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HomeMy WebLinkAboutCC 7 CLAIM #91-26 07-01-91CONSENT CALENDAR NO. 7 AGENDA7—/ 7-1-91 .T_ ����:e1, 0111 A: E7: : JUNE 2 4 , 19 91 TO: HONORABLE MAYOR AND CITY COUNCIL FRONT: CITY ATTORNEY SUBJECT: CLAIMANT: VICTORIA STEPHENSON; D/L: 05-23-91; DATE FILED W/CITY: 06-03-91; CLAIM NO: 91-26; CARL WARREN FILE NO: 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. Very urs, J OURKE City Attorney 1 G R: jab:6-21-91(CL-9126. jab) Enclosure: Copy of Claim City of Tustin ... �M AGAINST THE CITY OF TU, N (For Damages to Persons or Personal Property) he law provides generally that a claim must be filed with the City Clerk of she City of Tustin within 6 months 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 number. 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 INR 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: 1. a. NAME OF CLAIMANT: VI ,'0TORIA L. SI'ERIENSON b. ADDRESS OF CLAIMANT: d. TELEPHONE NO: e. DATE OF BIRTH: - 2. Name, telephone and post office address to which claimant desires notices to be sent (if other than above): 3. This claim is submitted against: a: X The City of Tustin only. b. The following employee(s) of the City of Tustin only: C. The City of Tustin and the following employee(s) of the City of Tustin only: 4. Occurrence or event from which the claim arises: a. DATE : I Iaay 2_ , 1991_ b. TIME• 8:45 am C. PLACE (Exact and specific location): Driveway South of Hillyiew LiQuor Store, 13902 N. Tustin Aver Tustin cA 92680 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): Walking south on 'Tustin Avenue, irimped over raised, broken portion of walk,- _ Fell fnrwgrr1, 1 anrj i nto; nn knpp- , hand 2nd chin- e. WHAT particul action by the City, or employees, caused the alleged damage injury? Defective, nedl pcteH wU 1kway. 5. Give a description of the injury, property damage or loss so far known at the time of this claim. If there were no injuries, state "no injuries". Severe contusion of right hand, open wound right thumb cantusion right knee and chin 6. Give the name(s) of the City employee(s) causing the damage or injury: 7. Name and address of any other person injured: 8. Name and address of the owner or any damaged property: 9. Damages claimed: a. Amount claimed as of the date: b. Estimated amount of future costs: C. Total amount claimed: d. Attach basis for computation of amounts claimed (include copies of all bills, invoices, estimates, etc. 10. Names and.addresses of all witnesses, hospitals, doctors, etc. iletty R_ StPrhPnsnn (mother) address same as claimant nl _ nl i na -.,ter, 1 4642 Newport Avenue :Ste, 350 T»s .ins CA 92680 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 certify under penalty or perjury that the foregoing is TRUE AND CORRECT. Executed this _3_ day of 1viay 119 91 , at Tustin, California. DATE FILED: lyiay, 31, 1991 CLAIMANT'S SIGNATU B1:CLFORM Revised 4/29/91 VICTORIA L. STEPHENSON, LVN WORKING DAYS LOST: Doctors