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CC 6 CLAIM #92-44 11-02-92
r� CONSENT CALENDAR NO. 6 1G E N DAGENEWWWOMMEMB� 11-2-92 . DATE: OCTOBER 15, 1992 I n t e r- C O il'1 �L �� S, TO: HONORABLE MAYOR AND CITY COUNCIL FROM: CITY ATTORNEY SUBJECT: CLAIMANT: DEBORAH ROBINSON; D/L: 4-25-92; DATE FILED W/CITY: 9-14-92; CLAIM NO: 92-44; CARL WARREN FILE NO: S 72814 CLB After investigation and review it is recommended that the above -referenced claim be rejected and the City Clerk directed to give proper notice of the rejection to the claimant and to the claimant's attorney. /-�L JXG77"OROURKE, City Attorney JGR:jab:101592(CLr9244 jab) Enclosure: Copy of Claim cc: Carl Warren & Co. Finance Director City Manager W ELLMAN & ASSOCIATE ATTO KEYS AT LAN' 1400 QUAIL STREET; SUITE 270 NEWPORT BEACH, CALIFORNIA 92660 TELEPHONE: 714/476-2066 FACSIMILE: 714/476-5075 September 10, 1992 VIA CERTIFIED MAIL RETURN RECEIPT REQUESTED City of Tustin 15222 Del Amo Avenue Tustin, -California 92680 Attn: City Attorney's Office RE: Our Client Deborah Robinson Date of Loss- 4/25/92 Dear-Ladies/Gentlemen: Please be advised that we are the attorneys representing the above - referenced individual in the above -referenced accident. Consider this letter and the enclosed information to be a six month claim, pursuant to Government Code Section 911.2. Your prompt response would be appreciated. Very truly yours, WELLMAN & ASSOCIATES BRUCE CARR BC/rmr Enclosures CLAIM FOR DAMAGE OR INJURY 1. Claims for death, injury to person, or to personal property must be filed no later than 180 days after the occurrence (Gov. Code Sec.911.2.). 2. Claims for damages to real property must be filed no later than 1 year after the occurrence (Gov. Code, Sec.911.2). TO: City of Tustin Deborah Robinson Name of Claimant Address Zip Phone Age wpi lman & Associates 1400 Quail St., Ste. 270 Newport Beach, CA 92660 Address to which Claimant wishes notices sent. WHEN did damage or injury occur? April 25, 'x992 HOW and under what circumstances did damage or injury occur? f'laimant slipped on some unidentified substance located in the crutter, on Alliance Street in the city of Tustin. WHAT particular action by the City, or its employees, caused the alleged damage or injury? TmDrap= mnintenanrp o f the g1�ttPr fctrAA{- . WHAT sum do you claim? Include the estimated amount of any prospective loss, insofar as it may be known at the time of the representation of this claim, together with the basis of computation of the amount claimed: (Attach estimates or bills, if possible) mairrar^ Clinic $ 231-00 y7PrnmQ T nwd , M T) $_1,559-00 =nyc; r -a 1 T1�Pran�nynamics Tnc $ 2,525-00 Tryine Coast Magnetic Resonance M.G. $ 1,345.00_ r pnpra l T)amaaes $ 20r000-00 r i r Total Amount Claimed $ 25,660.00 NAMES and addresses of witnesses, Doctors and Hospitals: AEA • . ich HOSPITAL AND MEDIC. RE 3RD PARTY LIABILITY NAVJAG 5892LIZ S/N Ol OS -LF -105-8960 RCS TO: UN= S7= AZ'IIORNEYr CIVIL DIVISION, COIL=CNS UNITI DATE: G�S�Z� SOMME N DISTRICT OF CALIFORNIA, SAN D=O, CA - F ROJ'MICAL CARE RDOOV = ACT (MAULS OFFICE, NAVAL IJ93' , Submitsoon: aInitial Interim SER<IICE OFFICE SAN Dg70O CA 92136-5138 1. Patient Data (Include Name, Grade, Component. Urganizanon and Stanon, 2. Diagnosis (Use Standard Nomenclature) Home address, Branch of Service (i C.Army Navy, Air Force). Starus (i. e. EAD. Retired. Inactive Bury for training. etc.). Dare of Admission) ROBINSON; � DEBORAH TRALM TO REM KI`'£E-= ' UI:AD: UNITEDSTATFS MARINE CORPS TREArJ31,= RECE= AT NAVCARE, TUSTIN 3. Prognosis (Include expected length of hospitalization or number of outpatient visirs expected; FAIR 4. Cause of Injury (Append srarement of patient or accident rcporT if available) M=R VE 31= A== i 5. Agency Sponsoring Patient 6. Disposition 7. Date of Disoosil S. STATEMENT OF CHARGES M. Do IDE NAS i SF 9. Slgnattt\reP e�yt.Reeord�''OJS(�r)`� �� C. 0 t C=4ORr LT r JAGC r. USNRr MCRA CLAa S OFFICER, MMf SAN DIEGO (Continue items 1. 3. and 4 on separate sheer if necessary) PRIVACY ACT STATEMENT 1. AUTHORITY: 42 U.S.C. Sections26S1 -2653;31 U.S.C. Sections9S1-9S3: Executive Order 16060 2. PRINCIPAL PURPOSE(S): To provide Information for the collection of claims by the United States against third -party tortfeasors un0er 1 Care Recovery Act and the Federal Claims Collection Act. 3. ROUTINE USES: information furnished by Individuals receiving treatment at Government expense for injuries caused by thlr4-party tort, by -the Navy for the pursuit by the Navy of claims against third -party tortfeasors under the Medical Care Recovery Act and the Federal Claims Act; for the preparation of litigation reports to the Department of Justice; and for use In civil litigation by the Department of Justice. 4. MANOATORY/VOLUNTARY DISCLOSURE. CONSEQUENCES OF REFUSAL TO DISCLOSE: The disclosure Is voluntary. If the Indl not provide the requested Information. the Navy may require a written assignment of the patient's medical care claim. This Prev. Reports Total To Unit Charges Total Facility This Case Date Per OMB Charge (a) lbl INPATIENT - NUMBER OF DAYS S OUTPATIENT)NUMBER OF T^RE T 1 A3 03 $71.00 s 231.00 GRAND TOTAL S 231.00 9. Slgnattt\reP e�yt.Reeord�''OJS(�r)`� �� C. 0 t C=4ORr LT r JAGC r. USNRr MCRA CLAa S OFFICER, MMf SAN DIEGO (Continue items 1. 3. and 4 on separate sheer if necessary) PRIVACY ACT STATEMENT 1. AUTHORITY: 42 U.S.C. Sections26S1 -2653;31 U.S.C. Sections9S1-9S3: Executive Order 16060 2. PRINCIPAL PURPOSE(S): To provide Information for the collection of claims by the United States against third -party tortfeasors un0er 1 Care Recovery Act and the Federal Claims Collection Act. 3. ROUTINE USES: information furnished by Individuals receiving treatment at Government expense for injuries caused by thlr4-party tort, by -the Navy for the pursuit by the Navy of claims against third -party tortfeasors under the Medical Care Recovery Act and the Federal Claims Act; for the preparation of litigation reports to the Department of Justice; and for use In civil litigation by the Department of Justice. 4. MANOATORY/VOLUNTARY DISCLOSURE. CONSEQUENCES OF REFUSAL TO DISCLOSE: The disclosure Is voluntary. If the Indl not provide the requested Information. the Navy may require a written assignment of the patient's medical care claim. HEALTH RECORD CHRUNULUGIGAL ttt>rvr�u acm@r%AI rARC /d' . . . . w ii/ _02�j _y Z- 1 -Z4 - 1-Z4 249 WALNUT a -{u �f - � � - T7,-�A,SE ;= AVE. FTIN.CA S Flop, Als-w EP PR tip IPurF-OFEN,r _ (IPF ROFEPJ60,,MG I AFL E 4— 1 � TAr� TAF 3 TILES ADAY �y �Gc,U-4 z ILS- 04/ ?3 "PY CAUSE DfiDWSjNESSr Ak'EE ► 7REF^0 NAYCARE CL!NIr MY f' NO FINANCIA IA :- -- �Z vW ' �� FOR REFS RALS U ACKNOWLED EMEHT �j ; h\, . I9o5> J-< OY\- S- ATIENT'S IDENTIFICATION (Use this apace for Mechanicni RECOnDS Imprint)�1 MAINTAINED IATt ,^ vSEX � PATIENT'S NA" Ar,... i... W1,44410t�trt�tl NAVr_ARE ';'_,a';2 WALNUT A-._, TiJ:`rIr,1, CA ,. "i L,--41 �N�-' 1 � 1 N RELAT O 5 VJ •}-j .ROS I NS;ON , D E KORA" MAF T E ` f SPONSOR'S SEX: F DOD : 016 F ELS 1 ?70 PC -AT : F6. a. bV �'��.,j F f (,f, (.40 S S N : 44 -4'? -c_1465 FMP : 01 -vH'I-FORDR.N.P. DEPART./SE SPON: RUEINSJN,JAMES W F.A.N}:: P1'5I=, '.- I S I T DAT E : 2- FSPR 19':,'..' NC i , I_'71 CHRONOLOL ►fiesameo oy —#% ati -... FIRMR (41 CFR) 201-15.505 1 RADIOLOGY REPOR ALL X-RAYS AND REPORTS ARE RETAINED BY: M -4 r- 4 AGE: l4 F; I ;;I-ATERAL AND OPI-101..1{= : Pony, tr.abecul a struc4,--ore. and joint =pa.c? Are wl 1 Pr E. F" e.0 -I . There i nn evidence of fracture or dill ocation . .�rF^ 0 1 rma1 =-tud cd - , lei _ PR 2 a 1992 A I JOHN W. RICHEY M.D. p,piomate American Boaro of Raa,010gy • Doomate American Board of Nuvear medicine (213) 691-2613 I DOCTOR'S ORTHOPAEDICS ORTHOPAEDIC SURGERY, FRACTURES, INDUSTRIAL. PERSONAL INIURIES, SPORTS MEDICINE E. JE ROME LOWD, M.D. DIPLOMATE • American Board of Neurological & Orthopaedic Surgery • American &)ard of Clinical Orthopaedic Surgery • American Board of Indigstrial Medicine & Surges/ RE: Deborah M. Robinson DOI: 4-25-92 DOE: 4-29-92 2617 East Chipman Avcnuc Suitc 311 Orangc, CA 92669-3225 (714) 532-6864 (714) 532-6665 COMPREHENSIVE ORTHOPEDIC EVALUATION This 19 -year-old female is being seen for an orthopedic evaluation of her right knee. HISTORY OF PATIENT'S INJURY: The patient states that she was walking in front of a local apartment complex, when she slipped on wet cement, causing a twisting injury to'her right knee, and subsequently falling to the paved surface. There was no loss of consciousness. Immediately afterwards, she experienced a rapid onset of pains on both sides of the knee accompanied by swelling. She was not attended to by the paramedics nor did she go to a hospital facility. But after reaching home, she noted increased symptoms of pain with inability to fully walk. The next day she was seen at Navcare (a Navy medical care facility). She had an evaluation, including x-rays, of the knees. She was found to have no fractures. She was MAILING ADDRESS: Post Officc Box 11527, Sana Ana, CA 92711-1527 �l �1 RE: ROBINSON, Deborah M. 2 April 29, 1992 diagnosed as having a possible tendon sprain. She was given an Ace bandage, immobilization, Motrin 600 mg, and advised to be seen again. The patient states that she continued with the treatment recommendation, but has had persistent pains and discomfort in the knee with inability to fully ambulate. Because of same, she is being seen in this office for an orthopedic evaluation. PAST MEDICAL HISTORY: The patient states that she has not had any prior injuries to her knee, no history of sports -related or auto accidents and/or injuries, fractures, dislocations, extended hospita- lizations and surgical procedures. The patient gives a history of being allergic to codeine. PRESENT COMPLAINTS: Right Knee: A constant pain with swelling, but no numbness or tingling sensation. Pain increases from a slight to moderate to a moderate to severe degree of intensity on attempts at full weightbearing and is partially relieved with elevation. PHYSICAL EXAMINATION: General Appearance: The patient has been seen in no acute distress, complaining RE: ROBINSON, Deborah M. 3 April 29, 1992 of the aforementioned symptoms. Her height is 167.64 cm and her weight is 67.50 kg. Right Knee: Inspection: Visual inspection shows that the patient wears an elastic support from the mid-tibia to the mid-femur region. Upon its removal there is a moderate amount of non= -pitting edema present throughout the entire knee surface. There is no evidence of effusion. The patient ambulates with an an- talgic gait on the right. She is unable to stoop, bend, kneel or squat because of the severe pain. •Palpation: There is moderate tenderness along the medial and lateral collateral ligaments as well as the medial and lateral joint surfaces. There is tenderness upon compression of the patella without crepitation. Medial and lateral stress produces no subluxation or dislocation. However, pain is appreciated. There is moderate tenderness along the pa- tellar tendon in the inserts on the tibia. Medial and lateral stress causes increased pains. However, there is no frank and/or gross instability. The drawer sign appears negative. McMurray's and Lachman's tests cannot be performed at this time because of severe pain and discomfort. It should be noted that there is no effusion present. RE: ROBINSON, Deborah M. Range of Motion: 4 April 29, 1992 The knee lacks 15 degrees of full extension and flexes to 90/100 degrees before pain is elicited. X-RAYS: X-ray examination of the right knee dated April 26, 1992, shows no evidence of fractures, dislocations, subluxation, or degenerative joint changes. — CLINICAL IMPRESSION: 1. Bilateral collateral right knee strain. DISCUSSION: This patient has been seen because of continuous pains in the right knee following an accident of April 25, 1992. ORTHOPEDIC DISPOSITION: At this time it is recommended that the patient be placed in a knee immobilizer and undergo physical therapy to include heat, ultrasound, and massage over the area for a period of three weeks. At the end of that time there will be a reassessment, including a more definitive examination, in order to determine whether or not there is significant pathological changes that have occurred within the knee itself. 