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Home My WebLink AboutCC 5 CLAIM #93-12 06-21-93AGENDA___.__ CONSENT CALENDAR NO. 5 6-21-93 DATE: JUNE. 14, 1993 Inter-Com TO: FFIOM: SUBJECT: HONORABLE MAYOR AND CITY COUNCIL CITY ATTORNEY CLAIMANT: VERNELL CHAPLIN; CLAIM NO: 93-12; D/L: 10-17-92; DATE FILED W/CITY: 04-26-93; CARL WARREN FILE NO: S 74153 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 rejectioncla~to the ~nt and to the claimant's attorney. /~//~ ROURKE, city Attorney JA~S G. ~GR~:0602~(C~9312 j~ Enclosure: Copy. of Claim cc: Carl Warren & Co. Finance Director qity Manager -, City of Tustin ~ C' I GAINST THE CITY OF TUS (For Damages to Persons or Person=l Property) The law provides generally that a claim must be filed with the City Clerk of the City of Tustin ~onth~ after the incident or event occurred. Be sure your claim .is against the City of Tustin, not another public entity. Where space is insufficient, please use additional paper and identify information by paragraph n~her. Completed claims must be mailed or delivered to the City Clerk, City of Tustin, 15222 Del Amo Avenue, Tustin, California 92680 WHEN COMPLETING THIS FORM, PLEASE TYPE OR USE BLACK INK TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California: The undersigned ·respectfully submits the following claim and information relative to damage to person and/or property: NAF~E OF CLAIMANT: VERNELL CHAPLIN ADDP~ESS OF CLAIMANT: CITY/ZIP CODE: TELEPHONE NO: ( DATE OF BIRTH: DRIVERS LICENSE NO: Name, telephone.and post office address to which claimant desires notices to be sent (if other than above): BRENDA J. HAMERi Esq. OUBRE, MOSS & McDONALD 777. South Eiqueroa.'~Street, Tenth Floor, Los Angeles, CA 90017 This claim is submitted against: a. XXX .The City of Tustin only. b. ..The following employee(s) of the City of Tustin only: The City of Tustin and the following employee(s) of the City of Tustin only: 4 o Occurrence or event from which the claim arises: a. DATE: n~.!.~h~- ]7. 1997 b. TIME: c. PLACE (Exact and specific location): d. HOW and under what circumstances did damage or injury occur? Specify the particular occurrence, event, act or omission you claim caused the injury or damage (Use additional paper if necessary): BUS ACCIDENT~' I WAS DRAGGED AND INJU?~D e. ~-F~T particul' action by the city, or employees, caused the alleged damag r injury? NEGLIGENT uPBRATION OF BUS 5. Give a, description of the injury, property damage or loss so f~r known at · the time of this claim. If there were no injuries, state "no injuries". BODILY INJURY 6. Give the name(s) of the city employee(s) causing the damage or injury: 7. ~e and address of any other person injured: OTHER PASSFNGEP~ ~ ~u~ BUS WHOSE INDE~TITIES ARE UNKNOWN TO ME. 8. Name and address of the owner or any damaged property: Damages claimed: a. .Amount clai/ued as Of the date: 550.00 b. Estimated amount of future costs: 15,000.00 'c. Total amount claimed: ~0,000.00 d. Attach basis for computation of amounts claimed all bills, .invoices, estimates, etcJ (include copies of 10. Names and addresses of all witnesses, hospitals, doctors, etc. SHIRLEY WTNTi~T --,DR..BU~SCMTN~- ~T~ LOiS DOBBS (714) 956-3474. HEALT~ C~R~ ~TOAT. O~D n~ TUSTIB? ~N - ..MAIN STREET TOURS DR. SP~CNT - ~Ar. TN ~ ~nTCAL CE~:TER WARNING:~ IT IS A CRIMINAL OFFENSE TO FILE A FALSE CLAIM!! (Penal Code Section 72; Insurance Code Section 556.0) I have read the matters and statements made in the above claim and I know the same to be true of my own knowledge, except as to those matters stated to be upon information or belief and as to such matters I believe the same to be true. I cer~ify under penalty or perjury that the foregoing is TRUE A-ND CORRECT. Executed this 15th day of April ',19 93 , at Tustin, California. DATE FILED: APRIL 15, ]g93 CLAIMANT ' S SIGNATURE VERNELL CHAPLIN BI:CLFORM Revised 4/29/91 ~TiN HOSP EMERG MED GRO TE: 01/15/1993 ] ADVANCE BILLING CO BOX 308 ACCT ~ 491300 VINA CA 91723 t8) 854-2194 CHAPLIN, VERNELL L qTE CODE DESCR I PT I ON D I AGNOS I S AMOUNT BALANCE ~/17/92 C LEVEL 3 EVAL AND MGMT 111.00 FRACTURE, CLAVICLE (CLOSE 1/20/92 P Paid By: MEDICARE 44.66 1/20/92 A MEDICARE ADJUSTMENT 55.17 Balance 11.17 PLEASE NOTE: These charges are for emergency physician, not the hospital. CURRENT 31 - 60 61 - 90 91 120 OVER 120 · 00 0.00 0.00 11. 17 0.00 ~00000000000000000000000000000000000000000000000000000000000000000000000000000 AMOUNT BILLED TO INSURANCE AND STILL PENDING 11.17 AMOUNT DUE FROM PATIENT AFTER INSURANCE PAYMENT-PLEASE PAY 0.00 CHARGES FOR EMERGENCY DOCTOR. TUSTIN HOSPITAL MEDICAL CENTER · 14662 Ne~port Avenue, Tustin, CA 92680 DATE OF SERVICE: October 17, 1992. CHIEF COMPLAINT: The patient was an 83 year-old female who comes to the Emergency Room complaining of pain in her right shoulder secondary to a fall from a bus. The patient states she received no direct trauma against it, but.reached her hand up to grab something and felt the pain. She points to area of her right clavicle. She also has some low back pain she said. She did not have any head trauma or loss of consciousness. She had no neck pain. She has had no pain in her chest other than the area around her clavicle. She said there was no pain with respiration, and no abdominal pain. She has no pain in her extremities. ALLERGIES: The patient states that she is allergic to CODEINE. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 97.6. Pulse is 76. Respirations are 18. Blood pressure was 142/73. GENERAL: The patient is in mild distress complaining of pain in the area of her right shoulder. HEENT: Head had Do evidence of trauma. The face is nontender. NECK: The neck was nontender. CHEST: There was a large bruise over the area of the right clavicle near the sternoclavicular joint. Was no underlying rib tenderness. There was no crepitations. LUNGS: The lungs were clear. ABDOMEN~' The abdomen is soft and nontender. BACK: There was mild tenderness over the area of the left thigh joint. EXTREMITIES: There was a large bruise and tenderness over the left clavicle. There was no shoulder tenderness. The nerve and circulation were intact distally. PLAN: The patient was sent for x-rays of her clavicle and pelvis. These showed a fracture of the right clavicle near the head. A figure- of-eight was placed. She was given a prescription