The URL can be used to link to this page

Home My WebLink AboutCC 5 CLAIM #85-25 06-03-85TO: FROM: SU~J ECT: HONORABLE MAYOR AND CITY COUNCIL JAMES G. ROURKE, CITY ATTORNEY CLAIMANT: L.KENYON LILJEGREN; D/L: 03/12/85; DATE FILED W/CITY: 04/24/85; CLAIM NO: 85-25; CARL WARREN FTTiE Nh? .q4] 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. JGR(F4.se) Enclosure: Copy of Claim CLAIM AGAINST THE 'CITY OF TUSTIN (For Damages to Persons or Personal Property) Received by ~. ~via U.S. Mail Inter-office Mail Over the Counter The law provides generally that a claim must De ~iled with the City cler~ o£ the City of Tustin within 100 days after which 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 informa- tion by paragraph number. Completed claims must be mailed or delivered to the City Clerk, The City of Tustin, 300 Centennial Way, Tustin, California 9268q TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Tustin, California: The undersigned respectfully submits the following claim and information rela- tive to damage to persons and/or personal property: 1. NAME OF CLAIMANT: ~. ~o~ a. ADDRESS OF CLAIMANT: ~ ~¥%~, ~ b. PHONE NO: (~%) ~ c. DATE OF BIRTH: SOCIAL DRIVERS d. SECURITY NO: e. LICENSE NO: 2. Name, telephone and post office address to which claimant desires notices to be sent, if other ~han above: e This claim is submitted against: a. F" The City of Tustin only. b. The following employee(s) of the City of Tustin only: Ce The City of Tustin and ~he ~ollowing employee(s) of the City of Tustin only: Occurrence or event from which the claim arises: a. DATE: ~9. ~ ~9~ b. 'TIME: ~'.%O ~ c. PLACE (Exact and specific location): O~ ~;~IW--~ ~n ~ s,d~ d. H6w' and under ~hat circumstances did dama~or injury occur? the particular occurrence, event, act or omission you claim caused the inju~ or damage (Use additional paper if necessary). What particular action by the City, or its employees, caused the alleged damage or injury? '5. Give a description of the injury, property damage or loss so far as is known a= the time of this claim. If =here were no injuries, state 'no injuries'. 6~ Give =he name(s) of the City employee(s) causing the damage or injury: 7. Name and address of any other person injured: ~ o~ ~ 8~ Name and address of the owner of any damaged property: 9. Damages claimed: ~ 41,4- ---' a. Amount claimed as of =his date: b. Estimated amc)un= of future costs: 3 oO "-' c. Total amount claimed: 7! % --- ' d. Basis for computation of amounts claimed (include copies of all bills, invoices, estimates, etc.: $~ ~,[[~. 10. Names and addresses of all witnesses, hospitals, doctors, etc.: 11. ~y additional info~ation that might be helpful in considering this claim: WARNING: 1T IS A CRIMINAL OFFENSE TO FILE A FALSE 'CLAIM: (Penal Code Sec=ion 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 of perjury that the foregoing is TRUE AND CORRECT. Executed this ~4_4~ day of ~s~ , 19 ~ ., at Tustin, California. Office of the City. Clerk, Tustin, California CLAIM NO: ~- ~ ~'-- Revised 8/05/81 JGR:se:R:8/5/81 (A) DATE Dr'. Veolk~-,-,~ ~ ~ 3~,- .Pr-. V __. _ ab -- Dr', P.4-.-I--s I o 't- -- C ~',x4.-c.h e S 'TO' :-.-._ _,._ >.