1 �l RE: ROBINSON, Deborah M. 5 April 29, 1992 She is to take analgesics as needed, ambulate with full weightbearing on the right knee, but with the use of a knee immobilizer. The taking of the patient's history, physical examination, and dictation of this report have been carried out solely by the undersigned. Sincerely, E. JEROME LOWD, M.D. Orthopedic Surgery EJL:sg/cm ORTHOPAEDICS DOCTOR'S � ORTHOPAEDIC SURGERY, FRACTURES, INDUSTRIAL, PERSONAL INJURIES, SPORTS MEDICINE S O E. JEROME LOWD, M.D. DIPLOMATE Vr • American Board of Neurological & Orthopaedic Surgery • American Board of Clinical Orthopaedic Surgery • American Board of Industrial Medicine & Surgery 1 2617 East Chapman Avcnuc Suitc 311 Orangc, CA 92669-3225 (714) 532-6864 (714) 532-6865 RE: DEBORAH M. ROBINSON DATE OF INJURY: April 25, 1992 DATE OF EXAMINATION: May 13, 1992 EXTENDED ORTHOPAEDIC EXAMINATION A follow-up examination today -shows bilateral joint line tenderness. There is some increase in her range of motion. The McMurray's Test for internal derrangement is question- ably positive. The neurological, vascular systems remain intact. 'There is no gross joint instability. Orthopaedic Disposition The patient is advised to undergo a MRI of the right knee. She is to continue with the prescribed physical therapy for an additional three weeks. At that time she will be placed in a hinged brace. Sin erely, . JEROME LOWD, M. D. Orthopaedic Surgery EJL:nlc MAILING ADDRESS. post Officc Box 11527, Sanca Ana, CA 92711-1527 .1 DOCTOR'S ORTHOPAEDICS ORTHOPAEDIC SURGERY, FRACTURES, INDUSTRIAL, PERSONAL INJURIES. SPORTS MEDICINE E. JEROME LOWD, M.D. Vr DIPLOMATS • American Board of Neurological & Orthopaedic Surgery • American Board of Clinical Orthopaedic Surgery • American Board of Industrial Medicine & Surgery RE: Deborah M. Robinson DOI: 4-25-92 DOE: 6-29-92 2617 East Chapman AVcnuc Sustc 311 Orangc, CA 92669-3225 (714) 532-6864 (714) 532-6865 FINAL ORTHOPEDIC EVALUATION The patient has been seen today for a reassessment of her right knee. Since the last.examination, she has continued with the physical therapy and has since been weaned from the brace, and is currently ambulating satisfactorily. She states that are some residual pains and discomfort, especially on standing and walking, bending and stooping for extended periods of time. However, the pains do not increase nor are they prolonged. PHYSICAL EXAMINATION: On physical examination of the right knee, there is minimal tenderness along the medial and collateral ligaments. No joint instability or ligamentous laxity is present. The range of motion is from 0 degrees extension to 145/145 of flexion. There are no neurological or vascular changes appreciated. MAILING ADDRESS: Post OfCcc Box 11527, Santa Ana, CA 92711.1527 RE: ROBINSON, Deborah M. 2 June 29, 1992 ORTHOPEDIC DISPOSITION: Based on the clinical findings, it is my opinion that this patient's overall condition within the right knee has reached maximum medical improvement. There are some residual pains and discomfort that will probably exacerbate in the future. Therefore, it is within reasonable medical certainty that physical therapy should be prescribed on an as needed basis in order to alleviate any recurrent symptoms of pain and discomfort. Sincerely, JERO LOWD, M.D. Orthopedic Surgery EJL:sg/cm ATTORNEY F AW ENCLOSED: MEDICAL PrDO 1400 ?L f, S-270 NEWPC BEACH CA 92660 HEALTH INSURANCE CLAIM FORM row &0090"o _04C• AM wA..i "lcr^#wwMOL■ ani ow QwLnLnAM 1 A M 1 AI MAM V HAMPVA FECA K LU RTIiICATE SBM MEDICARE NO) IMEDICAID NO 1 (SPONSOR'S $SNI NA FILE NO) ISSN( _ PATIENT AND INSURED (SUBSCRIBER) INFORMATION • ' :'''�. = �.'"•: ;'� ' • '� 1 PATIENT'S NAME (LAST NAME. FIRST NAME. MIDDLE INITIAL) 2. PATIENT'S DATE OF BIRTH J INSURED'S NAME (LJ157 NAMf:, rlhsl Nwa•a. Mw�+�c �... ROBINSON DEBORAH M ROBINSON DEBORAH M CHECKED ABOVE. INCLUDE • PATIENT'S ADDRESS (STREET. CITY. STATE. ZIP CODE) 5. PATIENT'S SEX 0. INSURED'S I.D. NO. (FOR PROGRAM ALL LETTERS) T. PATIENT'S RELATIONSHIP TO INSURED e. INSURED'S GROUP NO. (OR GROUP NAME OR FECA CLAIM NO.) SELF SPOUSE CHILD OTHER DINSURED IS EMPLOYED AND COVERED BY EMPLOYER HEALTH PLANTELEPHONE NO. OTHER HEALTH r COVERAGE IENTER NAME OF POLICY- to. WAS CONDITION RELATED TO. CAND 11. INSURED'S ADDRESS (STREET. CITY. STATE. ZIP CODE) ti HOLDER AND PLAN NAME ADDRESS AND POLICY ORMEDICAL ASSISTANCE NUMBER) TELEPHONE NO. NONE 11.8 CHAMPUS SPONSOR'S B ACCIDENT El 17 OTHER I ACTIVE DECEASED BRANCH OF SERVICE DUTY AUTO STATUS RETIREO 1 13 1 AUTHORIZE PAYMENT Of MEDICAL BENEFITS TO UNDERSIGNED 12 PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE (READ BACK BEFORE SIGNING) INFORMATIONTHISIM. I ALSO SS LO PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. IAMTI AUTHORIZE THE RELEASE OF ANY MEDICAL GOVERNMENT BENEFITS EITHER TO F OR O THE PARTY WHO ACCEPTS A BELREOOW. SIGNATURE CONTAINED IN SIGNEDSTGNATURE CONTAINEDDA •�r .. �t�-�iw�'•.t''�M.`��" ,;..�.,.•,..•:._ .•:;: �,,�,��;���PHYSIClANGOR..SUPPUEpJNFORMATION->*":►�;��� t• PATE OF: ILLNESS (FIRST SYMPTOM OR INJURY GATE FIRST CONSULTED YOU FOR THIS 16. IF PATIENT HAS HAD SAME OR SIMILAR 16.a. 1F EMERGENCY ILLNESS OR INJURY. GIVE GATES CHECK MERE 115. (ACCIDENT) OR PREGNANCY (LMP) CONDITION 4-7 04—>9-92 17. DATE PATIENT ABLE TO 16. DATES OF TOTAL DISABILITY GATES OF PARTIAL DISABILITY RETURN TO WORK FROM THROUGH FROM THROUGH NAME OF REFERRING PHYSICIAN OR OTHER SOURCE (a.p. PUBLIC HEALTH AGENCY) 20. HOSPITALIZATION FOR SERVICES O TO HOSPITALIZATION GIVE GATAT ES HOSPITALIZATION DAT ADMITTED DISCHARGED AND ADDRESS OF FACILITY WHERE SERVICES RENDERED (IF OTHER THAN HOME OR OFFICE) 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? 21 NAME YES NO CHARGES: 23 A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, RELATE DIAGN SI TO PROCEDURE IN COLUMN D 8Y REFERENCE B. NUMBERS 1.2.3. ETC. OR OX CODE EPSOT res [] x No 844.9 SPRAIN;KNEE 2 FAMILY PLANNING — — YES-- x No _ — 3 PRIOR AUTHORIZATION NO F DAYS H LEAVE BLANK • 2• C. FULLY DESCRIBE PROCEDURES. MEDICAL SERVICES OR SUPPLIES 0 s.. PUCE FR�UpR�NEISHED FOR EACH DATE GIVEN DI IS FROM ATE OF SERVICE TO SEROF VICE IIOENO CURE CODE I (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES( CODE T�FY CHARGES UN TS O.S. I 1 Q% 1 I —%CI— i % QQ Y—PAY I , 0 1I I 04-99-92 Q4 E T 1 I 1 - i -9? 00-> 1 F, Nr')Pn ngTHn F Am A I 11 16-580 I ( I —� — - IQ907n ° 25 SIGNATURE OF PHYSICIAN OR SUPPLIER (INCLUDING DEGREES(SI OR 26. ACCEPT ASSIGNMENT (GOVERNMENT 27 TOTAL CHARGE 1 2e. AMOUNT PAID2e. BALANCE DUE CREDENTIALS) It CERTIFY THAT THE STATEMENTS ON THE REVERSE CLAIMS ONLY) (SEE BACK) 1 APPLY TO THIS BILI AND ARE MADE A PART THEREOF) 0 9 - 00 NOR GROUP NAME, ADDRESS.ZIP' YES ED 0 NO 31 CODE LINO TELEPHONE NO AN'S. SUPPLIERIO {_ 0 W D M. ./ 0 0 C S T H O PA 30. YOUR SOCIAL SECURITY NO DOCTOR 'ORTHOPAEDIC S P.O. BOX 11527 DATe07-13-92 SANTA ANA, CA 92711 32, YOUR PATIENT'S ACCOUNT NO. 33. YOUR EMPLOYER I D. NO. 714-532-6864 ID NO OnRTWcM] • PLACE OF SERVICE AND TYPE OF SERVICE IT O.S I CODES ON THE BACK APPROVED BY AMA COUNCIL Form HCFA -1 500 (C-1) (1-84) t-orm vwvr--i ouw REMARKS ON MEDICAL SERVICE 543 Form CHAMPUS -501 Form RRS-1500 Pi i i urs.vGY tiT I_AW 1400 Ol'' TL , S-270 NEWPO'EACH CA 92660 HEALTH INSURANCE CLAIM FORM rolr.rrwaao .C•4 Cr A/•lIC1iE POMP~ lk OLK 1*tOW M I A M I AI HAM U HAMPVA FE CA K LUNGH (MEDICARE NO 1 (MEDICAID NO 1 (SPONSOR'S SSKI (VA FILE NO 1 ISSN► RTIFICATE SSM :•r.•, PATtEt+ITAND INURED (SUS$CR18 '1NFORMATIOW I PATIENT'S NAME (LAST NAME. FIRST NAME. MIDDLE INITIAL) 2. PATIENT'S DATE OF BIRTH 3 INSURED'S NAME (LAST NAME. FIRST NAME. MIDDLE INITIAL) ROBINSON, DEBORAH M ROBINSON, DEBORAH M a PATIENT'S ADDRESS (STREET, CITY, STATE. ZIP CODE) S. PATIENT'S SEX e. INSURED'S I.D. NO. (FOR PROGRAM CHECKED ABOVE. INCLUDE ALL LETTERS) 7. PATIENT'S RELJ► IONSHIP TO INSURED ADMITTED I DISCHARGED 1. INSURED'S GROUP NO. IDR GROUP NAME OR FECA CLAIM NO.) SELF SPOUSE CHILD OTHER El 0 D INSURED IS EMPLOYED AND COVERED BY EMPLOYER ❑ HEALTH PLAN TELEPHONE NO. El HEALTH INSURANCE COVERAGE (ENTER NAME OF POLICY- 10. WAS CONDITION RELATED TO: 23 A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN 0 BY REFERENCE 1I. INSURED'S ADDRESS (STREET. CITY, STATE. ZIP CODE) fi. OTHER HOLDER AND PLAN NAME AND ADDRESS AND POLICY OR MEDICAL NONE TELEPHONE NO. I t.a. CHAMPUS SPONSOR'S PRK)R S. ACCIDENTi ED F-1 OTHER ACTIVE DECEASED BRANCH OF SERVICE Li DUTY AUTO STATUS1 RETIRED I 13. 1 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED Q. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE (READ BACK BEFORE SIGNING) ANY FATIONTPROCESS THIS CLAIM IASR T PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. I THOUZFTHE RELEASOF MTAL O AFGOvTNEFIS EIHER MYSELF EHE PAY SASSIGNMENT BELOW SIGNATURE CONTAINED IN SIGNEDSIGNATURE CONTAINED IN THE PROVIDERoARECORD 4T14Tc�A-sbdE&APT"zli NT .. ._ . _.L - _ _.....we..w. A &1. ^92-451111311211. 1I=IM'fiUCf%0U'ATlf%N ARNAM199 • ��'!:: : !�!•`\tF;.�Dir.r!`' yC:!t]S�JRyPs.C• • • • �.�.�._ _.�..__. - --- ---- --•-- - -- 14. DATE OF: ILLNESS (FIRST SYMPTOM) OR INJURY 15. DATE FIRST CONSULTED YOU FOR THIS --- -- --- 16. IF PATIENT HAS HAD SAME OR SIMILAR /o.&. If EMERGENCY ILLNESS OR INJURY. GIVE DATES CHECK HERE (ACCIDENT) OR PREGNANCY (LMP) CONDITION 1 • — -- —• .--- 04-25-92 04-29-92 ON MEDICAL SERVICE 5-83 17. DATE PATIENT ABLE TO 16. DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY RETURN TO WORK FROM THROUGH FROM THROUGH NAME OF REFERRING PHYSICIAN OR OTHER SOURCE (e.g. PUBUC HEALTH AGENCY) 20. FOR SERVICES RELATED TO HOSPITNJZATION GIVE HOSPITALIZATION DATES ADMITTED I DISCHARGED NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED (IF OTHER THAN HOME OR OFFICE) 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? 