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Litigation-Rucks v. CityA. '"� •i / /// Cty• of Okeechobee 55 S.E. Third Avenue ' Okeechobee, Florida 34974 - 2932.813/763 -3372 March 9, 1994 Donna Rucks 485 S.E. 16th Ave. Okeechobee, Florida 34972 re: Accident of Deccm?,er 17, 1989 Dear Ms. Rucks: I have learned ecenLly from the Finance Department at the City that you have z: +.zest., d authorization for the City to pay for certain additional medicai tests, arising out of your injury in December, 1989. This is the fir :,'. I have heard back from you since my letter to you in April, 1991; and at this point, I'm afraid I must advise the City that they swuld no longer be responsible for this claim, due the lapse of over foul_ years since the incident. Kindest Regards,, it John R. Cook City Attorney JRC /rb xc: John Drago . Medicare Provider - 71901 12 - DAVID -.W. GRIFFIN, M .D. — je Medicare Provider.N.6- 31126.. 03 - GEORGE K. NICHOLS. M.O. Medicare,Provider.r 31160 VtfiU Oh I MueutulCS 1300 36th STREET • . SUITE C . VERO BEACH. FLORIDA 32960 (407) 569 -2330 P.A. GROUP t 99520 -- TAX I.D. R 59- 1651556 G OFFICE VISITS 1 CPT FEE S/C X-RAY CONTINUED CPT FEE S/C CASTS CONTINUED Limited -Est. Pt. 2 90050 t 37 Shoulder 2 Views <. 73030 70 Cast - C tinder - CPT FEE ' re-0 • 90050 ' 38 Humerus 73060 71 2935 Cast Clubfoot 3 Post-0 • 90050 39 Elbow AP & Lat. 73070 72 29450 Cast - Bilateral Clubfoot ermediate A 5 Intermediate 90060 r-- .J 40 Elbow 3 Views 73080 73 29455 Cast - Short Fiber. Material -New Pt. 3 Est. Pt.'' 90015 41 Foreman - 73090 74 A4590 Cast - Bootwalker-13260 7 Com 90080 42 Wrist 73100 75 Cast Removal 29700 .-New Pt. 3 2nd O.inion 90020 43 Navicular Series 73110 - Intermediate 2nd 90651 44 Hand 73130 SUPPLIES O•inion - Extensive 2nd O•inion 90652 45 Finer 73140 76 Ace - Com.lex 90654 46 Chest 2 Views 71020 77 Air Castda•e 29799 29799 _ X 47 Ribs Unilateral - 71100 78 Jacobi Bunion Stint L3100 -RAYS 1 Cervical 48 Ribs Bilateral - 71110 - 79 Cervical Collar 10120 S. ine 2 Views 72040 49 Scano • ram 76040 80 M ocollar -- -- - -- Cervical Seine Com.lete .. 72050 Inter .retation -26 81 _ Cervical traetior► Unit 10140 3 Cervical Seine FIex.Ext. 72052- 82 - -- Clavicle S.lint :_ _ E0860 13650 Thoracic Sine 72070 INJECTIONS 83 Slin. -- - A4565 lumbar S.ine AP & Lat - Lumbar S.ine Com.lete 72100` 72110 ' - 50 -- 51.. In'ection - Soft. Tissue In := Arthrocentesis -Int. 84 85 20550 20605 ' Elbow Pad E0191 Heel Cu. °- " -_— Scolosis 72090 - - - ,32 In':= Arthrocentesis Ma'or 20610 86 Heel Pad v L3430 E0191 3' P is AP Onl 72170 • 55 In'. - Tetanus -> 90703 87 3 -D Knee S•lint L1880 Sacrum & Cocc x 72220 88 Hin•ed Knee S. int - L1810 Pelvis and Both Hies 73520- - - -- _ 89 Don'o Knee S.lint 11840 Pelvis and One Hi. Femur 73510 -- _. 90 Pateller Knee S•lint L1825 < Knee 73550 .->',- CONSULTATIONS 91 Post 0• Knee S•lint -- 11830 AP & Lat 73560 56 Consultation - Intermediate 90605 92 S•iral Knee S•lint 11800 Knee AP Lat. wfobli.ues min. 3 view 73562 -57 Consultation - •Extensive 90610 93 Cartila.e Knee S•lint L1820 58 Consultation - Com.. 10620 94 Dorsal Lumbar Corset 10974 Knee Complete-inc. obli • ues/Tun. - 73564 -59 Consultation - Com.1ex - 90630 95 Lumbar Corset L0976 - - 1 96 Lumbar Traction Unit E0890 Total Knee 76040 - CASTS 97 Ortho • last S•lint -- 13906 Tibia .73590 60 Cast - Lon. Arm 29065 98 Wooden Shoe Post O. 03260 Ankle AP & Lat. 73600 61 Cast - Lon• Arm S.lint 29105 99 Wrist S.lint L3B00 Ankle 3 Views 73610 ' 62 Cast - Short Arm 29075 100 Deluxe Wrist S•lint L3805 Calcaneus - -73650 63 Cast- - Navicular 29085 101 Fin.er S•tint 29280 Foot -- -Toes, 73620 - 64 -Cast -Short Afm S.lint 29125 - 102 Tennis Elbow - X3999. . - 73 0 "w? ..