---5. YOUR E [ANATiON OF MEDICARE ;:3ENEFITS HEALTH CARE FINANCING ADMINISTRATION L~LE K LILJEGREN READ THI~ NOTI~ CAREFULLY AND KEEP ~ FOR YOUR RECORDS THIS IS NDT A BILL 490-*-6935 87 Apr 15, 1985 For more information call or write= TRANSAMERICA OCCIDENTAL LIFE INSURANCE Box 54905 Terminal Annex Los Angeles, Ca 90054 Phone= 213 Area= 748-2311 O~her Areas: 1-800-252-9020 Thls explains Deneflts on your asslgned clalm for $18.00 from ORANGE COAST ~AD MED. Billed Approved Diagnostic X-ray Approved amount ilmlted ~y Item 5con =ack. Mar 12, 1985 $ 18.00 $ 17.30 Total approved amount .............................. $ 17.30 Minus your deductible remaining for this year .................. $ 17.30 Amount remaining after subtracting the deductible amount ............ $ 0.00 Medicare Payment (80% of the approved amount remaining) ............. $ 0.00 ORANGE COAST RAD MED agreed to charge no more for the above approved services than the amount approved ~y Medicare. No payment is being made to ORANGE COAST PJ~D MED because the total approved amount of $17.30 was applied toward your annual $75.00 deductible. You are responsible to the physician / supp11er for the total approved amount. If you have private insurance, it may help with %he part Medicare did not pay. (You have met $17.30 of the $75.00 deductible 'for 1985) DO YOU HAVE QUESTIONS ABOUT THE INFORMATION ABOVE? we will be happy to answer any questions you have about thls notlce. If you Delleve payment was made for a servlce you did not receive, or there is some error, please write or call inu~ediately. Use the address or phone number shown aDove. IMPORTANT: IF YOU WANT A REVIEW OF THIS CLAIM, YOU MUST WRITE TO US BEFORE:-,OCt 15, !985-- TO REQUEST IT (See Item ! on the back). If you write or call, please give us your: Health Insurance Claim Number: ~-481 01 3820 A -~ a~d Claim Control NumDer:**5100 948 163-~ ~.' ~ ' LE N~, . SG-N NG r · ~OU. PATIEN] & INSURED (SUBSCRIBER) IIqFLH ;M.['U IO['..~ F ',PL nY. ? :_ .t?' T_-A'~/; T I :,r., l, :' .~ MEI IC;R~./3CC ~. : LYLE it L1LJEG.RF',~ ................... . ~ .................. ~ PHYSICIAN OR SUPPLIER INFORMATION I i'-~ FAMILY PLANNING ~ERV~CE CHAH(~E S 0 : !rio 0 t I Fron~ D I I I -J ~ r,~. it~ ........ I.. .,, r,,~'C~ argus;. OFFICE VISIT -- NEW PATIENT I [] Brief ..................... go000 ~ r'l Umlt~l ................... [] Intermediate .............. 90015_ [] Gomprel~eneive ........... gO020_ I OFFICE VISIT -- F. STAB. PATIENT 'J [] Brief ..................... [] Intermediate .............. g0060_ [] Extended ................. gO070 ~ [] DMV Claes A ............. g0220 __ [::] Complete Hist. & Physical. 90220 ,__ [] Periodic Pelvic/Rectal ..... 900~8 IPROCEDURES J n Excision .................. 11100 .__ ~ Ankle Tapping ............ 29525 ~ Shave Biopsy ............. 11050 r'l Trigger Point Inj ........... 20550 [] Ear Lavage ............... 69210 O Incision & Drainage ....... 10060 [] Laceration Repair ......... 12001 [] Laceration Repair ......... 12002 n Laceration Repair ......... 12004 [] Needle Aspiration ......... 19000 [] Removal Foreign Body .... 20520 [] Splint Application Le ....... 29515 [] Splint Application Ue ...... 29125 [] Removelof Nail ........... 11730_ [] LLAEORATORY .] [] Throat Culture ............ 87060 __ [] CBC, Panel 20(2402) .... 80119-g0 __ [] SED Rate .............. 85650-90 ILABORATORY ~CONT.) J [] CBC with Differential ... 85022-90 [] Electrolytes. (5009) ..... 80104-90 [] Hematocrlt ............ ,.. 85034 [] Blood Sugar ........... 82947-90 [] Urlnelyele ................ 81000 0 Culture and Sensitivity.. 87184.90 [] Serum Pregnancy ...... 82ggS-g0 [] Urine Pregnancy .......... 86006 0 PAP Smear ............ 88155-90 O Biopsy ................ 88304-90 [] KOH and WET Mount ...... 87210 [] Arthritis Panel (3155) .... 82112-90 [] Pane120, CRC, T4(3154). 80119-g0 [] CBC, STS, (2489) ........ 