintiff Datel April 24, 1997 CIRTI.ICATZ O. SIRVIcs I, Marcy L. Moyer, an employee of the law firm of Angina & Rovner, P.C., do hereby certify that I am this day serving a true and correct copy of PLAINTI..' S PRI-TRIAL ....ORANDUII on the following via postage prepaid, first class United States, requested addressed as follows: Donald R. Dorer, Esquire RUbinate, Jacobs & Saba 214 Senate Avenue, Suite 503 Camp Hill, PA 17011 Date: April 24, 1997 , ,.-0.,' ".^~ ",. ,":1" .,.~;.", """. .... ~.".~' ",. '-.--"'-' L - ...._r... 15. TINA R. HAUS, Plaintiff IN TIm COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION -LAW VS. DANIEL W. PETERS, JR" Defendant 95.5462 CIVIL TERM IN RE: PRETRIAL CONFERENCE Present at a pretrial conference held April 311, 1997, were Lawrence S. Barone, Esquire, attorney for the plaintiff, and Donald R. Dorer, Esquire, attorney for the defendant, This case arises out of a rear-end motor vehicle accident that occurred on January 28, 1994, The plaintiff contends that, as a result of the accident, Ms, Haus sustained Injuries to her back. The parties have been discussing settlement. In the event the matter is not settled, n trial should be of no more than one day's duration. The plaintiff would like to bring In Thomas A. Boch, D,C., for live tcstlmony but cannot do that without a date certain for trial, A videotape deposition Is scheduled for Thursday, May 8, 1997. The plaintiff will cancel the deposition if the Court Administrator is nhlc to schedule this matter for a date certain. The court indlented to counsel that such scheduling was unlikely but that It should be coordinated directly with the Court Administrator's Office. April 30, 1997 , AJ- Lawrcnce S. Barone, Esquire For the Plaintiff Donald R. Dorer, Esquire For the Dcfl'ntlnlll :rlm " "',""'C[,",: ,.:'....-,t . " In I"'i - I ~': 09 1.-1."" IL.;,,-..;H,.:-.'j ..~ ;;'\ \1') '.. .,. , : Ie; ..;J . ~'.~ .[ .. t... ("'l , I, u3; ~"":: , ~.J I. , ,",:.. p.- "lij , " ~;l r(l 'f) \ ..' ~ ,'OJ " 'I,J ! J , ,.. Hi. t.:.\. . , " I ;li: "'1 II. b\ i;J CJ .e ~ fI) .... .- I!! ~II B~li~~~ !~~~~~g !i!i~g= 'C.. '" !iN i ~ .' " .. . .'