• 5- Cast: -L• • L- • - -- 29345 103 Tennis Elbow Air Cast "' 129799 Clavicle --E , > 73000 - 66'- Cast =-ton • Le• S•lint 29505 104 Unna Boot - AC Joints "' 73050 -- "67 = CastShort Le. S•lint 29515 � <.: Sca • ula • - : 73010 - 68 - Cast Short Le. 29425 TOTAL CHARGE THIS DA } i '__ Shoulder 1 View -- 73020 , 69 Cast- -PTB =" . 29435 =� r PREVIOUS a • '. I'M; ,. -.,- ADJUSTMENTS ._ __ 'GNOSIS. • k '3ATURE ON FILE DATE •E :...4 NEXT APPOINTMENT DATE:, 77114 • - DOCTOR NO: PATIENT #- - a) DATE '] 1t , i NAME ADDRESS. HOME PHONE WORK PHONE; INS. COMPANY: INS. GROUP • INS. I.D. 0: PAYMENT RECD. THIS DATE $ ❑ CC O Cash `❑ Check ' NEW BALANCE DUE $ - Code No FINANCIALLY RESPONSIBLE • PHYSICIAN'S SIGNATUR 31 -60 61 -90 1 1 1 THIS RECEIPT IS FOR INSURANCE FILING AND TAX PURPOSES. . L- Vh11� M.0 • Medicare Provider 1 7t901 02 — DAVID W. GRIVFIN, M D , Medicare Prow (Sr 11.6-31126 103 — GEORGE K. NIC( LS. M Provider 31160 OFFICE VISITS r VERO' ORTHOPAEDICS 1300 36th STREET SUITE C VERO BEACH. FLORIDA 32960 (407) 569 -2330 X -RAY CONTINUED Post-0 90050 90050 90050 CPT FEE Humerus ermediate Est. Pt. 2nd O•inion - Intermediate 2nd O•inion - Extensive 2nd O.inion - Com.lex 90015 90080 90020 90651 90652 90654 Elbow 3 Views Foreman Wrist Navicular Series CASTS CONTINUED Cast - C tinder Cast Clubfoot P.A. GROUP TAX I.D. 59 -1i. CPT 29365 29450 FEh, Cast - Bilateral Clubfoot Cast - Short Fiber. Material Cast - Bootwalker Cast Removal 73110 X -RAYS 72040 Cervical Sine Com.tete 72050 lumbar S'.ine AP & Lat Lumbar S.'ne Com.tete Scolosis Pelvis AP OnI Sacrum l. occ 'x 72052 72070 72100 72110 72090 72170 72220 Fin.er Chest 2 Views 73140 71020 Ribs Unilateral Ribs Bilateral Scano • ram 71110 Inter. retation - 26 SUPPLIES Ace Banda.e Air Cast Jacobi Bunion S.Iint Cervical Collar M ocollar Cervical Traction Unit INJECTIONS In'ection - Soft Tissue In'.- Arthrocentesis -Int. In'.- Arthrocentesis Ma'or In'. - Tetanus 20610 90703 Knee AP Lat. w /obli.ues min. 3 view Knee Complete inc. obli • ues /Tun. Total Knee Tibia Ankle AP & Lat. Ankle 3 Views Calcaneus Foot 73510 73550 73560 73562 CONSULTATIONS Consultation - Intermediate Consultation - Extensive 73564 76040 73590 90605 90610 10620 •nsultation - Com.lex 90630 CASTS 60 Cast - Lon. Arm 73610 73650 73620 Elbow Pad Heel Cu Heel Pad 3 -D Knee Stint Hinter ed Knee Splint 89 Don'o Knee Splint 90 Pateller Knee Splint 91 Post O• Knee S • lint S•iral Knee Splint E0860 L3650 A4565 E0191 13430 E0191 93 94 95 196• 97 ,Cast - Lon. Arm Splint Cast - Short Arm Cast - Navicular Cast - Short .Arm Splint Cartila.e Knee Splint Dorsal Lumbar Corset Lumbar Corset Lumbar Traction Unit Ortho.last S. lint Wooden Shoe Post O. Cast - Long Leg Cast - Lon. Le • Splint Cast - Short Le • Splint Cast Short Le Cast - PTB Shouldgr 1 View 73050 73010 73020 29105 29075 29085 99 100 101 L3800 Deluxe Wrist Splint Finer Splint Tennis Elbow Splint Tennis Elbow Air Cast Unna Boot TOTAL CHARGE THIS DATE $ PREVIOUS BALANCE $ ADJUSTMENTS $ \GNOSIS: .-1 NATURE ON FILE DATE ✓.`, 9 r) ".'g4_ - �. NEXT APPOINTMENT DATE: If1'-"' DATE 07/10/90 #5911 DOCTOR NO: PATIENT • 3727 Fee Twpe: 4 DCINN n Rul_:E:s 'Re>S 485 SE 16TH AVENUE cU<EEC :HC 1I3EE FL 34974 4EPHONE ( .1.2i)'TU-7-3' WIC: -NOT LIN FILE- VERO € R1 HOPAEDI _ E CEC'RGE L. NI I= HAIL S , N.D. CASH D.O.D. SE F REFEF :F;ELJ 1 Y: PAYMENT RECD. THIS DATE $ O CC D Cash D Check NEW BALANCE DUE $ Code No FINANCIALLY RESPONSIBLE • cJ 1 NAME ALLEN PL.,11 ::l:'c> ADDRESS 4135 S.E. i uTH HVLNtJE- i +kEECI 11OE :EE: FL 34';,74 HOME PHONE ( 6 1 " 763 - 2.2 4 WORK PHONE —fyC'1 ON FILE- E: T ; INS. COMPANY. :4U 1 N5 - • 11_1 1�d'� _IF:Rf�•_E 1111111111111111111111'111/11111i111 11111111111 :131!1'111 ?111'111;11111 INS GROUP • INS. I D. • PHYSICIAN S SIGNATURE 0.0d THIS RECEIPT IS FOR INSURANCE FILING AND TAX PURPOSES. 