80104-90 [] CBC, eTS, Rubella(3157) 80104.90 [] Thyroid Panel (2649) .... 80119-90 [] Epstein BarrTIter. ...... 86999-90 [] Cytomegalovirue Titer .. 86999.90 [] Herpes Simplex Culture. 87163-90 GERAi. D A. YOLKMAN, M.D. INC. 0#q. OtaATE AMERICAN BO&RD (:~ FAMILY 801 North Tuetln Avenue, Suite 201 Santa Ar~k California 92705 (714) 972-2818 IRS 1~.~54370 C~i. Uc. SERVICE PROCEDURES (CONT.) [] Pulm. Func. Peak Flow .... 94009 __ [] PuJm. Fur~FVC, FEVl, Pefr. 94600_ [] Pulm. Func. FVC, FEY1, MW, PF ....................... 94600__ [] Pelm. Func. Bronco~lllator. 94603 __ IsuPPLIEs I [] Supplies ................. 99070_ [] Suture ................... 99070_ [] Dressing ................ ~ 99070_ [] Sterlle Tray ................ 99070_ [] Earwicke ................. 99070_ [] OTHER SERVICES J [] Insurance Billing .......... 99080 PAYMENTS AND ADJUSTMENTS I [] Payment Cash ............ ,~"Payment Check ........... Z I INJECTIONS I [] DPT ...................... 90720 [] OPV ...................... 90720 [] DT ....................... 90720 [] MMR ..................... 90723 [] 612 ...................... 90730 ~ [] Estredlol ....... ~ .......... 90730 ' [] Surg. Aries. Iai ............. 90730 []. l SERVICE PROCEDURES I o EKG ..................... 93OOO [] Insurance. 0 Adj. +/-- . TOTAL ~. CHARGES RESPIRATORY Upper Respiratory Infection. 487.1 Pharyngitis ................ 462.0 Tonsillitis ................. 463.0 Sinusitis Acute ............ 461.9 GENITOURINARY Sinusitis Chronic .......... 473:9 Genital Herpes ........... Bronchitis, Acute .......... 466.0 Cystitis Acute ............ Asthma ................... 493.9 Urinary Tract In fection .... Obstructive Chr. Bronchitis. 491.2 Vaginal Infection .......... Laryngotracheitis .......... 464.2 Urethrltls ................. Emphysema ............... 492.8 Prostatism ............... Inguinal Hernia ........... EAR Cervicltis ................. Otitis Media Acute ......... 382.0 Swimmers Ear Acute ....... 380.12 MUSCULOSKELETAL ENDOCRINE Disperse Mellltu$ .......... 250.0 Hypothyroidism Acquired... 244.0 GASTROINTESTINAL Gastroenteritle ............ 008.8 Esophagltis ............... 530.1 IrritaPle Bowel ............. 564.1 Diarrhea .................. 558.9 054.1 Hernia Umbilical ........... 553.1 595.0 Cholelithiasis .............. 574.2 599.0 Gastritis .................. 535.5 616.1 Herpetic Gingivostomatitis. 008.0 597.0 Diverticulosis .............. 562.10 600.0 Peptic Ulcer Disease ....... 533.9 550.9 616.0 DERMATOLOGY Eczema Herpeticum ........ 054.0 Viral Warts ................ 078.1 Impactecl Cerumen ......... 380.4 Vertigo ................... 386.11 ALLERGY Tenosynovitis Shoulder .... 726.0 AliergicConjunctivitis ...... 372.14 Tenosynovitis Elbow ....... 727.09 Allergic Rhinitis ............ 477.9 Tenosynovitis Wrist ........ 727.05 CARDIOVASCULAR Essential Hypertension ..... 401.1 Angina Pectoris ............ 413.9 Atrial Fibrillation or Flutter.. 427.3 Congestive Heart Failure 428.0 Varicose Veins Lower Veins. 454.9 Internal Hemorrhoids ....... 455.0 Gout ...................... 27'L~ Molluscum Epitheliale ...... 078.0 Sprain Ankle/Foot ......... ~ Nevus ..................... 448.1 Sprain Wrist ............... 842.00 Tines Unguium ............ 110.1 Tinea Cruris ............... 110.3 Tines Pedie ................ 110.4 Exanthem ................. 782.1 Synovitis .................. 71g.20 Dermatitis Atopic .......... 691.8 Muscle Inflamation ........ 728.9 Dermatitis Contact ......... 692.9 Dermatitis Nonspecified .... 