21. YES f7a NO CHARGES: 23 A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN 0 BY REFERENCE B. NUMBERS 1.2.3. ETC. OR DX CODE EPSOT YES X No 4 4 .9 SPRAIN :KNEE 2 FAMILY PLANNING — — YES �_— X NO — — 3 PRK)R NO -AUTHORIZATION F. DAYS H. LEAVE BLANK 4 2� C. FULLY DESCRIBE PROCEDURES. MEDICAL SERVICES OR SUPPLIES D. A PLACE FURNISHED FOR EACH DATE GIVEN DIAGNOSIS E. 0. ' DATE OF SERVICE OF PRQpCCEEDUKE CODE FROM TO SERVICE (IDENTIFY 1 (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) CODE CHARGES UNITS T O I 05-30-92 3 99070 KNEE BRACE FUNCTIONA 1 28500 1 1 1 1 06-29-92 3 90699 FINAL ORTHO EXAM 1 165d0 1 1 1 I I BALANCE NOW DUE: 1 1,55910 I 1 I . i 1 1 25 SIGNATURE OF PHYSICIAN OR SUPPLIER [INCLUDING DEGREES) OR 26. ACCEPT ASSIGNMENT (GOVERNMENT CLAIMS ONLY) (SEE BACK) 27. TOTAL CHARGE ; 2e. AMOUNT PAID 29. BALANCE DUE CREDENTIALS( (I CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART THEREOF) 4 SOdO Q Q 1450.00 ' _ O W D M ' D . /DOCTOR ' O R O P A E YES Q � No 31 PHYSICIAN'S. SUPPLIERS, ANDIOR GROUP NAME. ADDRESS ZIP CODE AND TELEPHONE NO D O C T O R 'ORTHOPAEDIC S X. YOUR SOCIAL SECURITY NO. P.O. BOX 11527 SANTA ANA, CA 92711 DATe07-23-92 714-532-6864 32 YOUR PATIENT'S ACCOUNT NO 33. YOUR EMPLOYER I.D. NO. ROBINSON I.D. NO. ____ •w — 11 nom• r._— Ail//'►!f -aGAf1 -PLACE OF SERVICE AND TYPE OF SERVICE IT.O.S.) CODES ON THE BACK APPROVED BY AMA COUNCIL r-U111I nvrr+- 1-1%#w %` -, % • —,I • — -- —• .--- REMARKS ON MEDICAL SERVICE 5-83 Form CHAMPUS -501 Form RR13-150 1 CASE HISTORY _.. Name A �4 A-) Date Address % -: City State Zip Telephone Social Security N / % Driver Lic. N - Age Birthdate Sex j Status M ©W D No. Children_ Occupation EiV'I Employer �— Years Employed Employer's Address f City State Phone i Occupaton E Dloyer � Spouse's Name � Loc) wrn>T _ bid eferred b Person responsible for this account y What is your major complaint? n CE h U AP 4:!,- Other complair>Zs � How long have you had this condition? -9 4.0 e-- Ee'S Have you had this or similar conditions in the past? O What activities aggravate your condition? Is this condition getting progressively worse? YesX No O Constant O Comes and goes O Is this condition interfering with your. Work' Sleep O Daily routine Other How long has It been since you really felt good? List surgical operations: �G 7 Are you taking any medications?CSWhat kind? Tr'D.,j - Any non-prescription drugs? /--�hat kind? OTHER DOCTOR SEEN FOR THIS CONDITION: mop DC O DO O DDS O Doctor's Name_ 1 d Diagnosis X-rays Urinalysis Blood Tests -7 01) - Other N Treatment: edicat ion - Physiotherapy Results --- Length of time under care w�F� Were you off we If so, how long Have you returned to your same job? If not, why INSURANCE INFORMATION: Are you covered. by Medicare? Yes O No -V Medicare N State Insurance Aid? Yes O No O Do you have any group, union or personal health and accident insuranJce? Yes No O Name of Insurance Company �4,- m4y5 Claim N Z /� S it Group M Address Phone ' Agent m ��AiP dditional Insurance Company Claim N Group f# Address Phone Agent Is your condition due to an accident? illness O Other ACCIDENT INFORMATION: Did your accident occur while at work? Yes O No,z Were you involved in an automobile accident? Yes O NONC Date Time ' O1�2_ injury repoed to employer O Yes 6o Name of Supervisor Description of accident' Were you injured? C5 How? h�t-- Location I U5 ( A)11 A-'uCG ' EUc 057-71 A-) Were you unconscious? Fractures ^� c7 Cuts J Abrasions A,) v Bruises Patient taken to )_ el- Hospital for Treatment. confined to hospital for _� Days 10" Hours. Name of hospital doctor Have you had any other personal injury or accident? O Past year O Past 5 years O Over 5 years None Describe Do you have an attorney? N Yes O No Name & A dress E 1�� �N o iigTt vt_i, �t acv poor amu. CL L �':.:.: `; fl D I clearly understand that if I suspend gr Patient's Signature ee that all services rendered to me are charged diredtly 1:75me and that I am personally responsible for payment. I also understand in my care and treatment. any fees for professional services rendered to me will be immediately due and payable. G101 1- Reorcer N.J. Rosa Co. (7/4) 5392130 Date: s -9- 9 z !i0j, W-, ' FnJ4 PHYSICAL THERAPY DYNAMICS, INC. 2854 N. Santiago Blvd. • Suite 103 - Orange, CA 92667 (714) 282-6575 • Fax: (714) 282-S18 May 4, 1992 RE: ROBINSON, DEBORAH TO WON IT MAY CONCERN: Deborah Robinson was first seen in this office for evaluation and treatment at the request of Dr. Lowd, M.D., on May 4, 1992, for pains she is experiencing in her right knee due to a slip and fall accident on April 25, 1992. HISTORY: Ms. Robinson stated that whilst she is a full time student, she stated that she was stepping up a curb and stepped in wet cement, twisted her knee and fell into a car. Patient is still having discomfort in the right knee area. DIAGNOSIS: Dr. Lowd's diagnosis is: 1. ACUTE STRAIN AND SPRAIN OF THE RIGHT KNEE. EVALUATION: Patient complains of severe pains and spasms in the left knee area. Extension and lateral movement are very painful. Patient experiences pain even With passive movement. Patient also stated that she has pain on full flexion and extension and eversion and inversion. There is slight edema in the right knee area. Range of motion is within normal limits with pain. Patient has about 21 degrees movement above the knee and 14 degrees of movement below the knee. Patient is wearing a knee immobilizer for strength ad support. 1 � 1 PAGE: -2- ROBINSON, DEBORAH TREATMENT PLAN: After the evaluation we asked Dr. Lowd for a physical therapy treatment plan and he ordered.hydropool, ultrasound and massage for the right knee to increase strength, decrease pain and increase mobility. CURRENT MEDICAL CARE NEEDS: Dr. Lowd's prescription for physical therapy is for three times a week for two weeks. Patient is to return to see Dr. Lowd for follow-up care and re-evaluation. ADDENDUM: After having examined this patient, these are my findings, and if you have any further questions regarding this patiente please feel free to contact our office. Sincerely, CRIS:SCIHOULEMAN, R.P.T., Ph.D. CS:das ;�pQtl` �1% �p ADVANCED MEDICAL SYSTEMS 2854 N. Santiago Blvd. ■ Suite 103 ■ Orange, CA (714) 282575 PHYSICAL APY /2 4,/ _ -1 Pc�sc��ioN 1 W -S 3411 Date] L9 Patient Name Frequency of Treatment 1 2 3 4 5 � Per week Duration of en l D osis 1 PHYSICAL TO EVALUATE, MODIFY &. TREAT PER IN( �g��,�,pgoGRAM IRACKPROGRAM Hydro -Pool Exercise __Hy dro-Pool Exercise A �. �d trasound _._____Ultrasoun Massage Lst Heat Moist Heat 'Therapeutic/ Posttaal Fxerci Traction Body IvLec units oyothcraPy Traction Electrical Stimulation CrYothm-APY Biofeetmack rlaxrical Stimulation 'Iherapuetic Exercise Whirl Pool Home Program intzrfarmcial Other Home Program Other Hydro -Pool Ex Hy dro-pool Excdx Whirl Pool ____._Moist Heat Therapeutic Exerdse Ultra Sound Cryother2pyTlxrpeutic Exatisc plogessive Resistive Fxerri-x Electrical Stimulation Cryotherapy Gut Training Electacal Stimulation Acuscopc Acisopc Interfarencial intafa=dal Homc Pro Home Progznl 77 zz:Z, 7 e'er gf an� you ri!�o m f err. 64L % f=ud �� •I V 4•MIN - • • • • • • . _ : ■■�fiQ�■■■�■■fir■ ■rte"' � ■■■■■■■■■�' ■�■1■■//� ■■■■■■■■■■■ 0 mm mm mm mmm■■ ■����� ■m■■ - r7 liq-- pl- •OAF Dally Unit Value -rr�rr�r�r�rr�r�T� reatment Diagnosis: „-._. /--O) A .,, , DATE• 'Pin / - r7 liq-- pl- •OAF POW P2W.P Initial Anending Physican Hoon No. v i �I �o urs�ori 1 o :_� Zwo V 1 ! O tLr« W f �0u 1 •' t C6 • Iaz dc • w 41C ;= = 'l1 �_=sSsS G a Or Ott am yi s<f W apit� N r � Q==oi Q r z��00 Ir 4 =zaV.n.. L - azQa�w �� Al t. � .. > V � � u • >to ti wt.Tcwco � • • . t. HEALTH INSURANCE CLAIM FORM For- 600110 1) CNEc. APPL"W PEOGRAMkOCK BELOW I OINA4 0938.ODOO MEUI:•ARE ME DICA 7 LHAMPUS .,HAMPVA F L -A Y,A(.K LUN(. 1MEIa IMEDK.AAE N!l • IMEDIr A.-- ••c I ' I{PONSOWS SSNI I IW FILE NO 1 I ISSN) I (CEwTKICATF �-iNc PATIENT AND INSURED (SUBSCRIBER) INFORMATION I PATIENT'S NAME (LAST NAMr-. FIRST NAME. MIDDLE .'. "AL 2. I+ATIEN 'S DATE Of BKITH 3. NWREO'S NAME %LASY NAAAL• FIRST NAME. MIDDLE NII IAL, 161 IF EMERGENCY )ACCIDENT) OR PREGNANCY (LMPI CONDITION PATIENT1 ADDRESS ISTREET• CITY, iTATC. ZIP OZE 5. ✓ .RENT'S SE) o. INSURCD'S W. NO. %FOR PROGRAM C.M-LCKED ABOVE.INC, uDE ALL LETTERS) .� .- - .• . - . ..• .- MALE FEMALE %!`� INSURED 1S EMPLOYED AND CARRIED BY TELEPHONE NO. ADMITTED DISCHARGED EMPLOYER HEALTH PLAN 8. OTHER HEALTH INSURANCE COVERAGE IENTER NAME ;.F POLICYHOLDER 10. VMS CONDITION RELATED TO; 1 t INSURED'S ADDRESS ISTREET, CITY, STATE. ZIP CCDE) AND PLAN NAME AND ADDRESS AND POLICY OR MEDICAL ASSISTANCE OFFICE) NUMBER) A PATIENT'S EMPLOYMENT ^ , T I.&. CHAMPUS SPONSOR'S: ETC. OR DX CODE B. ACCIDENT I ACTIVE DECEASED BRANCH OF SERVICE EPSOT YES NO 1311 AUTO1:1 El OTHER FAMILY PLANNING YES NO 3. STATUS : DUTY , 24• A. b,• FULLY 1OCEDURES. M 1C.4- SERVICES OR SUPPLIESF. D. RETIRED DATE OF SERVICE PLACE CURNISMED FOR EACH DATE GIVEN FROM TOOF U (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) DIAGNOSIS CODE 12. PATIENT'S OR AUTHORIZED PERSON'S SK;NATURE •FEAD SACK BEFORE SIGNING) 13.1 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED 1 AUTHORIZE TAE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. I ALSO REDDEST PAYMENT PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. _ r. SIGNED "" 'r ' _ - -'• ' --' - DATE - SIGNED IINSURED OR AUTHORIZED PERSONS J:INE1r04"�E•7:9-iIi» 41 =1:11:1 141:1 'J -v ifel: i+. DATE OF; ILLNESS (FIRST S O'MPTOMI OR INJURY 15. DATE FIRST CONSULTED YOU FOR THIS 16. IF PATIENT HAS HAD SAME OR 161 IF EMERGENCY )ACCIDENT) OR PREGNANCY (LMPI CONDITION SIMILAR ILLNESS OR ODURY, GIVE DATES. CHECK HERE 17. DATE PATIENT ABLE TO 18. DATES OF --C--AL ZiSABIUTY DATES OF PARTIAL UISABILITY RETURN TO WORK :ROM THROUGH FROM THROUGH 19. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE ,0A. PUBLIC HEALTH AGENCY) 20. FOR SERvICES RELATED TO HOSPITALIZATION GIVE • i M 1" Y 1 J1 I�' D A SEE r* r'1 PCT A"' - ! !7 1 i 7 t t 7 ^ . r i HOSPITALIZATKiN DATES %!`� !. •a -� •-.I T 11 I I"A 1 r+ -r- r, ^ ♦ I r . r , I\ F« -r .1 _ ^ r•,'_ ^ ^ r� _, _ ' •+ _ ADMITTED DISCHARGED 21. NAME AND ADDRESS OF FACUTY WHERE SERVZES REN0E-R-E-0-tVFMHER TIHANHOME OR 22. VAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? OFFICE) YES NO CHARGES: 23. A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE N COLUMN D BY REFERENCE NUMBERS 1.2. 3. a ETC. OR DX CODE 1•4'•tom•- + ^••. ^I-• -,/'• -N-3 >,1 EPSOT YES NO 1311 2---7 + I (/tit • - �-. K • I i 94a I �I,IEZ r A-Lly FAMILY PLANNING YES NO 3. ----------------------------------------------- PROP 4. AUTHORIZATION NO. 24• A. b,• FULLY 1OCEDURES. M 1C.4- SERVICES OR SUPPLIESF. D. M. LEAVE BLANK DATE OF SERVICE PLACE CURNISMED FOR EACH DATE GIVEN FROM TOOF U (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) DIAGNOSIS CODE E. CHARGES DAYS OR G. - T.OS. SERVICE UDENTI Y 1 UNITS r. 1 + . , T r. IY r. I . 40, 11 , �! v / i / A. .a .' t• _ ZI - .7 . r rl V9 7 4 ..I 1 -1%*AZ., , , 774 : I • I • 25. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING .'.EGREE%Si OR 26. ACCEPT ASSK;NMENT (GOVERNMENT 27. TOTAL CHARGE , 28 AMOUNT PAID 29. &►LANCE OuE CREDENTIALS) (I CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TO CLAIMS ONLY) (SEE BACKI THIS BILL AND ARE MAGE A PART THEREOF YES NO E] El • � 1 T I� 31. PHYSICIAN'S SUPPLIER'S, AND/OR GROUP NAME. ADDRESS. ZIP CODE AND TELEPHONE NO. ' R SOCIAL SECURITY NO. .Y / _ _ 1 ,- , �. ^ -. r •.. �+ `/, • ��...-. . 1 v•v.1L� I I".A=•:Hr i ✓ 14%1-1i':�vv ck 114`A� vrt C, . 32. YOUR PATIENT'S ACCOUNT NO, 33. YOUR EMPLOYER LD. NO. _ _ I + .DINB. _2��-J.0 1_ 5 •mac v. JG••.•..0 II.V.al6!�VGJ Vn •nc N•1,.A ����..-w o. •...•.. yVV•.M,L rorm li-a41 corm vw%.a--ToVV `•�' • -" REMARKS: ON MEOOCAL SERVICE 6.63 Form CHAMPUS -501 Form RRS-1500 WELLMAN AND ASISOC'&P" 1 C/ O (RUTH RAHALLI 1400. DUAIL SUITE- 6---' 7 0 NEWPORT PEACH CA 52'&2 0 HEALTH INSURANCE CLAIM FORM room ha"10 Eo :NECIk APPLICAW »OGAAMkOCA KLOWI ore la 0936 -Owe 'MEDICARE MEG.:•: I MAMPUJ CMA/APVA E + bLA(.K IUNb DIMER -MEDICARE NO ` IME DICA •.0 i I IS"%OR'i SSN. I I 'VA PILE NO I I ISSN. _ _ I'CFRTwK'ATF S44. PATIENT AND INSURED (SUBSCRIBER) INFORMATION F Q 1. PATIENTS NAME (LAST NAMt. FIRST NAME. MIDD,c '•• ^L• 2. PATIENT S DATE OF BIRTH 3 INSURED S NAME ,ASI NAME, FIRST NAME, MIDDLE "IIALI OrINSON DEBORAH OBINSONJ DEBORAH 4. PATIENT'S ADDRESS (STREET, CITY, STATE. ZIP COLE SELF SPOUSE CHILD OTHER INSURED IS CARRIED BY TELEPHONE NO. EMPLOYER HEALTH PLAN N 8. OTHER HEALTH INSURANCE COVERAGE -ENTER NAME :.= POLICYHOLDER AND PLAN NAME AND ADDRESS AND POLICY OR MEC'CAL ASSISTANCEr NUMBER) 10. V^S CONDITION RELATED TO A. PATIENT'S EMPLOYMENT YES ❑ �No I I INSURED'S ADDRESS ,STREET, CITY, STATE. ZIP CODE( ^ TELEPHONE NO I IA. CHAMPUS SPONSOR'S: B. ACCIDENT AUTO D � OTHER � STATUS ACTIVE DECEASED DUTY BRANCH Of ERvI E B. �T41 ox CODE _ : RETIRED 2. 12, PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE .;;LAO SACK BEFORE SIGNING( I AUTHORIZE THE RELEASE OF ANY �-0.THENECESSARY TO SS THIS CLAIM I ALSO REQUEST PAYMENT 13.. AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED _, T P ,�I,Jp ER_ R,SEf)tAC,F� DESCRIBED BELOW. O GOVERNMENT BENEFITS EITHER�TO MYSELF OREDICAL PARTY WHO ACCEPTS ASSIGNMENT E OW llI,H 1 y tjj( LJ IV 1L� SIGNATURE ON FILE 05/15/92 4, SIGNED DATE I SIGNED (INSURED OR AUTHORIZED PERSONI PHYSICIAN OR SUPPLIER INFORMATION 14. DATE OF: ILLNESS (FIRST SYMPTOM) OR IWURY 15. DATE FIRST CONSULTED YOU FOR THIS 16. IF PATIENT HAS MAO SAME OR lea. NF EMERGENCY 4-25-92 44 IACCIDENTI OR PREGNANCY (LMPI CONDITION SIMILAR ILLNESS OR INJURY, GIVE DATES. CHECK HERE 17. DATE PATIENT ABLE TO 18. DATES OF ICTAL DISABILITY DATES OF PARTIAL DISABIUTY RETURN TO WORK - - - - - - - - _ _I.j p FROM THROUGH El= P T 20. FOR SERVICES RELATED TO HOSPITALIZATION GIVE 41210 QUAIL SUITE 270 NEWPORT PEACH CA 9 660 HOSPTTAUZATK)IDATES ADLIITTEO DISCHARGED 21. NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED IIF OTHER THAN HOME OR 22. VAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? OFFICE) YES NO CHARGES: 23. A. DIAGNOSIS OR NATURE OF ILLNESS OR NWURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE NUMBERS 1, 2.3. B. �T41 ox CODE _ _ 8 1. �+ J EPSDT YES NO EENO 2. FAMILY PLANNING YES 3. -------------------------------------------- PRIOR 4, AUTHORIZATION NO. 24. A. C. FULLf DESCRIBE PROCEDURES. MEDICAL VI U U D. F. H. LEAVE BLANK DATE OF SERVICE PLACE FURNISHED FOR EACH DATE GIVEN DIAGNOSIS E. DAYS G. • _ OF U FROM TO (EXPLAu`N UNUSUAL SERVICES OR CIRCUMSTANCES) CODE CHARGES OR T.O.S SERVICE I:DENnFY 1 UNITS 7 141 b 1 W- i H - b ..J ! 4 15/13/92 3 97010- H T PACK L 4006 1'974 15/13/92 3 9 7 124- M SSAGE THERAPY 4006 2974 I I I I 25. SIGNATURE OF PHYSICIAN OR SUPPLIER IINGLJOING CEGREE(SI OR 26. ACCEPT ASSIGNMENT -GOVERNMENT 27. TOTAL CHARGE , 28. AMOUNT PAID 29. BALANCE DUE CREDENTIALS) 11 CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TO CLAIMS ONLY) (SEE BACK) THIS BILL AND ARE MADE A PART THERcnc YESEl 1:1 NO ►� 1[, I 31. PHYSICIAN'S SUPPUER'S. AND/OR GROUP NAME. ADORES:. ZIP CODE NO 'Wi`` iL.r'°rl THERAPY DYNAMICS 3O. YOUR $OGIAL SECURITY NO. 92 '6154 N SANTIAGO BLVD #103p CRIS SCHOULEMAN.R.P.T. 0 S ANGE CA92667 DATE • G 14 67 -0►_ -6 575 32. YOUR PATIENT'S ACCOUNT NO. 33. YOUR EMPLOYER I.D. NO. I.D. NO. 0002560 CLAIM#:900791 A/ 5-4346215 - r = yr JtnvA.t ANU ITrt UP' AGHVIC,t I I.U.A.( GUC3t5 UN Int BACK -^ ^'•'^ a.vv^- ror;n 11VrA-70VV-VL T 7 -ori rul nl vRa.r-.mow REMARKS: ON MEDICAL SERVICE 6-83 Form CHAMPUS -501 Form RRO-1500 WEL.L,1AN AND ASSCC:AT� C/O RUTH RAHALL: 140k.) QUAIL SUITE 570 „ NEWP'ORT REACH CA 9�::60 HEALTH INSURANCE CLAIM FORM FOWArrRMC) :MEC• AA'ALICABLE POMP" BLOCK BELOI I OMB NO 0936•000! F-1 MC..wA E I I ME 'v •Atz I �HAZIPUS AM P WI .,A LAL,K LUNY M -MEC:'CARF NC! . .'MEDICAIC '.O 'SPONSOR'S SSN) L I tW BILE NO i ISSN' I ICFRTWK ATF SCN! F SELFSPOUSE CHILD OTHER IS OYED NO CARRIED BY B. EPSOT YES NO 11E = = EETELEPHONErNO. = EMPLO FR HEAINSURED L H PLAN 0. OTHER HEALTH INSURANCE COVERAGE (ENTER NAME :; POuCYr:OLZER 10. WAS CONDITION RELATED TO. 11 NSURED'S ADDRESS (STREET, CITY, STATE. ZIP CODE( AND PLAN NAME AND ADDRESS AND POLICY OR MED'CAL ASSISTANCE •, AUTHORIZATION NO. NUMBERI A PATIENT'S EMPLOYMENT VES NO 11AL CHAMPUS SPONSOR'S: T PACK. B. ACCIDENT AUTO OTHER � ACTIVE DECEASED BRANCH O SERV -1=Z 31 9 014- E STATUS DUTY 5000; 1 23 74 5/ 15/92 S 9 RETIRED SSAGE THERAPY 12. PATICIJT'S OR AUTHORIZED PERSON'S SIGNATURE 'AE;,D BALK BEFORE SIGNING) 13.. AUTHORIZE PAYMENT OF MEDICAL BENEFIT' TO IND RSK-NEO I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMAnON NECESSARY TO PROCESS THIS CLAIM. I ALSO REOUEST PAYMENT WNYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. OF GOVERNMENT BENEFITS EITHER TO MYSELF OR -O THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. SIGiNATURE ON FILE SIGNED SIGNATURE ON FILL oAn 05 / 1 8 / 9 ` SIGNED #INSURED OR AUTHORIZED PERSON) PHYSICIAN OR SUPPLIER INFORMATION 14. DATE OF: ILLNESS (FIRST 3yMPTOMI OR MUURY 15. DATE FIRST CONSULTED YOU FOR THIS 16.'F PATIENT HAS HAD SAME OR 16A. IF EMERGENCY (ACCIDENT) OR PREGNANCY (LMP) 4-25-92 CONDITION SIMILAR ILLNESS OR NNJURV• GIVE DATES. CHECK HERE 17. WE PATIENT ABLE TO 1S. DATES OF TOTAL DLSABILITY DATES OF PARTIAL DISABILITY RETURN TO WORK FROM TMROUGM FROM TMROUGN - - mss- f�Q-�E� GLLI'IMIYERpII�/�YSIOM LR f }Jl�tx�C!• P:(!-?OALTM 11QIJ RAHALLI !""11 V LJ hi +r'7 r �..7 v lJ I ��+ I li 20. FOR (TRU ATI RELATED TO NOSPITAUZATION GIVE MOSPRAUZATION DATES 400 QUAIL SUITE 270 NEWPORT BEACH CA 92660 ADMrrTED - - IDISCHARGED- - 21. NAME AND ADDRESS OF FACAJTY WHERE SERVICES RENDERED IIF OTHER THAN HOME OR OFFICE) 22.:vAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? YES1-111 NO CHARGES: 23. A. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE M COLUMN D BY REFERENCE NUMBERS 1. 2.3. ETC. OR OX CODE 1.8449 KNEE & LEG SPRAINS B. EPSOT YES NO 11E 2 FAMILY PLAWANG YES NO 3. ------------------------------------------- PRIOR •, AUTHORIZATION NO. 24. A. o. .,. w;-, DESCRIBE PP-.)CEDURLS. Mc 1 AL t VICE-% OR SUPPLIES DATE OF SERVICE PLACE FURNISHED FOR EACH DATE GIVEN OF " o_ DIAGNOSIS FROM TO (EXPLAIN UNUSUAL SERVICES OR GRCUMSTANCESI CODE SERVICE 110ENnFY 1 E. CHARGES F. DAYS OR UNITS H. LEAVE BLANK G. T.O.S. 5/ 15/ 9E C g 010- H T PACK. 400 '9 4 5/ 15/92 31 9 014- E EC ST IMLULATION 1 5000; 1 23 74 5/ 15/92 S 9 154- M SSAGE THERAPY 414)01'1 ''574 O/ 15/92 3 9 158- ULTRASOUND 551L ' '974 I I ' ' ' ' ' I ' � s 25. SIGNATURE OF PHYSICAAN LIR SUPPLIER 'INCLUDING ;EGREEtSI OR CREDENTIALS n CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART THEREOF. k6. ACCEPT ASSIGNMENT tGOVERNMENT CLAIMS ONLY) (SEE BACK) YES1:1 NO 27. TOTAL CHARGE � 14 5) 0 0 28. AMOUNT PAID 29. BALANCE DUE 31 PHYSICIAN'S SUPPLIER'S. ANO/OF GROUP NAME. ADDRE: S, ZIP CODE AND TELEPHONE NO. 30. '(OUR SOCIAL SECURITY NO. 'HYJICAL THERAPY DYNAMICS =- 2,$54 N SANTIAGO BLVD #1031 CR VXTE OR NGE CA92667 �► 282-6 57�.J cr 32. YOUR PATIENT'S ACCOUNT NO. 33. YOUR EMPLOYER I.D. NO.'1 0002560 C L A I M #: 9, 0 Q, a 1 G A/5-4346215 / .'yr a 'm. ...v.a.' �'"- vn'n¢." rurm rl.rA-lGE{JvwL t7-0-01 rVI RI V7IIVr-IBVV -••--- REMARKS; ON MEDICAL SERVICE 6-83 Form CHAMPUS -501 Form RRB-1500 WELLM"N AND C / O RUTH RMr' ALL I i 400 QUA :16- SU I -E a70 NEWPORT BEACH CA 926 BIZ N HEALTH INSURANCE CLAIM FORM room AAMato ,CHECK A»LICA6-E AIIOGgAME.aA 6E.OWI awe NO 0034.0008 IAL CHAM US LRAM W r �� PLALh MUNI, OTHER I/AED)CASIF N^ (IAME IGIIAIO •IO . I ICPnNSfIC'G S%w f I RVA ArILE NO , I ISSN• I I ICERTKK'AT[ S104, PATIENT AND INSURED (SUBSCRIBER) INFORMATION PA*,ENT S NAME I&AS' '.AME. FIRS% NAME. WOULE-;.I'Id" PATIENT S DATE OF BIAIH 3 INSUR ';� NAME ..AS NAIL. FIRST NAME. MIUDLL INII TALI ROBINSON DERCR'AH ROBINSON DEBORAH 4 PATIENT'S ADDRESS (STREET, CIT',. STATE. Z:P LCGE, SELF SPOUSE CHILD OTHER INSURED IS EMPLOYED AND CARRIED BY TELED-ONE NO E::� EMPLOYER HEALTH PLAN S. OTHER HEALTH INSURANCE COVERAGE REN ER NAME OF'AOLICYNOLDER 10. VAAb CONDITION RELATED TO. 11. INSURED'S ADDRESS (STREET. CITY. STATE. ZIP CODE) AND PLAN NAME AND ADDRESS AND POLICY OR MEDICAL ASSISTANCE NUMBER) A. PATIENT'S EMPLOYMENT YES �NO- YES TELEPHONE NO CHAMPUS SPONSORS: NO CHARGES: B. ACCIDENT AUTO OTHER El I STATUS ACTIVE DUTY DECEASED BRANCH RW E / 6449 KNEE LGLS JF- R. 11 J EPSOT YES No E13 ... RETIRED 3. 12. PATIENT S OR AUIHORZED PERSON S SIGNATURE -READ BACK BEFORE SKININGI I AUTHORIZE TME RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM I ALSO REOUEST PAYMENT 13 1 AUTHORIZE PAYMENT OF MEDICAL BENEFI S O UNDERSIGNED .1NYSIPA Q Y� -FOFV4 RVIC E.S RIfSD BELOW. OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. 1 V I V H� U H G U G SIGNATURE CN FILE 05/x:0/95 F. SIGNED GATE SIGNED (INSURED OR AUTHORIZED PERSON( PHYSICIAN OR SUPPLIER INFORMATION 14. DATE OF. ILLNESS (FIRST 3YMPTOMI OR INJURY 1S. DATE FIRST CONSULTED YOU FOR THIS 16. IF PATIENT HAS HAD SAME OR 16.A. IF EMERGENCY 1AGCIDENT) OR PREGNANCY ILlAPI 04-55-95 � CON V °'-08-95 SIMILAR ILLNESS OR *"M. GIVE DATES. CHECK HERE 17. DATE PATIENT ABLE TO to. DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY RETURN TO WORK — — — — — — — — FROM THROUGH FROM THROUGH IN IPGx ri RRriR=_ 1 20. FOR SERVICES RELATED To H5SPITAUZATK'N1 GIVE 1400 QUAIL SUITE 270 NEWPORT REACH CA 92660 ���� DAMS - - ADMITTED DISCDWRGED 21. NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED (IF OTHER THAN HOME OR 22, WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? OFF'ICEI YES NO CHARGES: 23. A. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE NUMBERS 1. 2. 