31 -60 61.90 OVER 90 PREVIOUS BALANCE DUE VERB I ORTHOPAEDICS 1300 36TH STREET -- SMITE C VERO BEACH ,f FL 32960 DATE 5911 ' DESCRIPTION CODE 07/10/90 07/10/90 •• ACCOUNT:iVQ BALANCE AS OF LAs 1 I A F OFFICE V1S11 - 1NIERMED1ATE --ES1 . X-RAY -RAY KNEE CAP AND LA T ] %PARENT ••.. 0-80 DAYS," EMENT F' 90060 73560 DEBITS /CREDITS 54.00 56.00 0.043 P 3/L 1 P 3/L 1 5911 07 -16 -90 110.00 0.00 "619O::DAYS 0.00 =. 904i--,DAYS 7' 0.00 BALANCE •bUt 110.00 • : _ V RQ_, ORTHOPAED I GS 1300 36TH STREET - SUITE C VERO BEACH , FL 32960 PH: 4073692330 DONNA RUCT;S C/O ALLEN RUCI<S 485 S.E. 16TH AVENUE O<EECHOBEE, FL 34974 J 1 VCRO ORTHOPAEDICS 1;'00 36TH STREET - SUIT V :0 BEACH , FL 32960 .1 01/18/90 01/18/90 NIZAMIMPAIMEIR 0":71;7'7: Way IMANA r, .,r r..,�.. " pHLA .A$ OF LAST STAT OFFICE VISIT.-LIMITED-EST ,PT X -RAY - PELVIS ( ONLY, • ,. MLNT g21llE7[ ' yr DUE S; .r81 IN Sa �: f'VEf O 1300':' '34T VpQ ; BEA PH t : 407 DONNA 'RUCKS. C/O ALLEN. RUCKS 485 S ,E , 16TH AVENUE L OVEECHOBEE, FL' 134974 • • (a '4.41.1 I 1lritalL.11....11%.).....11 0..14 1 tru...\ • . OKEECHOBEE, FLORIDA 34972 , (813) 763-2151 . . ,-, _. - test Middle ( ) ! ..«f YOU HAVE BE I EN SEEN BY DR --- - 1_1.4\4415 , .„,. FT_Kmg_mcgmialmTHE ELKE NOTE: The examination. treatment and X-fay reefing yeitidare received in the Emergency Department have been rendered on an emergency basis only, and they are not intended to be a substitute for or an effort b guptorde (OIAPLETE medical cam X-ray readings done in the Emergency Department am preliminary readings .ii , Final readings wit be bone by the Ref tologist and you will be notified of any other findings. Your lotiow-up doctor /named below) can receive a copy of your records and all test reports. It is imponard that you it Mn .cheric you again and that you report to him any new or remaining problems at that time, because 11 15 impossible to recognize and beat al elements c4 • 4 a lnnett in a sine Emergency Department visit Meanwhile. FOLLOW DIE Ns-mum-low BELOW as indicated for you. . .. ' . PAIN & INJURY INSTRUCTIONS - you may gently wash your stitches with peroxide or RV soap and water and re-cover with a dean dressing •■•• use neosporin or similar ointment on the stitches keep the dressings clean and dry despite the greatest care, any wound can be infecixl. if your wound becomes red, swollen, shows pus or red streaks . orleefs more sore as days go by, you must report to your doctor right arov: use heat or cold on the injured area- whichever sirs to help the most Be careful not to burn yourself. rest as much as possible until you are improved aid positions and movements that make the pain rre. relax emotionally-if you are tense the problem w (ay be v•xxse, and we don't want that_ elevate the injured part to lessen swelling. d p.I kitten. use chair cushions with pillows or blankets for corrdort. ice packs also help prevent swelling, especially. • the fast 48 hours. place ice in plastic or rubber bag. cloth coverin" g. r If you have an elastic bandage, rewrap it I too tigh4.1 tqp loose. Avoid any use of injured part a only limited use of the part - You need not necessarily limit activity - Use crutches - Wear soft collar when out of bed May return to work If you are unable, to vatic in days. you roust nee a • . longer. •-• • kx further evaluation and parmission b retum 4 lioxisplk,0 b. . „ OTHER IN UCTIONS 1' GENERAL INSTRUCTIONS use vaporizer take clear liquids by mouth - (weak tea, jell% clear vomiting, diarrhea and abdominal cramps subside, t to a normal diet The sugar content helps. so avoid " drink large amount of liquids. use acetaminophen (-tylenol-) mg every fever. mg may be given as a bedtime dose. CjfernvaZ, it maitnre°fetalrCen along mg witgracartielrlinophen. call the emergency department on or after results d X-Ray Lab Tests. Instruction sheet Number soup -) until nausea, hen praduady return Diet drinks. 