for Darvocet N. She is from out of this area. She has a doctor and she will see PAGE 1 EMERGENCY ROOM REPORT CHAPLIN, VERNELL COPY STEPHEN C. SPECHT, M.D. TUSTIN HOSPITAL MEDICAL CENTER 14662 NeWport Avenue, Tustin, CA 92680 her doctor on Monday. She was told that if she has any increased pain or a new injury, to return to the Emergency Room. IMPRESSIONS: FRACTURE, RIGh~ CLAVICLE. SS/gla/42/3420 D: i0/17/92 T: 10/21/92 STEPHEN C. SPECHT, M.D. EMERGENCY ROOM REPORT CHAPLIN, VERNELL PAGE 2 COPY STEPHEN C. SPECEIT, M.D. TUSTLN HOSPITAL MEDICAL CENTER 14662 l~e~port Avenue, Tustin, CA 92680 DATE OF SERVICE: OCTOBER 17, 1992. CHIEF COlfPLAINT: The patient is a 6 year-old male brought to the Emergency Room by his parents after sustaining a fall and injuring his left arm. They said he fell on the cement. They didn't see the actual mechanism of the fall. There were no other injuries. They did give the child' a Tylenol with Codeine because he complained of severe pain. When he calmed down, they brought him to the Emergency Room. PAST HISTORY: MEDICAL: The child has not had any other systems symptoms. generally in good health. ALLERGIES: He has no known allergies. He is PHYSICAL EXAMINATION: VITAL SIGNS: Temperature was 98.9. Pulse was 120. Respirations were 16. GENER/~L: The patient was in no acute distress and was lying quietly. HEENT: There was no headache abnormality. EXTREMITIES: There was some swelling of over the area of the left elbow. There is tenderness in the area. The nerve and circulation were intact distally. The patient was given cocktail of Demerol, Phenergan and Thorazine, 20, 20 and 10. The child had an x-ray which showed a supracondylar fracture. The orthopedic doctor was here, saw the patient, put the patient in a splint and will follow the patient. IMPRESSIONS: SUPRACONDYLAR FRACTURE, LEFT ELBOW. SS/gla/42/34!3 D: 10/17/92 T: 10/21/92 'C STEPHEN . SPECHT, M.D. pAGE 1 EMERGENCY ROOM REPORT NORTON, BENJAMIN COPY ..STEPHEN C. SPECHT~ M.D~ shed 99202 ~/JO043/ FEE { )Gail Training CPT4 975OO FEE 97520 97116 97540 97530 977OO "~ 97~ ,_/_~_/_~_/_~_/_~_/_~____ '' ~"~ ~ "~/' ' ,cos ~ Date (818) ~7'6379 STAT~-MENT OF PROFESSIONAL SERVI¢ S DANIEL R. BURSCHINGER, M.D. ORTHOPEDIC SURGEON 612 W. DUARTE RD., SUITE 504 ARCADIA CA 91007 TELEPHONE (818) 447-2147 IRS~95-2238336 M/CARE~00A1695 ACCOUNT: )83459 01/15/93 VERNELL CHAPLIN SERVICE DIAGNOSIS I CHARGE~REDJTS (-) E PATIENT :. PHYSICIAN RLACE CFT-COOE MDFR DESCRIPTION OF SERVI~E ~CO-~CODE /20/02/ ¥~i!~LL b'H~LI~ BU~I~GKR, DAHI~[, R ~ 9920~ ~ D~ 0V ~ PT 181000 75.00 /20/92 V~,L ~PLIN , ~IBG~, D~IZ:, R ~ 7208~ ~ I~Y LS ~I~ 2 [81000 46.00 /20/92 VEH~ ~ME BORSCBI~G~, D~IE E ~ 7300d ~ ~Y C~VlC~ [81000 33.00 t27/~, VK~KLL C~PLI~ B~ING~I, DANIK ~ ~ 7208~ ~B l~l LS SPI~S 2 181000 46.00 '16/92 -VK~ ~LIR B~I~GK~, D~IK ~ ~ 9921~ FOCSD OV KST PT K9249 35.00 ~OCS~ O~ ~S~ P~ [81000 , 35.00 CONTINUED ORTHOPEDi~ bU~ON 612 W. DUARTE RD., SUITE 50~ ARCADIA CA gl00? TELEPHONE (818) 447-2147 IRS~g5-2288886 M/CARE~00A16! 51 ACC(~T.T, CHAPLIN b/f~ VE~KLL C~LI~ ' R~INGER, D~I]L 3 730 50 ~ I-gl, C~I~ 181000 3~.00 ,, , _0 .0 ~.Oi 106.~0 ~ OF ~IVIT) FO~ 10/20/92 TO 01/05/93 ~NCK D~) 111.01