3. B. ILTC, OR DX CODE / 6449 KNEE LGLS JF- R. 11 J EPSOT YES No E13 2- FAMILY PLANNING YES NO 3. ----------------------------------------------- PRIOR 4. AUTHORIZATION NO. 24. A. C. .,. FULLY DESZRIBE PROCEDURES,MEDICAL t VIC U U F. H. LEAVE BLANK DATE OF SERVICE PLACE FURNISHED FOR EACH DATE GIVEN N DIAGNOSIS E. CHARGES • DAYS OR G. - T.O.S. FROM OF c (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) CODE SEPVICE I ID NT1FV I UNITS 05/18/92 3 97014 ELEC S71MLULATION 1 0izi0 1 5974 Ir A. J. 05/ 18/92 3 97158 ULTRASOUND I 1 .?,5C�0 1 ::974 I I I I , I -j. WGNATURE OF P"YSI;,.Ah UR SUPPLIER ,INCLUDING ZEGREEISI OR 2b. ACCEPT ASSIGNMENT (GOVERNMENT 27. TOTAL CHARGE , 28. AMUUNI PAID 29. BALANCE DUE CREDENTIALS) II CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TO CLAIMS ONLY) ISEE BACK THIS BILL AND ARE MADE A PACT --corm 14 �Id1Z1 YES IE NO 31. PHYSICMN'S SUPPLIER'S., AND/OR GROUP NAME. ADDRESS. ZIP CODE THERAPY DYNAMICS 30. fOUR SOCIAL SECURITY NO. I-'rl�i J! l.HpL-' - 5854 N SANT I HGO BLVD #101-3 CR.L S SCHOULEMAN, R. P. T. ORANGE CA956E+7 ITE 714 585-6575 „ YOUR PATIENT � AG:.:AJNT NO. �, 33. YOUR EMPLOYER I.D. NO. 20Z2 5E, 0 CLAIM# : 9008%31 A / N n5-43:04GEE' 1c I.O.NO. • PLACE OF SERVICE ANZ TYPE OF SERVICE (T.O.S.) CODES ON THE BACK APPROVED BY AMA COUNCIL Form MCFA-1500-C2 (1-84) Form vWCP-IDOU REMARKS:I ON MEDICAL SERVICE 6-83 12 9. 1 5 U Form CHAMPUS -501 Form RRB•1500 WELL.MAN AND ASSOC I AT,/ C / O RUTH RAHALL I 1400 QUAIL SUITE 270 NEWrIORT PEACH CA 9 ='' L. 0 C HEALTH INSURANCE CLAIM FORM From AreOyED ."ECK AALaCAA E 8QOGAA#Ak0CK BELOW, OMB NC U38 -00w AF -DI( -ARL I IA I �HAMVI:S I �,MAMPW ` I ^ „A LAI.A LYNN 1. NES MEDICARE NC 1 IMEC'CA'7 •.O 11!.Pf 1N5C1R'i !;SN, I IW BILE NO I ASN, I I ,(:fpTK1('ATC SSKI PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1. PATIENTLS NAME (LAST NAME. i,RS7 '•AME. MIDUIc PATIENT S DATE OF SIAIM -NSURED S NAME 'LAST NAME. V#RFl NAME MIDULL TNITIAL, ROBINSON DEBORAH ROB INSON DEBORAH 7 -PATIENT -5 ADDRESS (STREET, CIT,. aiATE. L:P L;,:,E 5. rATIENT'S SEX o J NSURED'S 1.0 NO ,FOR PROGRAM CMECn ED ABuvL. IN"U✓E -LL LETTERS, SELF SPOUSE CHILD OTHER INSURED IS EMPLOYED AND CARRIED By TELEPHONE NO. 400 QUAIL SUITE270 NEWPORT REACH CA 92660 EMPLOYER HEALTH PLAN 9. OTHER HEALTH INSURANCE COVERAGE (ENTER NAME :F RC.LICY01OLDER 10 WAS CONDITION RELATED TO. I I .NSURED'S ADDRESS (STREET. CITY, STATE. ZIP CODE, AND PLAN NAME AND ADDRESS AND POLICY OR MEC:CAL ASSISTANCE OFFICE) NUMBER) A bATIENrSEMPLOYMENT YES a NO a Ila. CHAMPUS SPONSOR'S: 8 B. ACCIDENT AUTO OTHER I ACTIVE DECEASED BRANCH O SERtiI c 2. FAMILY PLANNING YES STATUS I DUTY PRIOR AUTHORD:AT*N NO. RETIRED 12. I;ATIEfJT'S OR AUTHORIZED PERSON'S SIGNATURE SEAL SACK BEFORE SIGNING) 13,: AUTHUHIZL PAYMENT OF MEDICAL BENEFITS O UNDERSIGNED I AUTHORIZE THE RELEASE OF ANY MEDICAL INFCAMAnON NECESSARY TO PROCESS THIS CLAVA. I ALSO REOUEST PAYMENT PHYSICIAN OR SUPPLIER FOR SERME DESCRIBED BELOW. OF GOVERNMENT BENEFITS EITHER TO MYSELF OR -o -'•E PARTY WHO ACCEPTS ASSIGNMENT BELOW. SIGNATURE ON FILE SIGNED SIGNATURE ON FILE DATE 05/21/92 SIGNED (INSURED OR AUTHORIZED PERSONI PHYSICIAN OR SUPPLIER INFORMATION 14. DATE OF: tLNESS (FIRST 3YMPTOMI OR INJURY 1E. DATE FIRST CONSULTED YOU FOR THIS 16. IF PATIENT HAS HAD SAME OR 16.a. IF EMERGENCY ,ACCIDENT) OR PREGNANCY (UAP) CONDITION 1 SMAIL.AR ILLNESS OR *&KM. GIVE DATES. CHECK HERE 04-25-92 05-08-92 17. DATE PATIENT ABLE TO 18, DATES OF TOTAL ZISABIUTY DATES OF PARTIAL DISABILITY RETURN TO WORK — — FROM — — THROUGH — FROM — — THROUGH — — t%SH RAHALL 20 To HosP(TAuzATKx+GIvE TINEDAMS I HOSSERVICES P IALIZ 400 QUAIL SUITE270 NEWPORT REACH CA 92660 Awmmo — —I DISCHARGED — — 21. NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED IF OTHER THAN HOME OR 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? OFFICE) YES NO CHARGES: 23. A. DIAGNOSIS OR NATURE OF ILLNESS OR RQUAY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE NUMBERS 1.2.3. 8 ETC. OR OX CODE 8449 KNEE & LEG SPRAINS EPSDT YES No []ENO 2. FAMILY PLANNING YES 3. --------------------------------------------- PRIOR AUTHORD:AT*N NO. 24. A. b. • .,. FULLY CESCRIBE PROCEDURES. MEDICAL SERVICES U 0. F. H. LEAVE BLANK DATE OF SERVICE PLACE FURNISHED FOR EACH DATE GIVEN OLAGNOWS E. DAYS G. FROM To OF (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) CODE CHARGES OR T.O S. SERVICE I IIDENTIrY 1 UNITS 05/20/92 317010 OT RACK 1 401p0 1 2974 05/20/92 C 37014 LEC STIMLULATION 1 30 00 1 2974 05/210/92 C 7 1 MAS23AGE THERAPY I 1 40120 1 2974 05/20/92 .3 9 71 8 ULTRASOUND 1 X500 1 ::'974 I, I 25. S0GNA1URE OF PHYSICIAN VR SUPPUER IINCLUDING u'EG;;EEISI OR [6. ACCEPT ASSIGNMENT (GOVERNMENT 27, TOTAL CHARGE , 26. AMOUNT PAID 26. BALANCE DUE CREDENTIALS) (I CERTIFY THAT THE STATEMENTS ON TINE REVERSE APPLY TO CLAIMS ONLY) (SEE BACK) ' THIS BILL AND ARE MADE A PART IwFCcrr c YES111 E] NO 31. PHYSICIAN'S SUPPUER'S. AND/OR GROUP NAME, ADDRESS, ZIP CODE AND TELEPHONE NO. 0. YOUR SOCIAL SECURITY NO PHYSICAL THERAPY DYNAMICS 5 21/92 2,854 N SANTIAGO BLVD #101—:0 D ' ORANGE CA926&7 4714'4 282-6575 32. YOUR PATIENT'S ACCOUNT NO. 33. YOUR EMPLOYER I.D. NO. • PLACE OF SERVICE AND TYPE OF SERVICE (T.O.S.) COCES ON THE BACK APPROVED BY AMA CGUNCIL Form HCFA -1500-C2 (1-84) Form OWCP-1500 GF REMARKS: ON MEDICAL SERVICE 6-83 Form CHAMPUS -501 Form RRB-1500 12 8:.36J wELLMAN AND i,SSJCii=+ ; E 15. DATE FIRST CONSUL ED YOU FOR THIS Ib.:F PATIENT HAS HAD SAME OR SIMILAR ILLNESS OR ILJURY. GIVE DATES. C: G RUTH RAHALLI i ACCIDENTI OR PREGNANCY (LMP) CONDITION 11 :400 QUAIL SUIS E 62-70 04-25-92 wEC 4;-DRT BENCH CA SEtin cIZI 1:. DATE PATIENT ABLE TO 18. DATES OF TG -.AL DISABILITY DATES HEALTH INSURANCE CLAIM FORM roRr APNEAOVEG RETURN TO WORK :.-ECP, AP-L.C. .E ProGMu kOCK SE.D*, ow No 0938 -ecce ML ILARc AE K.A::. (MEDICARE NO ( II./EDICA'-^ '•�` (�H AMVU., AM. VA I rSPYINROR'S -,SNI I I'lA E.LE NC1 . -WiA bL A, -K LUN" 1 155N� I I .CEP>T1FK;ATE SSwI 3H N H Of�rAEF�W Cu► alc- LLi ZO PATIENT AND INSURED (SUBSCRIBER) INFORMATION =AI.ENT t, t6AMt BLAST NAML.:IRST NAML, MIUULL HOSW&aATKNd DATES PATNENV, UAL OF BIRTH a .:+SURE S NAM 'LAST NAME. rIRST NAME. MIDD" INITIAL) ROLIIhJSUhJ DEE�O�,�=IH WAS LABORATORY %.:� R3BIN�ChJ DEBORAH a PATIENT S ADDRESS ISTREE:. GIT\, STATE.:.:P CCCE OFF10E) S PATILN1 5 SEA MALE X FEMALE b •ySuRE S I.D. NO %FOR PROGRAM GHECKEU AtlUVE. INGLUDE ALL ,ETTERSI E. SELF SPOUSE CHILD OTHER INSURED IS EMPLOYED AND CARRIED BY H. LEAVE BLANK DATE OF SERVICE PLACE FURNISHED FOR EACH DATE GIVEN DIAGNOSIS � EMPLOYER HEALTH PLAN � TELEPHONE NO s. OTHER HEALTH IISuFIANCE COVERAGE (ENTER NAME := PGUCY►:OLDER IU WAS CONDITION RELATEO TO. I I ,NSURLD'L, ADDRESS (STREET, CITY. STATE. 21P CODE( AND PLAN NAME AND ADDRESS AND POLICY OR MEC:ZAL ASSISTANCE A PATIENT'S EMPLOYMENT 1 B. ACCIDENT AUTO ❑ 05/c:9a OTHER 11.8 CHAMPUS SPONSOR'S' MASSAGE THERAPY (i 1 ACTIVE DECCASED BRANCH F SERVICE 1 2974 I S 71 L8- STATUS I DUTY 1 .9 74 RETIRED 12 FATIENVS OR AUTHORIZED PERSON'S SIGNATURE -PE-D BACK BEFORE SiGNINGI I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM.1 ALSO REOUEST PAYMENT 13 1 AUIHORIZE PAYMENT OF MEDICAL BENEflTS TO UNDERSIGNED PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. OF GOVERNMENT BENEFITS EITHER TO MYSELF OR -O THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. SIGNATURE ON fF- ILI SIGNATURE ON FILE DATE 0=%J/26/92 SIGNED IINSURED OR AUTHORIZED PERSONI SIGNED s�..���►�.►� no �u�o9 ��Q �91tRaQMeT1�N I- DATE OF. ILLNESS IFIRST Z'MPTOMI OR INJURY 15. DATE FIRST CONSUL ED YOU FOR THIS Ib.:F PATIENT HAS HAD SAME OR SIMILAR ILLNESS OR ILJURY. GIVE DATES. lbs. IF EMERGENCY CHECK HERE i ACCIDENTI OR PREGNANCY (LMP) CONDITION 11 04-25-92 1:. DATE PATIENT ABLE TO 18. DATES OF TG -.AL DISABILITY DATES OF PARTIAL DISABILITY RETURN TO WORK - — — FROM - - THROUGH FROM THROUGH - 3H N H Of�rAEF�W Cu► alc- LLi ZO TO HOSPITAUZATKN+GiVE wmAME HH �, 7 HOSW&aATKNd DATES 1400 QUAIL SUITE 270 NEWPORT PEACH CA 9266Icl ADMITTED - - 101SCHARGED - - 21. NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED (IF OTHER THAN NOME OR 22. WAS LABORATORY WORK PERFORMED OUTSIDE YouR OFFICE? OFF10E) YES 0 40 CHARGES: 23. A. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE NUMBERS 1. 2.3. B. ETC. OR DX CODE 1. 8449 x LEG S I 1 S EPSDT YES NO I][] FAMILY PLANNING YES NO 2 1 -------------------------------------------- PRIOR • AUTMORIZ:JION NO. A 24. A. o .. UL -T c IPROCEDURES. MEDICAL VI U U D E. F. DAYS H. LEAVE BLANK DATE OF SERVICE PLACE FURNISHED FOR EACH DATE GIVEN DIAGNOSIS CHARGES T.O.S..SERVICE FROM TO OF U c (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) CODE UNITS 'IDENTIFY I 051;_2'/92' G 7010- OT PACK i 4100 1 1.974 IZ15/;'`/9` 13 7>Z�14- LEC STIMLULATION .:,�[11ZIiz 1 '974 05/c:9a ,?, 712'4- MASSAGE THERAPY (i 1 40tPO 1 2974 I S 71 L8- ULTRASOUND 135+c10 1 .9 74 I I' 2-. S :GNATURE OF PHYSICIAN OR SUPPLIER #INCLUDING CEGREEOo OR 2b. ACCEPT ASSIGNMENT (GOVERNMENT 27 TOTAL CHARGE 2b. AMOUNT PAID 26. BALANCE DUE CREDENTIALS) Ii CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TO CLAIMS ONLY) (SEE BACK( 14 560 THIS BILL AND ARE MADE A PART THEREOF, YES El El NO 3. PHYSICIAN'S SUPPLIER'S. AND/OR GROUP NAME. ADDRE:.S. ZIP CODE 30. YOUR SOCIAL SECURITY NO. AND TELEPHONE NO. PHYSICAL THERAPY DYNAMICS X854 N SANTIAGO BLVD #103 OACORIS SCHOULEMANIR.R.T. C ANGE CA92'E67 IeN1 O 32. YOUR PATIENT'S ACCOUNT NO, 33. YOUR EMPLOYER I.D. NO. 0IZI05614) CLAIM#:900690 A/ E 95-41346`15 1 / :.-,— AW[ D.15A0 CFI • Ao oLAUL Jr btHV:Lt ANU I YVt Ur bt HVILt I:.U.a.I V.i-. ca UI. .nc REMARKS: ON MEDICAL SERVICE 6•83 Form CHAMPUS -501 Form ARS -1500 WE"LL°(�R'"fi�CCfi'"'i�'�`3'1'Ej H RAHALL I B. ACCIDENT AUTO ❑ OTHER t, a. CHAMPUS SPONSOR'S OFFICE) A TY DECEASED BRANCH OF SERVICE B. ETC. OR Ox CODE 1. 8449 KNEE R LEG SPRAINS EPSDT YES NO ' STATUS � DUTY 3. IOR •--------- ^d7mORIZATIONATION NO. a. 4. A. FULLY 1 U , M IL"AL VI - LI RETIRED DATE OF SERVKE PLACE FURNISHED FOR EACH DATE GIVEN 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE ,4EAD BACK BEFORE SIGNING( 1 AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. 1 ALSO REOUEST PAYMENT 13.1 AUTHORIZE PAYMENT OF MEDK:AL BENEFITS TO UNDERSIGNED PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. SIGNATURE ON FILE SIGNATURE -ON FILE DATE 05/27/92 SIGNED.INSURED OR AUTHORIZED PERSON( SIGNED wuvdL-lAV A V nn Cl Inns neo u1Cn12MATInN 11. DATE OF: ILLNESS (FIRST SYMPTOMI OR IFLJURY 15. DATE FIRST CONSULTED YOU FOR THIS ib. IF PATIENT HAS HAD SAME OR lb.a. IF EMERGENCY SIMILAR ILLNESS OR IMJURY, GIVE DATES. CHECK HERE (ACCIDENT) OR PREGNANCY (UMP) CONDITION 1 04-25-92 05-08-922 17. DATE PATIENT ABLE TO 18. DATES OF TOTAL DISABILITY DATES Of PARTIAL DISABILITY RETURN TO WORK FROM THROUGH — FROM — — THROUGH — — WE"LL°(�R'"fi�CCfi'"'i�'�`3'1'Ej H RAHALL I 20' ��ATON DAMS TO HOSPILUJZATION GIVE 14120 QUAIL SUITE 270 NEWPORT PEACH CA 92660 ADMITTED - - IIXSCHARGED — — Y 1. NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED IIF OTHER THAN HOME OR 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE OFFICE) YES NO CHARGES: 23. A. DIAGNOSIS OR NATURE OF ILLNESS OR INduRY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN 0 BY REFERENCE NUMBERS 1. 2.3. B. ETC. OR Ox CODE 1. 8449 KNEE R LEG SPRAINS EPSDT YES NO FAMILY PLANNING YES NO 2. 