4 hours for pain or nig every 4-6 hours pm on • HEAD INJURY INSTRUCTIONS Report to your doctor immediately it anything listed occurs (even within several months). Persistent vomiting, stiff neck, fever. Unequal pupils (one pupil large, one small). _____ Confusion or unusual drowsiness. ......:,-;-Convutsions or unconsciousnesi., --i--- Stumbling or other problem with normal use of arms or legs, or areas of skinnumbness. NOTE: Waken patient for.first night every two hours to be sure patient can be mused. E . EYE INJURY INSTRUCTIONS Any eye injury is potentially: hazardous. Any increasingly see ort, redness or sudden krpairment of vislcxi should be reported iimmediately to your or eye specialist below. 0-6 • 'RETURN TO THE HCA RAULERSON HOSKIN_ iENCY DEPARTMENT IN DAYS ON AT 9 AM. Fold 1 Suture Removal,' 1 Wound Check.' Rpcli•essing. I 1 Recheck if problems or signs of infection. - _A .• I 14 (0. ` FOR FOLLOW-UP .ARE SEE: DR_ 194 SPECIAUTY DR SPECIALITY OR DOCTOR OF CHOICE. O CALL AS SOON AS POSSIBLE TO ARRANGE AN APPaNTMENT. 0 CALL IF CONDITION WORSENS TO ARRANGE AN AlqeiD4ENT. O CALL OR RETURN IF CONDITION WORSENS 0 Tetanus Toxoid Given, is good for 5-10 years. so iemereher '" • as the year of your last dose. I hereby acknowledge receipt of the instructions indicatetiowe. 1 understand that I have had emergency treatment only and that 1 may be released before alt of my medical problems are known or treated. I wit ani y tollow-up care as instructed above. I understand that if 1 havenot contacted the above physician within 7 days, he is no longer resporeabie 10 see ma ... 4 • •i(!urE!) • • • • • • . . . . . . . • •,- gin:,..:..... AULERSON HOSPITAL BOX 1807 HOBEE FLORIDA 8497 c: - :, PATIENT NAME RUCKS DONNA RUCKS ALLEN 45 SE 16TH AVE OKEECHOBEE FL 84974 ACCOUNT NUMBER 3441576 STATEMENT OF ACCOUNT RETURN THIS PORTION WITH PAYMENT r-. HCA RAULERSON HOSPITAL RUCKS DONNA 89 -12 -17 89 -12 -17 89 -12 -17 89 -12 -17 89 -12 -17 89 -12 -17 89 -12 -17 89 -12 -17 89 -12 -17 89 -12 -17 E.F. CHARGE BLOOD ALCOHOL LAB STAT CBC LAB STAT LIMITED KNEE COMPLETE ELBOW COMPLETE LUMBAR SPINE - ALL XRAY STAT ACCOUNT BALANCE „c Cam. 'ti" ^- �_ i 50.00 77.00 16.00 55.00 16.00 35.00 82.00 80.00 123 :.00 16.00 550.00 BILLING DATE 12 -22 -89 BALANCE CURRENT DUE OVETt`IE� MINIMUM DUE NOW 550.00 550.00 -0 550.00 e►r 3 ,.`t • _F-t . Pa'6e alb c4- 01 r-8- 76–S2 ". V. CHAU1 -1APY. M.D. -- ILL IN ; OFFICE -- 144 .1 T yILL iLVO P113 W FS' ?Alm ?FAC 1 FL 3343E -6013 �— 59– :'345515 L ALLEN PUCKS 4 SE 15 T-1 AVE CKFCH0a.EE FL 34974 TH 13 STATEMENT IS c0R INT= RPRETATICN OF X –RAV SE9 VICES ?ERFCRMED IN H. ". RAULERSCN HOSPI TA L Please direct all inquires and payment to our Billing Office at the address above or at Telephone * 813 -4 57 -2 111 o not call the hospital as they cdn not help you with this bill. If payment has been sent within the past 10 days your credit will appear on your next statement. Account Number 1-0 13441 5' Patient Name iONNA RUCKS Payment Du. 1 /1 9/90 Bolan. Due 87 . nr Please tear off and return upper portion to Insure proper credit 11 you duke a receipt p /ease return entire statement DATE DESCRIPTION 8 -76 -62 1- 00344157 1 -00 CHARGES 141718.7LUM3AR SPINE 72 11 3 42100 ttL /1 y17139EL30W COMPLET 73080 22100 1417111KNcE COMPLETE 73564 23100 I4 `COL HAVE INSURANCE THAT CAN COVF•n THE SERVICE ON TH1 