Hospital Santa Ana Ivlay 24, 1991 8 hours w $12.97 = $103976 Healthcare Medical Center of Tustin May 25 thru 29, 1991 40 hours L $10.92 $436.80 n A a C oo wuc. or ACCT, CA/M �o�. LA pREVIOUATF TC H A R G E S C R E p l T.5 BALANCE PATIENT'S NA4tE CURRENT PROCEDURAL TERMINOLOGY -- r1 ,",r •F OF SEnVICE: f I OFFICE n) IOSPITAL f]E n. LIOTI fER ---- DATE OF SERVICE: _ L-9 / DESCRIPTION CODE FEE DESCRIPTIO_l. N CODE FEE DESCRIPTION CODEFEE nfFICE VISIT -- NEW ^ESTAS.- - - A. -LABORATORY (Cont.) D. - PROCEDURES 1 90000 90040 11 IICT 85014 -_-_- O Audiometry 92551 -- 0 1 ir11110.0 90010 90050 n K 1 84132 n EKG 93000 - -- r _ ,r, Irate ti0a 0()fi0 l�J - f] Cholesterol 82465 _ - 0 Anoscopy 46600 F) 140L Cholesterol 83718 0 Olic lava - I I Frrnrvl•v1 9001 69210 9(X170 _--_- • - n Ttigl. 84478 _ 9P W/Broncho. 94060 - n ('nr.,t.,..l,nn�00 ivr 920 90x185 _ . O FSI1 O Spironx-lry, _ . 83000 ----_ f3 Acorn Therapy 946150 n tJr• rn Frnrrt 90757 _ 1) Thyroid Profile 80070 _- ❑ _- n I„1rn.r T., I Yr. 90754 90764 _ . n Blood Profile 80050 n--- -- - - -- - f 1 Atln� I rr, 4 90753 90763 _ - (1 Lipids Profile 80061 ❑ __.... _ f 1 n Tissue Specimen, Single 88305 ---"" �_,•- - - -- --- - - - E. •PHYSICAL THERAPY O Hn-pilnl Admil I list d Phys. 90220 Cl Tissue Specimen, Multiple 88304 --_ - _ O _ _ ❑ Hol or Cold Packs 97010 - n Iln�r•.,•,I'Ji.ils 902E>0 __---__---- CJ _------- - _ ❑Ultrasound 971?8 .._.._ n nays Per Day --_---.- -- _-.... .-- _---__-- p ❑ Hydro -Pulse 97139 n ni�.rt,nrclrt Summary 90292 _ __. _-_- _8_INJECTIONS b IMMUNIZATIONS O Diathermy 97024 _ ❑ --- - = n Therapeutic Injertion 90782 O A. •LABORATORY -_--- ❑ Antibiotic Injection 90788 O --- n Spnrrn,.•rt I l tnmin9 99000 n --- - - - - --- ji- F. - UPPUES n Vrnitrun, hDe 3Fi4I5 .- -- -•-- f) DT 90702 0.9p or - f 1 I Ir..,nl�.�k Contprele 81000 - - - O DPT - - - -- - -- 90701 ✓ / \ I 1 f1i►r r?tii k 81005 n folio Live Oral 90712 r7 Ilrirr., ('��Ilu►e 870116...n Mn ---_-• .. -.-- Measles. Mumps, Rubella 90707 11 t :b n •.• n 82948v - -- f1 T.B. Test 86580 l 1/6), "4 n Slrv.l r ,r r,dt n o od x 1 82270 G. - MISCELLANEOUS - - - - n Measles Vaccine 90705 n Slr f I O rum mood x 3 82273 ----------- - - --- n Mnrn86300 , 1'rrnnn n 1118 • Vaccine 90731 _ f 1 rl,..r (', rlh ue 87060 ----•- - -•---- -- --•----- ---•-- -- f) PrnrT•inr,r1• Teel Urine 84702 n ----- -------• --- - O - .-- - - --- f) Prnnnlnr y Tr+�t nkx�d ©4703 . _... ___.. - O P-,11 -fin 0iltute 87250 _ C._X_RAY l,ln- mrr 87109 in chest 71020 I , (r,l C'ullure 87102 ._-... n C -Spine, Cerv. AP d Lat. 72040 _ 1 (;f `•„IlrrrP 87081 _- n Lumbar Spine 72110 I G•;nn r„Il,11e Pinel 80055 .-----.