3. IOR •--------- ^d7mORIZATIONATION NO. a. 4. A. FULLY 1 U , M IL"AL VI - LI F. H. LEAVE BLANK E. DAYS G. DATE OF SERVKE PLACE FURNISHED FOR EACH DATE GIVEN DIAGNOSIS CHARGES OR T.O.S. FROM TO OF PROZEDURL CO t IEXPLAw UNUSUAL SERVICES OR CIRCUMSTANCESI SERVICE IIDEtMry I - CODE UNITS 05/26/92 3 97010 0 HOT PACK 1 4OZO 1 2974 OZ5/26/92 3 7014 -LEC S71MLULATIGN 1 3001'4) 1 2974 05/26/92 3 71;_4 AID -SAGE THERAPY �LTRASOUND 1 40bO 1 ;=:574 05/26/92 C 71228 1 G00k1 1 2974 1 1 I ' 1 25. SIGNATURE Of P Y R SUPPLIER IINCLUDINV ZEGREEISI OR 26. ACCEPT ASSIGNMENT (GOVERNMENT[ H SK:IAN O Su u 7. TOTAL CHARGE ' 26. AMOUNT PAID 29 BALANCE DUE CREDENTIALS) It CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TO CLAIMS ONLY) (SEE BACK) ; THIS BILL AND ARE MADE A PART •W.EREOF. YESEl El NO31. 14 51 0 PHYSICIAN'S SUPPLIER'S. AND/OR GROUP NAME. ADDRESS. ZJP CODE AND TELEPHONE NO. _.... 30. YOUR SOCIAL SECURITY NO. PHYSICAL THERAPY DYNAMICS . 00/27/52 2804 N SANTIAGO BLVD #103 -RIS SCHOULEMAN R. P. T. ORANGEQ CA92667 DA' 32. YOUR PATIENT'S ACCOUNT NO. 33. YOUR EMPLOYER I.D. NO. I.D7NO. 4 Lv`—ti5 / J 0002560 CLAIM# 900898 A/N95-4346215 i - - .... I,,,. . c....., urcA_-fSnn-[_7 11.A41 Form OWCP-1500 GFI - db - PLAL.0 Vt JCHVILC REMARKS: ON MEDICAL SERVICE 6-83 Form CHAMPUS -501 Form RRS-1500 L2 10:473 WEr— LLt1l.AN C / O kUTH RANALLI 4+L 0 C:UAIL SI;I T E � : �� NEWPORT BEACH CA 92E,60 HEALTH INSURANCE CLAIM FORM COMM Ells"D :.c_CK &wLIWL: 060GAAN ROCK BELOW, 3w! 110 003E -COOS ,_...,... ,HAM VA LUNYI HtN ' I, -IEC -..A ,HAM U7 ! I 'yA i1Lc NO1 !ISSN, I,CFRTwIcATF SSN, ' MrVIA E I ,SPf1NSr1R' SSN _ 1 iMED CARE NO 'MED CAi, -:C I PATIENT AND INSURED (SUBSCRIBER) INFORMATION , 007-.' '. NAML ,LAST NAME. r RS7 :WML Ml"LE V', =, PATIENT'S UAE OF BIRTH J ,N$UR DJ NAME .N, NAME. ;'RSl ;'RSNAME, MIDDLL INITIAL, ROSINSON DEBORAH SI I �- ROBIN'� 'N )t u�Hr, 6 :N6URED'5 I.D. NO w;,R PROGRAM LHELKED ABOVL.,NGLUDL ALL .I PA ADDRESS ,STREET. ; . g ATE. :P L _E a. I-A1tENT'S SEX SLE ❑ v FEMALE LETTERS, '_ SELF SPOUSE CHILD OTHER ��j INSURED AND CARRIED BY � .� •— Y A HEAEMPLOYEDHPL IL_ EMPLOYf.R HEALTH PLAN TELEPHONE NO—EZ 9. OTHER HEALTH INSURANCE COVERAGE ,ENTER NAME LF �OLICYt-:OLDER IV. WAS CONDITION RELATED TO. t. ,NSUREO•S ADDRESS ,STREET. C. -TY, STALE. ZIP COOL) AND PLAN NAME AND ADDRESS AND POUCY OR MEDICAL :SSISTANCE A. PATIENT'S EMPLOYMENT _ _ AM0.r PLANNING VES I'10 FAMILY B. ACCIDENT AUTO OTHER T t A. CHAMPUS SPONSOR'S: I AC DECEASED BRANCH OF RVICE AUTi/CRIZATtON NC. 1, ' STATUS I Y DUTY 0. DIAGNOSIS E• OAFS CHARGES OR T.OS. OF cU t SERVICE •IDENTIFY (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) CODE UNITS 05/C7/92 G RETIRED 'HYSICAL THERAPY RE—E 12 v: T'ENT'S OR AUINORIZED PERSJN S SIGNATURE ,ALAC; fsAA;K BEFORE SIGNING) RELEASE OF ANY MEDICAL INFORMAnON NECESSARY TO PROCESS THIS CLAIM. I ALSO REDDEST PAYMENT 13. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. I AUTHORIZE THE OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. SIGNATURE ON FILE SIGNED SIGNATURE C N FILE DATE 05/23/92 SIGNED ,INSURED OR AUTHORIZED PERSON) wuvi.a vA►s An des Anni lCn INCAQBIIATlnN 14. DATE OF: ILLNESS ,F,RST 3YI.IPTOMI OR INJURY • • 15. DATE FIRST CONSULTED YOU FOR THIS 16. IF PATIENT HAS HAD SAME OR 16.a. IF EMERGENCY SIMILAR ILLNESS OR INJURY. GIVE DATES. CHECK HERE 'ACCIDENT) OR PREGNANCY (LMP) CONDITION ,)4— -2-5-4'=' 17. DATE PATIENT ABLE O IB. DATES Of ,DIAL :1S-LBILITY GATES OF PARTIAL DISABILITY RETURN TO WORK IFROM_ _ - .� FROM •- - THROUGH - - 20. FOR SERVICES RELATED TO HOSPITALIZATION GIVE FOR 1g INCE LtFj F£QRIN�P►{`($ICIA Cr��l f>rSCIJH tfs BL�yH�blm /IG;N�.�1HO RANALLI �IM-ITE Lt*1�..►N NB (ER -5 t �;,H u I•,(u I NDATES 1400 QUAIL P 270 NEWPORT BEACH CA� =' �� � AOMTTTED - - DISCHARGED - - 21. NAME AND ADDRESS OF FAG" TY WHERE SERVICES RENDERED OF OTHER THAN HOME OR 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? OF7eM YES 140 CHARGES: 23. A. DIAGNOSIS OR NATURE OF IUIIESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE NUMBERS 1, 2.3. & ETC. OR OX CODE YES Ivo ' 8449 KNEE R LEG SPRAINS [311 AM0.r PLANNING VES I'10 FAMILY 2 3. - PRIOR AUTi/CRIZATtON NC. 1, F. H. LEAVE BLANK p. • •,. FULLY OE 1 PROCEDURES. MEDICAL a VI c U Ut 2a. A. F DATE OF SERVICE PLACE FURNISHED FOR EACH DATE GIVEN 0. DIAGNOSIS E• OAFS CHARGES OR T.OS. OF cU t SERVICE •IDENTIFY (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) CODE UNITS 05/C7/92 G 11-161Q� 'HYSICAL THERAPY RE—E 1 656.0 1 ='974 _ 9_ , T PACK 4060I =974 05/E7 / C) 3 7014 FLEC STIMLULATION 1 SOOk� 1 -974 71;_4 YlASSAGE THERAPY 1 4�c�00 1 L974 0- 5/;_7i 9` �:; 7014 LEC STIMLULATION 1 ,?,tc�0 1 ='974 05/27/92 I C 718 LTRASOUND 1 S5 2974 , I ; , I NCLLD,G �EGREE,SI 0;;i6. I5. S:G:.ATURE OF PHYSICu-N LAA SuPPL;E=, „ N ACCEPT ASSIGNMENT ,GOVERNMENT , 27. TOTAL CHARGE 26. AMOUNT PAID 29. bALANGE OuL CAEOENTIALS111 CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TO CLAIMS ONLY) ISEE BACK) , THIS B11 AND ARE MADE A PART THEREOF. YESE] El NO ;= 4�c�0►ZI 31. PHYSICIAN'S SUPPUER'S. ANOi OR GROUP NAME. AOOREF.S. ZIP CODE AND TELEPHONE NO. _40 (OUR SOCIAL SECURITY NO. PHYSICAL THERAPY DYNAMICS ' 2,854 N SANTIAGO BLVD #103 ORANGE CA92667 I 32. YOUR PATIENT'S ACCOUNT NO. 33. YOUR EMPLOYER I.D. NO. 1 7,! 4 282-C 575 000—'560 CLAIM#:9009 20 A/N 95-4346215 L— -nnen-1-- —, rr.i,•— —,— ur_ce.Y500.C2 11-841 Form OWCP-1500 CFI•.+6 —L00.t VF itnv'Lr. REMARKS: ON MEDICAL SERVICE 6-83 Form CHAMPUS -501 Form RRB-1300 c -' 12 -):.J 1 I�!: .N�'GRT Vic►-►�n :.rl �►.:: 6�� HEALTH INSURANCE CLAIM FORM FOIw AP4IOIIED CHECK AMLCAi_ 9QOGIIAAIQOCK 6ELOW� 3"N0 0036.0006 m-LAmM-LARE M h,A-L i(MEDICARE NO 1 I IMEDICAIC NO HAMPUa I NAMPVA ( ISPnNGOFYS SiN1 L (IVA FILE No I -L-- I!L K LUN INE ! 'SSKI I I)CFQTIFI( ATF SSN PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1 PATIENT'S NAME (LAST NAME. FIRST NAME, MIDDLE PATIENT S DAIL Of BIRTH 3..NSURE 'S NAME 6ASI NAME. FIRST NAME. MIDULE WIT TALI �cL,I,��,Cr3 ���,�t=t-? ,4. : =;Gr:L'SLtc:a�-; PATIENT'S ADDRESS (STREET. CITY. STATE, ZIP CODE( : SELF SPOUSE CHILD OTHER INSURED IS EMPLOYED AND CARRIED BY E�lEMPLOYER HEALTH PLAN TELEPHONE NO. INSURED'S ACDAESS ISTREET. CITY. STATE. ZIP CODEI B. OTHER HEALTH INSURANCE COVERAGE (ENTER NAME OF POLICYHOLDER 10. rwS CONDITION RELATED TO: 11. AND PLAN NAME AND ADDRESS AND POLICY OR MEDICAL ASSISTANCE NUMBER( A. PATIENT'S EMPLOYMENT _ •,_ B. ACCIDENT AUTO ❑ t OTHER t A. CHAMPUS SPONSOR'S: , AG IVE DECEASED BRAN F SERVICE STATUS � DUTY RETIRED 12 PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE •A"C; BACK B FORE SIGNING) I.S. 1 AUTHORIZE=AYMENT OF MEDICAL BENEFITS TO UNDERSIGNED I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. I ALSO REOUEST PAYMENT FOR SERVICE DESCRIBED BELOW. OF GOVERNMENT BENEFITS ERHER TO MYSELF OR TO THE PARTY WHO ACCP PTS ASSIGNMENT BELOW. _PH_YSICIAN_ORSUPPUER j 1 L7 j �I 1; , ._ ; ; ` 'O N '' 1 i... G SIGNED - 1 L.%' 1 A I v i i ` LIN I..... DATE __]SIGNED (INSURED CR AUTHORIZED PERSON) PHYSICIAN OR SUPPLIER INFORMATION 14. DATE OF: ILLNESS (FIRST SYMPTOMI OR INJURY 15. DATE FIRST CONSULTED YOU FOR THIS 16. IF PATIENT HAS 04A0 SAME OR 16.A. IF EMERGENCY (ACCIDENT) OR PREGNANCY ILMP) CONDmON SIMILAR ILLNESS OR INJURY. GIVE DATES. CHECK HERE 1`s4—`0-9 05-0S-9 17. WE PATIENT ABLE TO 18. DATES OF TOTAL DISABILITY SATES OF PARTIAL : ISASILITY RETURN TO WORK _ — — w FROM THROUGH FROM THROUGH MR 2 5 t 20. FOR SERVICES RELATED TO HOSPITALIZATION GIVE —,_"MRIAML .Z 1400- QUAIL SUITE 270 NEWPORT BEACH CA 92660 HOSPMMJUTION DATES — — — — ADMITTED DISCHARGED 21. NAME AND ADDRESS OF FAC4JTY WHERE SERVICES RENDERED IF OTHER THAN HOME OR 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? FF OICE) YES NO CHARGES: 23. A. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE NUMBERS 1.2.3. B. ETC. OR DX CODE 1, 6 4A49 d% L_i=L7 EPSDT YES NO 2. FAMILY PLANNING YES NO 3. ---------------------------------------------- PRIO AUTHORIZATION NO. 24. A.b•AC FULLYU . MEDICAL VI U F. H. LEAVE BLANK DATF. OF SERVICE PLACE FURNISHED FOR EACH DATE GIVEN DIAGwOSIS E. CHARGES DAYS on G. T.O.S. FROM TO `w ` (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) CODE UNITS SERVICE IIDENTFv I E '( A H` L. E T 1 C t= .ami 42 14 9 1 01 0 OT IACK I;2974 1 =►IZ►CI� 1 L. l.. `J i i i Y1 tJ L H i 1 t..11 Yi 1 6:I ILI �11LI � i<15i E9 / 9; I 4 ASAG THEP.Ar Y I 1 4K�A.�k� 1 29 ' 4 14, 7 7, I 1`5 ME, RH::,-5uIVU 1 , , , , , I , , 25. SIGNATURE OF PHYSICIAN OR SUPPUEFI IINCLUDING DEGREEIS) OR 26. ACCEPT ASSIGNMENT (GOVERNMENT 27 TOTAL CHARGE , 28.A MOUNT PAID 2v. BALANCE DUE CREDENTIALS) a CERnFY THAT THE STATEMENTS ON THE REVERSE APPLY TO CLAIMS ONLY) (SEE BACK) o ' 1 1��11L1 THIS BILL AND ARE MADE A PART THEREOF. .......... YESEl El NO 31 PHYSICIAN'S SuPPUER'S. AND/OR GROUP NAME. wDDRE55. ZIP COO 30 YOUR SOCIAL SECURITY NO. _ AND TELEPHONE NO. !� - �") '� ,L L. ,-� L THERAPY DYNAMICS, 13-54 ;N ;'A'vT ILAGO BLVD #1 Lac r El DAL 32. YOUR PATIENT'S ACCOUNT NO, r 3� 4 - S C -b J i J YOUR EMPLOYER IA. NO. Ql+�ca C�0 CLA I h1# ka'= caa 0 133. a; `a ; %5-4;j46E 1 C • PLACE OF SERVICE AND TYPE OF SERVICE (T.O.S.) CODES ON THE BACK APPROVED BY AMA COUNCIL Form HCFA -1500-C2 (1.84) Form OWCP• 1500 C -F' - 46 REMARKS: ON MEDICAL SERVICE 6-83 Form CHAMPUS -501 Form RRS-1500 L WELLMAN AND ASSOCIATE C/O kUTH RAHALLI 1400 QUAIL SUITE `70 NEWPORT PEACH L.o 9 at` CK'HEALTH INSURANCE CLAIM FORM rNaAp tMD .-ECK AM4GAB► 940GRAAI •.C.CA BELDW 3" NO )36-=b ....w_.. M i�A _ 'AEu.,+•.. ..AMPUz „r.AM w...A S. A„N .NNIv I (MEC CARE NO IIAECIrA .IO . I rSoc�NccN1 c SSN. I i Iw aLE NO I SAN, I ,CCRTIrIrATE ScN, PATIENT AND INSURED (SUBSCRIBER) INFORMATION PAl IENT'S NAME -� NAME. FIRS", ',,AML MICGIc .� ,A. OAT,c'vl S NA1E JF BIRiH INSURED S NAML ,. 1 NAME. FIRS1 NAME. MIUOLE INIIIAL, ROBINSON DEBORAH li -3RORINSOrJ DEBORAH vAT+ENT's ,E� o INSURED'S I.J. NU IFOH PROGPIAM LHELnED ABOVL. IN(,LUUE ALL PATIENT'S AGGRESS )STREET, C1Tv. 5'ATE. Z:P C _E. EIFEMALE TETTERS) INSURED IS EMPLOYED AND CARRIED BY EMPLOYER HEALTH PLAN INSURED'!, ADDFESS ISTREEI. C11 Y. STATE. ZIP CODE I T- - AND PLAN NAME AND ADDRESS AND POLICY OR MECICAL ASSISTANCE A. PATIENT'S EMPLOYMENT B ACCIDENT 11 D CHAMPUS SPONSOR'S: BRANCH1 AUTO TY OTHER i DUTY DECEASED STATUS RETIRED Z. JATIEI)T'S OF AUTHORIZED PERSON'S SIGNAI URE ,aEAD F3Ak;k dEFURE SI(;NINNI Q. I AUTHURIZE PAYMENT OF MEDICAL BENEFIT$ TO uNDERSIGNEi 1 AUTHORISE *HE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO P4OCESS THIS CLAIM. I ALSO REOUEST PAYMENT PHYSICIAN I SI N A T URE FOR O i SERVICE F IL E ED BELOW. OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. IGNED 'SIGNATURE ON FILE DATE 06/02/942, SIGNED IINSURED OR AUTHORIZED PERSONI PHYSICIAN OR SUPPLIER INFORMATION )ACCIDENT) OR PREGNANCY ILMP) 04-25-92 17. DATE PATIENT ABLE RETURN TO WORK HdSPILL12AT10N DATES 1400 QUAIL SUITE 270 21. NAME AND ADDRESS OF FACILITY WHERE SERVICES OFFICE) ETC. OR OX CODE 8449 2- 3. DATE OF SERVICE FROM TO 0i/9 06i 1211 /9 06/01/CJi NEWPORT REACH CA 92660 EPSDT YESHHNOFAMILY PLANNING YES HO -------------------------------------------- PRIOR AI)THORIZAMN NO. CREDENTIALSI 11 CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TU THIS BILL AND ARE MADE A PART :HEREOF AND TELEPHONE NO. �IHYSICAL THERAPY DYNAMICS Q 854 N SANTIAGO BLVD #1013 RANGE CA92667 I.D7A 4 ►=Btu—CJ / J r+I nTM4•t.n171171GC: n /M • " ACE OF SENVIGE AND TYPt U. btHvi" I I.v.a.I NVNGQ vr. ,.,c o...... ON MEDICAL SERVICE 6•83 Form CHAMPUS -501 Form RRB-1500 c. WELLMAN AND C/O RUTH R;4ip",LLI 1400 QUAIL SUITE 670 NEWF'OkT BEACH CA y =aa0 ` HEALTH INSURANCE CLAIM FORM FORM N+41104D CHEa A» SASLE »()GAAr LOCK KLOW ' OMS 4: Dob -00W LLA bLALK .UN%. H 1MEOICARE NO I 1 MEC"A '.O ' ' (RPANS(1R'i RRNI I .VA F1ILE NO, I SRN, rCFRT0riCATF SCN, PATIENT AND INSURED (SUBSCRIBER) INFvriMAliuk IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS OR INJURY. GIVE DATES. 