PILL. PLEASE C3NTACT OUR OFFICE Tor AY. CREDITS 1000 Y. �HAUJ-4A ?Y• M.O. PAY THIS AMOUNT , PLEASE READ OTHER SIDE OF TH._ -.TATEM.ENT S '00 1 •ERICAN PIONEER R. 30X 35.09 LINO0 75-02 FL 32902 LZ5 COMMERCIAL INSURANCE HEALTH INSURANCE CLAIM FORM $060C* READ INSTRUCTION$ BEFORE COMPLETING OR SIGNING THIS FORM ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS [ OTHER 1-IENT'S NAME (Farr name, mWON mm•r. lost name/ 4NA RUCKS 5 SE 16TH AVE EECHOBEE FL 34974 PHONE NUMBER Form Approved OMB No. 0938-0008 0 THER HEALTH INSURANCE COVERAGE • Enter Name of 11.cyho)der and Plan Name and Address and Pollcv or Med,UI ssstance Number RE Itlf.!J G 110 1 2. PATIENT'S DATE OF BIRTH 61 201 71 5 PATIENT'S SEX MALE 1 I X X 1 FEMALE 3. INSUREDS NAME I:esr name. .'1 ON *Niel Iasi n•me1 1/e elr! L 6. INSUREDS 1 D.. MEDICARE ANIDIOR MEDICAID NO /moue• env Nn•n1. - 261857570 8. INSUREDS GROUP NO. 10, Gmup Nemel -- RUCKS 7 PATIENTS RELATIONSHIP TO INSURED SELF SPOUSE NI OTHER( 10. WAS CONDITION N RE ATEO TO A. PATIENT'S EMPLOYMENT TIENT'S OR AUTHORIZED PERSON'S SIGNATURE IR0warca Wont 5901091 �lhpll• the R•Vaie of amr M•d•cal Inlonnanon Necessary 10 Process nN CNIm and ReQW•t Payment 01 MEDICARE finned' ^!• 70 MTS.I/ Or to the Pany Who ACCeots Asslenmenl Below YES 8. AN ACCIDENT AUTO MILLI NO OTHER 11. INSUREDS ADDRESS ISe, «r, cnr, semi. ZIP cowI S A M E '0 SIGNATURE ON FILE SICIAN OR SUPPLIER INFORMATION '•TE OF DATE 13. I AUTHORIZE PAYMENT OF MEDICAL BENEFITS ro UNDERSIGNED PilSe AN Of $((PELIEER ;OR Vrtl•Ct DESCRIBED BELOW SIGNED I',o,oA r Aomo,.,md PA,SOAI 7/05/90 ATE PATIENT ABLE TO TURN TO WORK ILLNESS (FIRST SYMPTOM) OR INJURY (ACCIDENT OR PREGNANCY (IMP) 15. DATE FIRST CONSULTED YOU FOR THIS CONDITION 18 DATES OF TOTAL DISABILITY FROM THROUGH aME OF REFERRING PHYSICIAN OR OTHER SOURCE Me. poel.c Aeom egencyl ME 6 ADDRESS OF FACILITY WHERE SERVICES RENDERED Id *Ow Men INvn• oNlcq ')IAN RIVER MEMORIAL HOSPITAL AGNOSIS OR NATURE OF ILLNESS OR INJURY RELATE DIAGNOSIS TO PROCEDURE IN COLUMN D REFERENCE NUMBERS I. 2. 3. ETC. OR DX CODE ICC9 -CM COCE 7804 A DATE OF IOM SERVICE TO 7/06/90 16. HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS? YES[ 1 INO 164. IF AN EMERGENCY CHECK HERE ❑ DATES OF PARTIAL DISABILITY FROM (THROUGH 20. FOR SERVICES RELATED TO HOSPITALIZATION GNE NOSPIT•LQATION DATES ADMITTED ( DISCHARGED 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? YES 1 1 I ND B EPSOT FAMILY PLANNING YES YES CHARGES 1 ( 1 NO NO x x) 1xx AUTHORIZATION NO 8• PLACE OF SERVICE C FULLY DESCRIBE PROCEDURES. MEDICAL SERVICES OR SUPPLIES FURNISHED FOR EACH DATE GNEN PROCEDURE CODE (IDENTIFY ) (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES! 0 DIAGNOSIS GOOF E CHARGES 2 70551 .MRI BRAIN 4464 175 DAYS ON UNIT!, G• 705 N LEAVE REAM! rat v ATURE OF PHYSICIAN OR SUPPLIER • 'PI. Nun IA0 fl•Ieme,Ils coo IM 'owls* apply p 0,77 •ne ••• mad• • P•n A•••0I) QED DATE 7/24/90 " Pa/ANT'S ACCOUNT NO 3- 01244704 OF SERVICE AND TYPE OF SERVICE IT OS ) CODES ON THE BACK 'Y)5 26 ACCEPT ASSIGNMENT IGOVERNME NT CLAIMS ONLY) (SEE BACK) YES XXI (NO 30 YOUR SOCIAL SECURITY NO 2 64 -76- 79E4 27 TOTAL CHARGE 175 DC 26 AMOUNT PAID 33 YOUR EMPLOYER I. D. NO 31 PHYSICIAN SUPPLIER'S S OR NAME. ADDRESS. ZIP CODE 6 PT L 0 NrHN. SKAGG S • K.C. 200L1 9TH AVE SUITE 2079 VERO BEACH FL 3296C 1 29 e1 7 51 U DUE L0 NO. 3I17E APIIOVED 8Y AMA COUNCIL ON MEDICAL SERVICE APPROVED 81. THE HEALTH CARE FINANCING ADMINISTRATION 6 CHAMPUS 540 PFONE: 407 - 778 -S934 Form HCFA- 1500101)110 -80) Form CHAMPUS -501 F-9 -75 -02 PAUL H. SKAGGS, M.O. -- °ILLING OFFICE -- 2C01 9TH AVE SUITE VERO 3E.ACF FL 32960 L_ 65- 0179678 r- ALLEN RUCKS L- 485 SE 15TH .AVE CJKEECH03EE FL 34974 THIS STATEMEAT