691.8 Urticaria .................. 708.1 Impetigo .................. 684.0 Cellulitis .................. 682.9 Abcess .................... 706.1 Wart ...................... 078.1 TRAUMA Facial Laceration .......... 873.4 Open Wound .............. 879.8 Contusion ................. 924.9 Burn ...................... 949.0 MISC. Fetique ................... 780.7 Abdominal Pain..: ......... 789.0 Osteoarthrosis Generalized. 715.0 Rheumatoid ArU~ritie ....... 714.0 Mass in Breast ............. 611.7 Common Migraine ......... 346.1 Classical Migraine ......... 346.0 Senile Organic Psychosis... 290.0 Anemia ................... 285.9 Heart Murmur ............. 785.2 Headache .................. 784.0 Seizure Disorder ........... 780.3 Flu Syndrome ............. 487.1 Tinnitus ................... 388.3 Pregnancy ................ V22.2 Conjunctivitis Viral ......... 077.9 MODIFIERS Etiology Unknown ......... 799.9 Rule Out .................. V71.9 ATE .1 d 1985 ~?.;.;~ PA TIENT'S NAME I GERALD A. VOLKMAN. M.D. INC. 0S~OM&TE AMi~ec,&N BOARD OF FAMILY ~ 801 North Tumln Aven~e, Suite 201 Santa Aha, California 927O5 0'14) 972-2818 OFFICE VISIT -- NEW PATIENT ] -] Brief ..................... g0000 -1 Limited ................... 90010 ~ Intermediate .............. 90015 :~ Comprehensive ........... 90020 OFFICE VISIT -- ESTAB. PATIENT ] -1 Brief ..................... ~O50~ ~(' Limited ................... :~ Intermediate .............. g006O D Extended ................. 90070 -1 DMV Class A ............. 90220 :3 Complete HI~. & Physical. 90220 -1 Periodic Pelvic/Rect al ..... g0088 I PROCEDURES I ::] Excision .................. 11100 -1 Ankle Tapping ............ 29525 ~ Shave Biopsy .............. 11050 L--] Trigger Point Inj ........... 20550 [] Ear Lavege ............... 69210 ~1 Incision & Drainage ....... 10060 [] Laceration Repair ......... 12001 _-1 Laceration Repalr ......... 12002 ~ Laceration Repair ......... 12004 ~ I NeedlsAspiration ......... 1gO00 ~ -~ Removal Foreign Body .... 20520 ~'T"~'""" ~.. Splint Application Le ....... 29515 . -1 Splint Application Ue ...... 29125 "~ Removal of Nail ........... 11730 ~ LLABORATORY ] '~ Throat Culture ............ 87060 -1 CBC, Panel 20(2402) .... 80119-90 "1 SED Rate .............. 85650-90 LABORATORY (CONT.} I ~ CBC with Differential ... 85022.90 F'I Electmlytas.(800g) ..... 80104-g0 ~ [] Hemetocrit ............... 85034 ~ I"1 Bloo~lSugar ........... 82947.90 ~ [] Urlnalyels ................ 81000 ~ [::] CultureendSeflettlvlty.. 87184-g0 D Serum Pregnancy ...... 82998-g0 ~ [] Urine Pregnancy .......... 88006 ~ [] PAPSmear ............ 88155-90 ~ r'l Biopsy ................ 88304-g0 ~ [] KOH and WETMount ...... 87210 ~ [] Arthritis Panel (3155) .... 82112-90 ~ [] Pane120, CBC, T4(3154). 80119-90__ O CBC, STS, (2489) ........ 80104.90 -- [] CBC, ST$, RuPella (3157) 80104-90- r"l Thyroid Panel(2649) .... 80119-g0 __ [] E~stetn BarrTIter ....... 8699g-g0 __ [] CytomegalovirusTIter.. 86999-90_ ~'1 Herpes$implex'Culturs. 87163~g0 __ INJECTIONS J r"l DFT ...................... 90720 I-I MMR ..................... 90723 [] B12 ...................... 90730 [] Estra,flol ................. 90730 1'1 Surg. Anes. Inj ..... ~.. .......90730 SERVICE PROCEDURES [] EKG ..................... 93000 SERVICE PROCEDURES (CONT.) [:J Pulm. Func. Peak Flow .... [] Pulm. Func. FVC, FEVl, PMr. 94600 [] POlm. Func. FVC, FEV1, MW, PF ....................... [] Pulm. Func. Broncoclllator. 