1 PATIENT S NAME,LAST NAML. SIRS' NAME. MIUiuLc PATIENT S UATE OF alAl HNbURLD S NAME (LAST NAME. FIRST NAME, MIDDLE INITIAL- DEBORAH 7ROBI JON DEBORAH "r"ROBINSON s. PATIENT';, ADDRESS ,STREE-. CIT Y. STATE. Z:P :.e S. ?ATIENT'S SEA 17. WE PATIENT ABLE TO o ,NSURED S I.D NU ,FON PROGRAM (;NECKED ABOVE. INLLuDL ALL LETTERS( SELF SPOUSE CHILD OTHER INSURED IS EMPLOYED AND CARRIED BY EMPLOYER HEALTH PLAN TELEPHONE NO.n 9. OTHER HEALTH INSURANCE COVERAGE (ENTER NAME CF POLICYKULDER 10. WAS CONDITION RELATED TU. 11 INSURED'S ADDRESS (STREET. CITY. STATE, ZIP CODE( AND PLAN NAME AND ADDRESS AND POLICY OR MECICAL ASSISTANCE A. PATIENT'S EMPLOYMENT t t.a. CHAMPUS SPONSOR'S: 24. A. �. FULLY' 1 U LL. MEDICAL VIC. LID B. ACCIDENT AUTO a OTHER F. AACTI E DECCASEO BRANCH OF SERVO =E DATE OF SERVIrE PLACE FURNISHED FOR EACH DATE GIVEN DIAGNOSIS E. CHARGES STATUS DU I FROM I OF (EXPLAIN UNUSUAL SERVICES OR GIRCUMSTANCE51 CODE SERVICE IoEwn" I , RETIRED 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE ..:LAO oACK BEFC,RE S4GNING1 I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. I ALSO REOUEST PAYMENT 13. 1 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. SIGNATURE ON FILE SIGNED SIGNATURE ON F 1 LG DATE 06 /14-) 5 SIGNED (INSURED OR AUTHORIZED PERSON) PHYSICIAN OR SUPPLIER INFORMATION I4. DATE OF: ILLNESS ,FIRS. 3Y%4PTOMI OR INJURY 1:. DATE FIRST CONSULTED YOU FOR THIS 16. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS OR INJURY. GIVE DATES. 164. IF EMERGENCY CHECK HERE (ACCIDENT) OR PIREGNANCY ILMP) CONDITION 04-25-92 17. WE PATIENT ABLE TO 16. DATES OF , OIAL JISABIUTY . OA ES OF PARTIAL DISABILITY RETURN TO WORK — — FROM THROUGH FROM THROUGH — C�Lf'8R'"f CP�-'A' SSan F�ES"ilaa AR13TH RAHALL I 20 . FOR SEAVICES RELATED HOSPITALIZATION DATES TO HOSPITNJZATION GIVE 1400 QUAIL SUITE 270 NEWPORT REACH CA 92660 ADMITTED - - DISCHARGED - - 21. NAME AND ADDRESS OF FACIUTY WHERE SERVICES RENDERED OF THER THAN HOME OR 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR FILE? OFFICE( , YESF11 NO CHARGES: 23. A. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE NUMBERS :. 2.3. 6. ETC. OR OX CODE 1. 8449 KNEE R LEG SPRAINS EPSDT YES NO 1111 2 FAMILY PLANNING YES NO 3. ';----------------------------------------- A AUTHORIZATION NO. 24. A. �. FULLY' 1 U LL. MEDICAL VIC. LID F. H. LEAVE BLANK DATE OF SERVIrE PLACE FURNISHED FOR EACH DATE GIVEN DIAGNOSIS E. CHARGES OA ORR G. T.OS. FROM I OF (EXPLAIN UNUSUAL SERVICES OR GIRCUMSTANCE51 CODE SERVICE IoEwn" I UNITS 06/0G/9` G 7110- THERAPUETIC EXERCISE 1 4000 1 5974 06 / 0 / 9 2 3 71210— HOT PACE'. 1 ( 40iZ10 1 2974 06 % 021 / 9 2 13 9 : 014— JELEC ST I MLULAT 10N 1 30QIO 1 29 7 4 06/03/92 I .3 71;_4— ASSAGE THERAPY i 40000 1 2974 Ic�6i Q►S/92 ., 77125— LTRASOUND 2<974 II ' I I , , ! 25. SIGNATURE OF PHYSICIAN VR SUPOUEF ,INCLUDING CEGREEISI OR 26. ACCEPT ASSIGNMENT (GOVERNMENT 27 TOTAL CHARGE 28. AMOUNT PAID 29. BALANCE DUE CREDENTIALS( 11 CERTIFY THAT THE STATEMENTS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART THEREOF. CLAIMS ONLY) (SEE BACK) ' 18500 YES No El 31. PHYSICIAN'S SUPPLIER'S. AND/OR GROUP NAME. ADDRESS. ZIP CODE AND TELEPHONE NO. PHYSICAL THERAPY DYNAMICS 30. YOUR SOCIAL SE%URITY NO. �C 1`-2854 N SANTIAGO BLVD #10G DA�.-RIS SCHOULEMAN. R. P. T. ORANGE CA92667 I DlNR 4 282-6575 32. YOUR PATIENT'S ACCOUNT NO. 33. YOUR EMPLOYER I.D. NO. 0002560 CLAIM#:901026 A/ 95-41346215 / • PLACE OF SERVICE AND TYPE OF SERVICE 1T.O.S.) COZES ON THE BACK APPHUVtU BY AMA LUUNLII Form H�.FA-77VV-AAL t: 1-0/J rVI .I, v�.v�- +• REMARKS: ON MEDICAL SERVICE 6.83 Form CHAMPUS -501 Form RR8-1500 i "TIEN B. ACCIDENT "A' TE CHAMPUS SPONSOR'S: 1 UBRANCH AUTO OTHER � • STATUS DUTYDECEASED �- RETIRED . 1 AUIMORtZE PAYMENT OF MEDICAL BENEFI S TO UNO RSIGN 12, PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE -RE-%Z)13 BACK BEFORE S1GNwGI 1 AU104 IAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. I ALSO REOLIEST PAYMENT OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. SIGNATURE ON FILE T n T DATE 2 SIGNED INSURED OR AUTHORIZED PERSON) SIGNED r„ PHYSICIAN OR SUPPLIER INFORMATION %ACCIDENT) OR PREGNANCY ILMPI OFFICE) 23.... DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROC M. OR OX CODE 1. 8449 KNEE & LEG SPRAINS 2. 3. >r6/Q15/9E 06/05/9G 06/05/92 06/05/92 CREDENTIALS) II CERTIFY THAT THE STATEMENTS ON "HE REVERSE APPLY TU THIS BILL AND ARE MADE A PART THEREOF. • PLACE OF SERVICE AND TYPE OF SERVICE IT.0.5.) cwts UN -Mt ont,n ON MEDICAL SERVICE 6-83 REMARKS: HAsPRAIJZATION DATES EPSDT YES 1__.Jt NO FAMILY PLANNNG YES NO ,--------------------------------------------- PRIOR AUTHC>RIz,%-ION NO. AND TELEPHONE NO. PHYSICAL THERAPY DYNAMICS 2,854 N SANTIAGO BLVD #101—:0 ORANGE CA92667 1.OMd4 i��i�—bJ7J / Form HCFA -1500-C2 (1-84) Form OWCP-1500 cFI-+a Form CHAMPUS -501 ' Form RRO-1500 WELLMAN AND ASCC: '-c =- 1 C / U Rul H ;;AHA::- I 1 40141 0 U A I L SU I' E 570 NEWPORT BEACH CA MEALTM INSURANCE CLAIM FORM loom ar"Mo 2. PATIENT'S DATE OF BIRTH J- INSURED S NAMt ,LAST NAML, FIRST NAME. MIDULE WITIALI CHea JIVwwCM{.F MOGAAM&LOCK BELOW+ owwo 09311-0on ,....m..... ME j -,-ARE ME I',A4+ tt CHAMPUS L,HAMPvA :,A OL AL,K LUNY ( H ,MEDICARF NO I I .MEDICAID NO I ( f ,SP(tNSOR't SAN, IVY( cKF NO � •SSN, ICFRTIFICAT( SSNI PATIENT AND INSURED (SUBSCRIBER) INFORMATION IF PATIENT NAS HAD SAME OR I PA71ENT'b NAME ILASI NAME. FIRST NAME. MIDOLE INITIAL, 2. PATIENT'S DATE OF BIRTH J- INSURED S NAMt ,LAST NAML, FIRST NAME. MIDULE WITIALI RUL- I NS0N DEri0r=;AH ROB I kolSONDEBORAH 4 PATIENT'S ADDRESS (STREET. CITY. STATE. ZIP CODE, 5. PATIENT'S SEX 17. DATE PATIENT ABLE TO o. INSUREDS I.D NAI. ,FOR PROGRAM CHECKED ABOVE, INCLUDI ALL LETTERS( SELF SPOUSE CHILD OTHER INSURED IS EMPLOYED AND CARRIED By 3. 1 AUTHOrnIZAT10N :40. E:l= = = EMPLOYER HEALTH PLAN TELEPHONE NO. 06/10/92, C 9. OTHER HEALTH INSURANCE COVERAGE (ENTER NAME OF POLICYHOLDER 10. WAS CONDITION RELATED TO: 11. INSURED'S ADDRESS (STREET, CITY. STATE. ZIP CODE( AND PLAN NAME AND ADDRESS AND POLICY OR MEDICAL ASSISTANCE 1 NUMBER) A. PATIENTS EMPLOYMENT YES � NO a / 1 a. CHAMPUS SPONSOR'S: B. ACCIDENT AUTO ❑ OTHER 59 74 ACTYE DECEASED BRANCH OF SERVICE 7014- C ST I MLULAT I ON STATUS � ?,k4Id1Z1 1 1- 74 1- _ RETIRED 97124- 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE (READ BACK BEFORE SsGNINGI 13. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED I AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM I ALSO REOUEST PAYMENT PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. S I G N A l' U R E • ON FILE SIGNED SIGNATURE ON FILE DATE 06 /l 1 / 9 2 SIGNED (INSURED OR AUTHORIZED PERSONI PHYSICIAN OR SUPPLIER INFORMATION 14. GATE OF: ILLNESS IFIRST SYMPTOM$ OR INJURY 15. DATE FIRST CONSULTED YOU FOR THIS 16. IF PATIENT NAS HAD SAME OR I6i. IF EMERGENCY (ACCIDENT) OR PREGNANCY ILMPI CONDITION SIMILAR ILLNESS OR IUURY• GIVE DATES. CHECK HERE r 04-`5-9L 17. DATE PATIENT ABLE TO 18. DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY RETURN TO WORK - - FROM - - THROUGH - - FROM - - THROUGH - - 1'n� FL ' �R"�i•�iC��` N° �°Y 'cj "`�':' i"H RAHALL I 20' � S ETON DATEg TO HOSPITALIZATION GIVE 1400 QUAIL SUITE 270 NEWPORT REACH CA 92660 ADMnnm - - JDISCKARGED - - 21. NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED IIF OTHER THAN HOME OR 22. NMS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? OFFICE) YES110 NO CHARGES: 23. A. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE NUMBERS 1, 2.3. 8. ETC. OR OX CODE 1• 8449 KNEE FC LEG SPRAINS EPSDT res No [Ill 2 FAMILY PLANNING YES NO 3. ----------------------------------------- 3. 1 AUTHOrnIZAT10N :40. 24. A. C. FULLY OF-SCRiBE PROCEDURES. MEDICAL SERVICES U LIF. H. LEAVE BLANK D. E. DAYS G DATE OF SERVICE PLACE FURNISHED FOR EACH DATE GIVEN DIAGNOSIS CHARGES OR T.O.S. OF FROM TD (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES( CODE SERVICE (IDENTIFY 1 UNITS 06/10/92, C 7111171- THERAPUETIC EXERCISE 1 4000 1 5974 06/10/92 C 7010- OT PACK. 1 40 1171 1 59 74 06/10/92 E 7014- C ST I MLULAT I ON 1 ?,k4Id1Z1 1 1- 74 1- 06/10/92 5� 97124- =SAGETHERAPY 1 4121Qi0 1 ;=_974 1216 i 1 01:'9` C 9 71::3- ULTRA'SOUND1 C5r1N: k� , 1 ;_974 I I ' I I , , 25. SIGNATURE OF PHYSy,1AN OR SUPPLIER IINCLUDINAs CEGREEIS, OR 2b ACCEPT ASSIGNMENT .GOVERNMENT 27. TONAL CHARGE 2b. AMOUNT PAID 29. BALANCE DUE CREDENTIALS( (I CERTIFY THAT THE STATEMEtITS ON THE REVERSE APPLY TO CLAIMS ONLY) (SEE BACK) ; THIS BILL AND ARE MADE A P ' - YES NO 1:1 Q J 0 18500, 31. PHYSICIAN S SUPPUER'S, AND/OR GROUP NAME. ADDRESS. ZIP CODE ANO TELEPHONE NO. 30. YOUR SOCIAL SECURITY NO. PHYSICAL THERAPY DYNAMICS 6/11/95 5854 N SANTIAGO BLVD #103 DARIS SCHOULEMAN. R. P. T. ORANGE CA95667 1.0ZN1 `f 282,-60-975 A 32. YOUR PATIENT'S ACCOUNT NO. 33. YOUR EMPLOYER I.D. NO. k11Z1k�;=:S61Z1 CLAIM# : 901 k�81 A; �- �4.p46`15 J / • PLACE OF SERVICE AND TYPE OF SERVICE (T.O.S.1 CODES ON THE BACK ArrHvvtU by AMA GpUNL,IL rorm nA.rA-1 avv-bi t l-0.01 rvl III v....r- . i-Pw REMARKS: ON MEDICAL SERVICE 6-83 Form CHAMPUS -501 Form RRB-1500 WEL' AMAIN AND aSSuC:r,"�,.I? 1 � ;' G RUTH RAHALLI 1400 QUAIL suI r- -,-Q iNEw�'ORT BEACH CA $2660 HEALTH INSURANCE CLAIM FORM FOW AApamo :NECK A80141CAIJ OROGRAW &' OCK KLOIMI Owe IID 0936.0008 M DILA L i MEZ.-A,..