IS FOR INTERP RE TA TI Ct' OF X -RAY SERVICES PERFORMED IA IVC.Av RIVER MEMCRIAL HOSPITAL Please direct all inquires and payments to our Billing Office at the address above or at Telephone # 4C7- 778 -9594 Do not call the hospital as they can not help you with this bill. If payment has been sent within the,oast 10 days our credit will a e r n y ur ext statement. PAYE 00E: 0500 PH: 13-733-3274 o Account Number 3- 01244704 Patient Name •LIANA RUCKS Payment Due 11/1`/90 Balance Due 175.00 Please tear oil and return upper portion to Insure proper credit. If you desire a receipt please return entire statement. DATE DESCRIPTION 8 -75 -02 3- 01244704 6 -00 CHARGES CREDITS 0706'9OQADIOLOGY (PLEASE 00 NOT ALLOW THIS ACCOUNT TJ 3ECOME SENO YOUR PAYMENT IMMEDIAT_LY. P.AUt?0H. SKAGGS, M.D. 17 5p 9 CEL Il■Q PAY THIS AMOUNT PLEASE READ OTHER SIDE OF THIS STATEMENT UE1 T. :DO- <S, DONNA OKEECHOBEE 913j SCu EE S `t 412 N.E. PARK ST. 763 -5100 OKEECHOBEE, F1A. 34972 S.E. 16TH.AV,E. 3CHOBEE, (-7/FL4" f'.t RX #4235008 THIS IS YOUR RECEIPT. PLEASE RETAIN FOR TAX OR INSURANCE. 185449 Dr.D.W.GRIFFIN 12/18/89 HYDROCODONE BITRTRATE ,r I30A;-‘ Amt $10.99 *PAY CASHIER* NET $10.98 laic =4dL a,;y ri31� ;maimibt PATIENT COUNSELING 4235008 Dr.D.W. GRIFFIN RUCKS, DONNA VICODIN TABS HYDROCODONE BITRTRATE May Cause Drowsiness Alcohol Adds Drowsiness Avoid Alcohol 12/18/89 THANK YOU FOR SHOPPING AT OKEECHOBEE DISCOUNT DRUGS HAVE A NICE DAY OKEECHOBEE e`D »ScOUnr-t l DRUGS 4P Kc PMk n 7635100 O cInq ax > ACCOUNT NO. 1 08,-01-90 DATE , -•••-• L AMOUNT DUE ON RECEIPT PAYMENT ENCLOSED $ PLEASE DETACH AND RETURN TOP PORTION WITH PAYMENT PLEASE CORRECT ANY INFORMATION WHICH IS IN ERROR HLLLN I E,E, ILTH SERVICES RENDERED T-77. 1LTH 1r rL - -224 -1716 DATE PROFESSIONAL SERVICES CHARGES/PAYMENT 06/30/90 BALANCE AS OF LAST STATEMENT 36,00 07/06/90 -07/06/90 *DRAL-= '111:.,F--';7-.: 00 0.0 *EXTENDED EEG 240.00 07/06/90 c.;—:NTEMEL,ITE 60,00 _•07/09/90 INSURANCE FILED (07/07/90) N/C 07/18/90 *EXRM—IN7ERMEDIF)TE 60.00 -.4%17/19/90:— INSURANCE FILED (07/19/90) _ , N/C PLEASE RETAIN THIS S TA rEAiry F OR /NCOAIE TAX PURPOSES NO 0 THER S TA TEA T WILL BE RENDERED DATE OF 06/11/90 AST PAYMENT 0-30 DAYS 31-60 DAYS 61-90 DAYS OVER 91 DAYS TOTAL 896,00 • 860,00 0.00 36.00 0.0 CURRENT THIS PORTION OF YOUR ACCOUNT IS PAST DUE iLY L)Ut RMH Indian River Memorial -- -- — Hospital •T NO 1244704 1000 36th Street, Vero Beach, Florida 32960 TELEPHONE 1407) 567 -4311 EXTENSION •ISSION DATE 7/06/90 BILLING DATE 9/22/90 iE DISREGARD THIS STATEMENT IF PAYMENT HAS BEEN MADE. 8/2/90 9/08/90 9/08/90 9/1!./90 BALANCE LASTEMEMT BALANCE TO PATIENT BALANCE TO PATIENT INSURANCE FOLLOWED UP KEEP THIS COPY FOR YOUR INCOME TAX RECORDS. ACCOUNT NO. 144704 T FC ACCCIWT N0. 1244704 �•T FINAL * ** ACCOUNT BALANCE PATIENT NAME: RUCKS, DONNA G 3111 TO RUCKS, BEVERLY 48S SE 16TH AVENUE, OKECHOBEEE FL 34971+ MESSAGE BILL TO TOTAL AMOUNT DUE - -3. 906.00 FYC#— 1 906.00CR9970019 906.00 :9970019 .00 ;9970004 906.00 906.00 906.00 906.00CR 906.00 .00 TOTAL AMOUNT DUE ---� 1 906.00 INDICATE HERE THE AMOUNT THAT IS BEING PAID TO ASSURE PROPER CREDIT -REMOVE - ,STUB - AND RETURN WITH REMITTANCE: " - :M•:'I�7 PHONE 813-763-5544 PATIENT NAME REASON(S) FOR AMBULANCE ^' OKEECHOBEE COUNTY FIRE RESCUE 301 NW 2ND STREET OKEECHOBEE, FL 34972 Rucks, Donna Arm Pain Leg pain Patient fall Allen Rucks re: Donna 485 SE l6tbe&veoue Okee Fl 34974 DESCRIPTION OF CHARGE Base rate Spinal Immobilization TOTAL CHARGES THIS CALL DESCRIPTION OF CREDIT TAX ID 59-6000-768 PATIENT NUMBER CALL NUMBER DATE OF CALL TIME OF CALL CALLER P. D. FROM Okee. TO HCA Raul F: 262-54-8224 self\Rucks Dairy 89-12-2751 892751 D3 12/17/89 101 Hrs. City Police Dept. erson Hospital QUANTITY PRICE PER UNIT EXTENDED 1 1 $100.00 $100.00 $25.00 $25.00 $125.00 RECEIPT PAYMENT DATE AMOUNT PAYMENTS MADE PRIOR TO THIS MONTH TOTAL CREDITS RECORDED $0.00 $0.00 PLEASE PAY THIS AMOUNT => $125.00 'DETACH ALONG ABOVE LINE AND RETURN STUB WITH YOUR PAYMENT' PATIENT NAME Rucks CALL NUMBER 892751 D3 AMOUNT $ PATIENT NUMBER 89-12-2751 BILLING DATE 03/01/90 ENCLOSED If payment not received within 10 DAYS, we will be forced to turn your account over for COLLECTION. Thank you. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ OKEECHOBEE COUNTY FIRE RESCUE 301 NW 2ND STREET OKEECHOBEE, FL 34972 813-763-5544 LAW OFFICES JOHN R. COOK 202 NW 5T11 AVENUE OKEECHOBEE, FLORIDA 34972 TELEPHONE (813) 467-0297 FAX (813) 467 -4798 April 17, 1991 % ) //("<7._-/ / Imo, - cp Q -� � a n I) ,, , e t. il !le Co_ U —C 4-1-x.--1- A) .F C IC�e >t d.) (Oa,,, y. ,(° r) 'd. (r ( r, ,, •‘-‘1 (Z 1 it `�. /1'V � 4 �! i1 r -( c t;r (4. ( ✓ i� ( [ }_a -� �6�f �< �� , 'i I, e/ ( /•' (,U_r r //t n0 Jr�l1 _ 41 I (ATC ( !ilt�/ t Donna Rucks �Q c 6 / . ZLS X,1 41j, 485 SE 16th Avenue �(� / / (i)1 c , �� f It c: Okeechobee, FL 34974 `` 1 `' r Dear Ms. Rucks: I have been directed by the City to contact you regarding the incident wherein you fell from the balcony at the police department and injured -our leg, on December 17, 1989. I understand you have incurred the sum of $3,057.34 in medical expenses as a result of this incident. If this figure is not accurate, please let me know. To assist you in this regard, the City is offering to pay this sum. You must execute the enclosed release in order to receive the check, and the release is without acceptance or assignment of fault or liability, by you or the City. Once signed, return it to Lola Parker at the City and a check will be issued. We leave it to you to forward such sums as necessary to the appropriate health care provider for any bills still unpaid. I_f you have any questions, feel free to give me a call. Kindest regards, JOHN R. COOK JRC:vb Enclosure GENERAL RELEASE The undersigned, DONNA RUCKS, for and in consideration of the sum of $3,057.34, the sufficiency of which is acknowledged and accepted, herein generally releases, discharges and forever absolves the CITY OF OKEECHOBEE, FLORIDA, a municipal corporation, its employees, officials, agents, successors or assigns, from the following: Incident occurring on December 17, 1989 wherein DONNA RUCKS was injured on city property, subsequent to an arrest at the Police Department, by falling from a balcony. This release is acknowledged to be without acceptance or assignment of liability or fault by the CITY for the incident, and constitutes a total, final and absolute release for any and all claim by me arising out of the incident for injury, expenses, pain and suffering, disability, or any other claim I may possess, both now and into the future, whether actual or contingent. I agree to hold the CITY harmless for any and all unpaid medical, or other expenses incurred by this incident. I have read this release fully, understand its meaning and knowingly execute same. Dated this day of 1991. DONNA RUCKS WITNESS WITNESS SWORN TO and SUBSCRIBED before me this day of 1991. NOTARY PUBLIC My Commission Expires: ROBERT V. KENNEDY Attorney at Law 1/6) July 8, 1994 City of Okeechobee 55 S. E. Third Avenue Okeechobee, FL 34974 Attn: Lola Parker, Finance Officer Re: DonnaRucks ' Settlement Agreeinent. Dear Ms. Parker: TELEPHONE 813/763 -8600 200 N.E., 4TH AVENUE OKEECHOBEE, FLORIDA 34972 Enclosed please find a copy of Attorney John Cook's April 17, 1991 letter to Donna Rucks, whose family I represent, and the original of the General Release