94603 ISUPF,,ES I D Supplies ................. gg070 [] Suture ................... gg070 [] Dressing ................. gg070 [] ~terile Trey ............... 9g070 [] Earwicks ..... ~ ........... 99070 OTHER SERVICES I [] Insurance BIIilng .......... PAYMENTS AND ADJUSTMENTS ,j~Payment Cash ............ Payment Check ........... [] Insurance... [] Adj. +/- . ................ TOTAL IDX RESPIRATORY ENDOCRINE Upper Respirator/Infection. 487.1 Diabetes Mellltus .......... 250.0 Phawngltls ................ 462.0 Hypothyroidism Acqulrecl... 244.0 Tonsillitis ................. 463.0 Sinusitis Acute ............ 461.9 GENITOURINARY Sinusitis Chronic .......... 473.9 - Genital Herpes'. ........... 054.1 Bronchitis, Acute .......... 466.0 Asthma ................... 493.9 OPstructfve Chr. Bronchitis. 491.2 Lawngotracheitis .......... 464.2 Emphysema ............... 492.8 EAR Otitls Media Acute ......... 382.0 Swimmers Ear Acute ....... 380.12 Impacted Cerumen ......... 380.4 Vertigo ................... 386.11 Cystitis Acute ............. 695.0 Urinary Tract Infection .... ; 599.0 Vaginal Infection; .......... 616.1 Urethritls .................. 597.0 Prostatism ................ 600.0 Inguinal Hernia ............ 550.9 CervicitiS .................. 616.0 MUSCULOSKELETAL Gout ...................... 274.9 Sprain Ankle/Foot .......... 845.00 Sprain Wrist ............... 842.00 .LERGY Tenosynovltis Shoulder .... 726.0 Allergic Conjunctivitis ...... 372.14 Tenosynovitls Elbow ....... 727.09 Allergic Rhinitla ............ 477.9 Tenosynovitls Wrist ........ 727.06 CARDIOVASCULAR Essential Hypertension ..... 401.1 Angina Pectoris ............ 413.9 Atrial Fibrillation or Flutter.. 427.3 ~ongestive Heart Failure ... 428.0 Varicose Veins Lower Veins. 454.9 Internal Hemorrhoids ....... 455.0 Synovitis .................. 719.20 Muscle Inflamatlon ........ 728.9 TRAUMA Facial Laceration .......... 873.4 Open Wound .............. 879.8 Contusion ................. 924.9 Burn ...................... 949.0 QASTROINTESTINAL Gaetroenteritis ............ 008.8 EsoDhagJtis ............... 530.1 IrrJtaDle Bowel ............. 564.1 Diarrhea .................. 558.9 Hernia Umbilical..... ....... 553.1 CholelJt hJasis .............. 674.2 Gastritis .................. 836.5 He~eticGIngivostomatitis. 008.0 Diverticulosis .............. 562.10 Peptic U~cer Disease ....... 533.9 DERMATOLOGY Eczema Herpeticum...: .... 054.0 Viral Warts ................ 078.1 MoIluscum Epitheliale ...... 078.0 Nevus ..................... 448.1 Tines Ungulum ............ 110.1 Tines Cruris ............... 110.3 Tines Pedls ................ 110.4 Exanthem ................. 782.1 MISC. Fatique ................... 780.7 APdomlnal Pain..: ......... 789.0 Ost eoarthrosis Generalized. 715.0 Rheumatoid Arthritis ....... 714.0 Maes in Breast ............. 611.72 Common Migraine ......... 346.1 Classical Migraine ......... 346.0 Senile Organic Psychosis... 290.0 Anemia ................... 285.9 Heart Murmur ............. 785.2 Headache .................. 784.0 Seizure Disorder ........... 780.;3 Flu Syndrome ............. 487.1 Tinnitus ................... 388.32 Pregnancy ................ V22.2 Conjunctivitis Viral ......... 077.9 MODIFIERS Etiology Unknown ......... 799.9 Rule Out .................. V71.9 Dermatitis Atopic .......... 691.8 Dermatitis Contact ......... 692.9 Dermatitis Nonspecified .... 691.8 %~"~- -- ~ - ,/-- - - Urticaria .................. 708,1 impetigo .................. 684.0 Cellulitis .................. 682.9 Abcess .................... 706.1 Wart ...................... 078.1