�.HAMPUS �.KAMPVA • I'L-A dLAL.K LUNO UT HEN IMEDICARF NO I IMFC'CA:'.r ICPI�JSC!R'R SSNI ( IVA F� •:O I ISSN F I ICFRTKICATF SRN PATIENT AND INSURED (SUBSCRIBER) INFORMATION 16. IF PATIENI HAS HAD SAME OR 1 PATIENT'S NAME ILAo, NAME. FIRS' NAME MICL.t '• - PATIENT S DA1L JF BIRTH J. INSUREDNA S ME LAS1 NAML. FIRST NAML, MIDDLE INITIAL! ROBINSON DEBORAH ��:; ROB:NS0N DEBORAH A. PATIENT'S ADDRESS (STREET. C,. `. STATE. ►:P CCCE SELF SPOUSE CHILD OTHER X = = = =1 INSURED IS EMPLOYED AND CARRIED BY = TELEPHONE NO EMPLOYER HEALTH PLAN fl. OTHER HEALTH INSURANCE COVERAGE (ENTER NAM_-:_C;YHOLDER AND PLAN NAME AND ADDRESS AND POLICY OR ME-- SAL ASSISTANCE NUMBERI 10. WAS C014DITION RELATED TO. A PATIENT'S EMPLOYMENT VES ❑No 11. INSURED'S ADDRESS STREET, CITY, STATE, ZIP CODE 11 AL CHAMPUS SPONSOR'S: ETC. FDX C2DE _ _ �}} AiNB S. ACCIDENT AUTO OTHER I STATUS I AC IVEDECEASED DUTY BRANCH OF SERVICE FAMILY PLANNING YES NO 3. ----------------------------------------------- �. RETIRED PRIOR 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE =EAZ; SAC,, BEFORE SIGNINGI I AUTHORIZE THE OF GOVERNMENT BENEFSITS EITHER TOM SELFE OF ANY MEDICAL FOo x'10 NECESSARY E PARTY WHOTACEPTS ASSIGNMENT BELOW OCESS THIS CLAIM. I ALSO REQUEST PAYMENT 13 I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED PH J L7I: 1D�tRF SF,iI�'C,E DFSGgIBf� BELOW. y 1 �JI'(t t�.JJ vv �� SIGMA rURE ON -ILE 06/112-1/92 SIGNED DATE SIGNED (INSURED OR AUTHORIZED PERSON) PHYSICIAN OR SUPPLIER INFORMATION 14. DATE OF: ILLNESS (FIRST S • MPT•;MI OR INJURY 15. DATE FIRST CONSULTED YOU FOR THIS 16. IF PATIENI HAS HAD SAME OR 16.a. IF EMERGENCY r (ACCIDENT) OR PCEGNANCY (LMP) CONDITION SIMILAR ILLNESS OR INJURY, GIVE DATES. CHECK HERE 17. DATE PATIENT ABLE TO 18. DATES OF T. C TAL :.USABILITY DATES OF PARTIAL DISABILITY RETURN TO WORK — FROM THROUGH — FROM THROUGH 1D. OISO SM NULY IAOENPVj 20. FOR SERVICES RELATED TO HOSPITALIZATION GIVE 1400 QUAIL SUITE 271-41NEWPORTPEACH CA 926 HOSTED MTED �1O�=DATES- - - ADMTrdSCFu►RGED 21. NAME AND ADDRESS OF FACILITY WHERE SERVICES RENDERED IIF OTHER THAN HOME OR OFFICE( 22. WAS LABORATORY r WORK WORK PERFORMED OUTSIDE YOUR OFFICE? YES ( S( I NO CHARGES: 23. A. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE CIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE NUMBERS 1.3.3. B. ETC. FDX C2DE _ _ �}} AiNB 1. % L— - EPSOT YES NO ElEl 2 FAMILY PLANNING YES NO 3. ----------------------------------------------- PRIOR a. AUTMORJJ11iON NO. 24. A. 5. C. ULa_Y Z:ESC:;kl8E PROCEDURES. MEDICAL SERVICES OR SUPPLIESF. DATE OF SERVICE PLACE CUPMSMSD FOP EACH DATE GIVEN D' OF •, -.0 DIAGNOSIS FROM TO (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) CODE SERVICr �` 7+ry I E. CHARGES DAYS OR UNITS G. • T.O.S. H. LEAVE BLANK _ L ..:v ! J M ii u■ 1 J 1 .71 V 1 ..!P J. a THERAPY TX ; I I I 25. SIGNATUQ' "�� _ ..• .. ,.-- _._ ')ING :-GnE-,Si OR 26. ACCEPT ASSIGNMENT (GOVERNMENT 27. TOTAL CHARGE I 2b. AMOUNT PAID 29. BALANCE DUE Cp _••,J.LS111 CERTIFY T -A- - _ "•-- - - =R'ERSE APPLY TO HIS BILL AND ARE c A PART THEREOF CLAIMS ONLY) ISEE BACKI YES El NO ED �iIL11L 31. PHYSICIAN'S SUPPLER'S'AND/OR GROUP NAME. ADDRESS. ZIP CODE -Z:b A NO P'� jftt�4L THERAPY DYNAMICS 30. YOUR SOCIAL SECURITY NO. 06/ 12i 9'= 2854 N SANTIAGO BLVD #103p ORIS SCHOULEMANIR.P.T. DATE ORANGE CA926a7 _ ,� / 1 4 `8�—�+ J -15 I.D. NO. 32. YOUR PATIENT'S ACCOUNT NO. IZ 002560 CLAIM#:901104 A/ 33. YOUR EMPLOYER I.D. NO. 9 5-413462115 • PLACE OF SERVICE AND TYPE OF SERVICE (T.O.S.) C --DES ON THE BACK APPROVED BY AMA COUNCIL Form HCFA -1500-C2 (1-84) Form OWCP-1500 CFI -.s6 REMARKS: ON MEDICAL SERVICE 6-83 Form CHAMPUS -501 Form RR8-1500 WILL -IAN AND ►=(SSVC =.�, Vi G RUTHRHr1ML-�1 14110 Q J A I L �6IUI7c 7I Nr--Wt'--'ORT BEACH CA $a -'E,60 NEALTM INSURANCE CLAIM FORM roles &pnbm: __. CI.ECK •P! SAW PROGA"SLOCK K.Ow- Jae llc 0936 4c MEDICARE MEDILAIC HAM UJ „r-AMDVA t 6LALK LUN. N (MEDICARE NO, I _ I $MEDICAID "0' ISPO P'S SSKI L � 114 A14l' NO I ( � $SSN$ ( I ICFpTKICATF SSN PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1 PATIENT'5 NAME (LAST NAME. FIRST NAME. MIDDLE -Nil -ALL 2. PATIENT'S LAE OF BIRTH 3. W,,UR '5 NAML $LAST NAM . FIRST NAME. MIDDLE AIIUALI Rb12.1NS0N IRCP1r4G0r4 DEBORAH ♦. PATIENT'S ADDRESS (STREET. CITY. STATE, ZIP CODE, 5 PATIENT'S SEA 6 INSUREDS I.D. NU. IFOR PROGRAM LMECK D ASOVL. INCLUDE AL. 17. DATE PATIENT ABLE TO Is. DA ES OF TOTAL JISABIUTY DATES OF PARTIAL DISABILITY LETTERS) , $ - . SELF SPOUSE CHILD OTHER NO CHARGES: YES FT 23. A. DIAGNOSIS OR NATURE OF ILLNESS OR e•LIURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE NUMBERS 1.2.3. 8. INSURED IS EMPLOYED AND CARRIED BY TELEPHONE NO. ^ EMPLOYER HEALTH PLAN 9. OTHER HEALTH INSURANCE COVERAGE (ENTER NAME OF POLICYHOLDER 10. WAS CONDITION RELATED TO. 11. INSUREDS ADDRESS $STREET, CITY. STATE. ZIP COOL AND PLAN NAME AND ADDRESS AND POLICY OR MEDICAL ASSISTANCE 3. ----------------------------------------------- NUMBER) A. PATIENT'S EMPLOYMENT YES ❑ � NO F. DAYS B. ACCIDENT AUTO ❑ OTHER$ t 1.A. CHAMPUS SPONSOR S: DIAGNOSIS FROM TO ttn= (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) CODE (IDENTIFY I AC ISE DECEASED BRANCH SERVICE T.O.S.SERVICE STATUS DAY 97110- 'THERAPUETIC EXERCISE 1 !H RETIRED 1 12. PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE $READ BACK BEFORE SIGNING) Q. I AUTHORIZE PAYMENT OF MEDII;AL BENEFITS TO UNDERSIGNED 1 AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PROCESS THIS CLAIM. 1 ALSO REOUEST PAYMENT PHYSICIAN OR SUPPLIER FOR SERVICE DESCRIBED BELOW. I OF GOVERNMENT BENEFITS EITHER TO MYSELF OR TO THE PARTY WHO ACCEPTS ASSIGNMENT BELOW. r G Iii H .1 URE LIN F1LE: SIGNATURE G N FILE / 9 �- SIGNED DATE SIGNED $INSURED OR AUTHORIZED PERSoIvt PHYSICIAN OR SUPPLIER INFORMATION la. DATE OF: ILLNESS (FIRST SYMPTOM$ OR INJURY 15. DATE FIRST CONSULTED YOU FOR THIS 16. IF PATIENT MAS MAD SAME OR 16.. IF EMERGENCY IACCIDENTI OR PREGNANCY ILJAP) 04-25-92 CONDITION SIMILAR ILLNESS OR %JURY. GIVE DATES. CHECK HERE 17. DATE PATIENT ABLE TO Is. DA ES OF TOTAL JISABIUTY DATES OF PARTIAL DISABILITY RETURN TO WORK - - FROM THROUGH FROM THROUGH - - tB. `FIR � O J.•j• C E 1 H KHM j 20. FOR SERVICES RELATED TO MOSPITAUZATION GIVE 1400 QUAIL SUITE 270 NEWPORT PEACH CA 92660 NOSPITALJZAIION DATES Aomnnz - -ascHARGEo - 2 t. NAME AND ADDRESS OF FACILITY WHERESERVICES RENDERED IIF MER MAN HOME OR 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? OPFICEI NO CHARGES: YES FT 23. A. DIAGNOSIS OR NATURE OF ILLNESS OR e•LIURY. RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D BY REFERENCE NUMBERS 1.2.3. 8. ETC. OR OX CODE 1. 8449 KNEE &- LEG SPRAINS EPSDT YES NO 2 FAMILY PLANNING YES E13"O 3. ----------------------------------------------- PRIOR �• AUTHORIZATION NO. 24. A. &•C. FULLI DES;.RIBE PROCEDURES. M CALVI U D DATE OF SERVICE PLACE FURNISHED FOR EACH DATE GIVEN F. DAYS G. M. LEAVE BLANK DIAGNOSIS FROM TO ttn= (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) CODE (IDENTIFY I CHARGES CHARGES OR UNITS T.O.S.SERVICE 06i 1.x/52 ::; 97110- 'THERAPUETIC EXERCISE 1 4001Z 1 2974 06/115/92 97145- ADD. 15 MIN r'HYSICAL 1 301210 1 2974 THERAPY TX 06/15/92 3 97010- 1 HOT PACK 1 4}Z10 1 29-174 0c 15/'32 C 701 ELEC STIIYILUL►=,TIONC47�c�k 1 25 7 4 �C6/ 15/92 3 9 7 1 ZP- ULTRASOUND 1 3�500 2974 $ $ $ I $ $ 25. SIGNATURE OF PHYSICIAN OR SUPPLIER $INCLUDING DEGREEISI OR CREDENTIALS) V CERTIFY THAT THE STATEMENTS ON THE REVERSE APPY TO 26. ACCEPT ASSIGNMENT IGOvERNMENT CLAIMS ONLYI (SEE BACK) 21. T TOTAL CHARGE $ 2b AMOUNT PAID 9. 2BALANCE DUE THIS BILL AND ARE MADE A PART THEREOF. 1 /JIG'rE5 NO F-1ED 31. PHYSICIAN'S SUPPUER'S. AND/OR GROUP NAME. ADDRESSLP OOE AND TELEP•IONE NO. PH'Y SICAL THERAFIY DYNAMICS 30. YOUR SOCIAL SECURITY NO, 2 ZB54 N SANTIAGO BLVD # 10.1* GATE ORAIv;;E. CAy2667 -7-14 2--' E3` -6.J 0 5 I.D. NO. 32. YOUR PATIENT'S ACCOUNT NO. 33. YOUR EMPLOYER I.O. NO. Ic�k10256k CLAIM#:'?01123 1=i/ 55-4346215 / • +��...-L i w $ iFE OF SE Fr%R� t I $.O.S.1 CODE ON 1 H BACK Avr"UVtU BY AMA CGUNCIL Form HCFA- 1500-C2 l 1-84' Form OWCP-1500 CFI - 46 REMARKS: ON MEDICAL SERVICE 6-83 Form CHAMPUS -501 Form RRS-1500 Irvine Cot Norm"Im! ,�■ Magnetic �� Resonance Medical Group MAGNETIC RESONANCE IMAGING ROBINSON, DEBORAH DOB: May 14, 1992 MAGNETIC RESONANCE OF RIGHT KNEE: Michael A. Sein, M.D.. Inc. Director Martin W. Wieler, M.D., Inc. Nader Morcos, M.D. Board Certified Radiologists BRAIN MAPPING #20336 DR. LOWD INFORMED CONSENT: The patient appeared to understand the indications for, the technique of, and goals of magnetic resonance imaging and agreed to undergo the examination after having read and signed the informed consent. CLINICAL HISTORY: Strained ligaments. PROCEDURE: Three acquisitions were obtained. Nflultiple 3.5 mm T1 sagittal and coronal scans were performed. 5mm T2 sagittal scans were also obtained. . 2cc of Valium was injected intravenously for sedation. The patient tolerated the procedure well. FINDINGS: _ LATERAL JOINT COMPARTMENT: Anterior and posterior horns of lateral meniscus are seen showing normal configuration without evidence of meniscal tear. CRUCIATE LIGAMENTS: Both anterior and posterior cruciate ligaments are identified and are seen to be intact. MEDIAL JOINT COMPARTMENT: A faint globular area of increased signal intensity is seen within the posterior horn of medial meniscus without definite communication with the articular surface .or the capsular margin representing Grade I intrameniscal signal and may indicate early meniscal degeneration. No meniscal tear is seen. Anterior horn of medial meniscus is normal. PATELLA: The patellofemoral joint is seen to be normal. Visualized quadriceps and patellar tendons are intact. No -suprapatellar joint effusion is seen. No. Baker's cyst is noted. COLLATERAL LIGAMENTS: Medial and lateral collateral ligaments are identified and are seen to be intact. CONCLUSION: Grade l intrameniscal signal seen within posterior horn of medial meniscus and may indicate early meniscal degeneration. No meniscal or ligamentous tear demonstrated. Suggest clinical correlation. MICHA A. SEIN, M.D. Hutton Centre - 201 E. Sandpointe Road, Suite 130 - Santa Ma, Calitomia 92707-5750 - (714) 957-19 1 - Fax (714) 957-2765 i J PAYMENT ACU CURRENT PREV10015 GATE REFERENCE OESCR�TIO►.N C"ARGE CRECHTS BALANCE BALANCE NAME This is your RECEIPT for this amount 4& This is a STATEMENT of your account to date G Mastercard .— / ;'r /. ,, -.., CURRENT PROCEDURAL TERMINOLOGY - 4 Cash C Check 0 r_1 Visa fI* Date of Service MAGNETIC RESONANCE BRAIN MAPPING IMAGING DEPARTMENT CPT CdbE: FEE 74191 C ABDOMEN 73220 = UPPER EXTREMITY 99090 O EEG 70551 Z) BRAIN 73221 = UPPER EXTREMITY 95619 O OEEG (mdudtng Bram Stem) JOINT (such as SHOULDER. ELBOW) 95925 O SSEP, X2, X3, X4 etc. 70552 ` BRAIN 70540 ORBIT • FACE - NECK 76499 O UNLISTED PROCEDURE (indudm0 Brain Stern)_ _ . _ .7A499 _^. UNLISTED PROCEDURE .. ^•• . ._ W CONTRAST 721116 _ PELVIS 76400 0 NE MARROW (also use for HIP) 71550 CHEST 70336 0 TMJ'S 2 u MYOCARDIUM (T joints) 1 O CERVICAL SPINE 99070 M SUPPLIESIDRUGS , of<2 10 CERVICAL SPINE /MATERIALS WITH CONTRAST O Mawwwot 72146 O THORACIC SPINE 3 Vallum 2 C L 721470 THORACIC SPINE 99071 -1 REPORTS WITH CONTRAST Duoi cation d Finis 721" CI LUMBAR SPINE 99072 -:2 TRANSLATION 72149 0 LUMBAR SPINE (Somsh) WITH CONTRAST _ 76459 ^ ADDITIONAL SEQUENCE 73720 0 LOWER EXTREMITY X9999 ❑ VOID 73721 OWER EXTREMITY '�� � _�' -99092 TAXI �JJ JOINT (such m6g)ANKLE) (TransIxinatan) �� v DIAGNOSIS ICD • 9 Looe L,stin9 GLOBAL FEE (Includes both Professional and Technical Components) PLACE OF SERVICE: G OFFICE ASSIGNMENT OF BENEFITS: I certify that the servlce+t Ii have been received and hereby authorize payment d below named doctor. SiG�aW// AHORIZATION TQ RELEASE INFORMATION I authonze the release of any medical information n to process this claim. t FED. TAX I.D. 033-0109741 IRVINE COAST MAGNETIC RESONANCE MEDICAL GROUP 201 E. Sandpolnte Road Suite 130 Santa Ana. California 92707-5750 (714) 957.1911 Michael A. Sein, M.D. A029354 Martin W. Wieler, MD G030123 Nader Morcos, M.D. C038427 DRS. SIGNATURE