---- n KUB 1 rap c:n,n•tr 88150 74000 I .V,•r r•�n,rnt 87210 _ n Waters View 70210.52 1 C A ' 87184 n Si eyries J / 70220 Sed ante 85650 1 Cnr 85025 U FO P AP OINTME T OCTnn'S SIGNATURE _ _ _ _ TURN _ s Months ISABI1 IT Y nFt AT 1.1 ILLNESS O ACCIDE MP YMFNT O P EGNANCY _Rlnf) OF nISAf11UTY: FROM -)n Iti!zt InANCE BILLING: I t,ereby authorize Olina E. I latwer, to Y1 TURN information to insurance carriers concerning this be,phy irrevocably assign to the doctor all payments lot medical services rendered. n5urn.frt;,r�r,litrt) _..._ Dale DIAGNpSIIS �r -oL2�t__LF TOTAL CHARGESC,- CA LIC: A40090 FED ID x 33 OOR?ltr;2 OLINA E. HARWER, M.D. Dil,lu,nnte.Ityierit•on 11r,rrr•rl r,/ 1•rrr,tilt 14642 NEWPORT AVE., SUITE 350 TUSTIN, CALIFonNIA 92680 PHONE: (714) 669-4143 0731-- 17. .,!ICU _.f._ - r O A 1 13 c D ar/c. oh ACCT. CA/N Aon. BALANC L-A CE IOU PATIENT'S NAME E C H A R G E S C R E D I T S CURRENT PROCEDURAL TERMINOLOGY PLACE OF SERVICE: ❑ OFFICE O HOSPITAL OE.R. ❑OTHER- DATE OF SERVICE: )ESCRIPTION CODE FEE DESCRIPTION CODE FEE DESCRIPTION CODE FEE ). :E VISIT NEW ESTAB. A- - LABORATORY (Cont.) D. - PROCEDURES 90000 90040 ❑ HCT 85014 O Audiometry 92551 n ted 9001c ] _ O K+ 84132 ❑ EKG 93000 -itermediate 90015 90060 ❑ Cholesterol 82465 ❑ Anoscopy 46600 O HDL Cholesterol 83718 ❑ Otic Lavage 69210 .xtended 90017 90070 ----------- _ ❑ Trigl. 84478 ❑ Spiromelry, W/Broncho. 94060 ;omprehensive 90020 90085 O FSH 83000 O Acorn Therapy 94650 4ewbom Exam 90757 ❑ Thyroid Profile 80070 ❑ slant To 1 Yr. 90754 90764 O Blood Profile 80050 ❑ +ges 1 to 4 90753 90763 O Lipids Profile 80061 O O Tissue Specimen, Single 88305 ., E. -PHYSICAL THERAPY O Tissue Specimen, Multiple 88304 ❑ Hot or Cold Packs 97010 lospital Admit. Hist 8 Phys. 90220 O iospital Visits 90260 O O Ultrasound 97128 ays Per Day O O Hydro -Pulse 97139 B. - INJECTIONS 3 IMMUNIZATIONS )ischarge Summary 90292 O Diathermy 97024 ❑ Therapeutic Injection ❑ Antibiotic Injection O 90782 90788 ❑ O • LABORATORY jpecimen Handling 99000 F. - SUPPLIES enipuncture 36415 ❑ DT 90702 O Analysis Complete 81000 O DPT 90701 O )ip Stick 81005 O Polio Live Oral 90712 O Ane Culture 87086 ❑ Measles, Mumps, Rubella 90707 ;fucose 82948 O T.B. Test 86580 O - MISCELLANEOUS tool Occult Blood x 1 82270G. O Measles Vaccine 90705 O tool Occult Blood x 3 82273 O HIB - Vaccine 90731 sono Screen 86300 O ❑ trap Culture 87060 O ❑ regnancy Test Urine 84702 ❑ O rec - -y Test Blood 84703 C. • X-RAY DIAGNOS r Culture 87250 O Chest 71020 'yt, ,rna 87109 i ^ i • " l arvical Culture 87102 ❑ C -Spine, Cerv. AP 8 Lat. 72040 /! ` C Culture 87081 O Lumbar Spine 72110 yne Culture Panel 80055 O KUB 74000 3p Smear 88150 O Waters View 70210-52 'at Mount 87210 O Si rias 70220 - 8 S 87184 �1 3d Rale 3C 85650 /^' 85025 a TOTAL CHARGES �--. .- FOLLOW-UP APPOINTMENT -OR'S SIGNA �'- = RE11,19N Days Weeks Months 31UTY RELATED O ILLNESS O,ACCI NT "O EM OYNT O PREGNANCY )D OF DISA : FROM TO NSURANFIE BILLING: I hereby authorize Olina E. Harwer, M.D., to furnish information to insurance carriers concerning this ❑ and 1 hereby irrevocably assign to the doctor all paym6nts for medical services rendered. red/Guardian) Date CA LIC: A40090 rFn ID * 33-0082062. OLINA E. HARWER, M.D. Diplorrruie.eImeric'an Board of hirnily Pructice 14642 NEWPORT AVE., SUITE 350 TUSTIN, CALIFORNIA 92600 PHONE: (714) 669-4443 i 07543