that was provided with that letter fully executed, witnessed and notarized on November 5, 1993. The Rucks informed me that the balcony outside the second floor exit of the police department has now been completed so this settlement agreement can now be finalized. I provide the original of this General Release to you as an escrow agent, to be held pending payment of the $3,057.34 in medical expenses that Donna Rucks incurred as a result of her injuries. I am aware that the statute of limitations has run for any form of legal action on the December 17, 1989 personal injury claim. However, this matter has been settled and reduced to a settlement agreement via John Cook's April 17, 1991 letter signed by John Cook as an authorized agent of the City of Okeechobee, providing the General Release without any time frame. If this matter is controlled by a statute of limitations, it would be the 5 year statute of limitations on contracts which is not expired. The Rucks informed me that only recently was the balcony completed which was a condition of this settlement agreement. Regardless, the Rucks family are long term residents of Okeechobee and have been reasonable in agreeing to settle this matter for the out of pocket costs incurred of $3,057.34. Additional expenses have been incurred and Donna continues with disabilities as a result of this incident. However, my clients are agreeable to living with this settlement agreement and merely ask that the City of Okeechobee not attempt to hide behind legal loopholes or technicalities and pay the amount agreed. Ms. Lola Parker -2- July 8, 1994 I am providing a copy of the letter and enclosure to Attorney John Cook. Should you need my clients to execute a voucher to complete processing this settlement agreement please provide same to me for Donna Rucks' signature. If there is any reluctance on the part of the City of Okeechobee to pay this settlement agreement, please coordinate a time for my clients to appear on the agenda of the City Council so that any misinformation can be clarified and this matter can be resolved amicably. Thank you in advance for your timely cooperation. Sincerely, Robert V. Kennedy RVK:cb cc John Cook Donna Rucks SCOTTSDALE INSURANCE COMPANY® February 13, 1991 Lola Parker, Finance Director City of Okeechobee 55 NE 3rd Ave. Okeechobee, FL 34974 -2932 RE: Insured: City of Okeechobee Police Department Policy Number: PPL 910346 Claim Number: 118818 -87 Claimant: Donna Rucks Dear Ms. Parker: Through your agent we have received a number of bills in reference to the above captioned incident. You may remember that Ms. Rucks was apparently injured while struggling from her DUI arrest by the insured officers. Scottsdale Insurance Company does not carry medical coverage for the City and it has not been established that the police officers were negligent in any way. It would be my recommendation that these bills be returned to the claimant's parents as the matter has not been adjudicated. If you have any questions my phone number is 1- 800 - 423 -7675, extension 2592. Thank you. tru y Mon �lR'e ```` VI e Sr. Claim Examiner MR /dfm IP7/1433 cc: Rayma Ball, Director Law Enforcement Hunt Insurance Group P.O. Box 12909 Tallahassee, FL 32317 -2909 Lori C. Berger Leonard Berger Insurance Agency P.O. Box 159 Okeechobee, FL 34973 Claims Department P.O. Box 4120 Scottsdale, AZ 85261 -4120 8877 N. Gainey Center Dr. Scottsdale, AZ 85258 (602) 948 -0505 FAX 602 - 483 -6752 1- 800 - 423 -7675 0 A Member of the Nationwide" Group December 21, 1989' 800 SOUTH PARROTS g VE 0E; • DKEECHOBEE. FLORIDA 34974 • PHONE (81 3y}) 783- 841jj1 BRANCH-_OFFICEi 3180 HIGHWAY 441 (B 1 SOUTH EAST • OKEECHOBEE, FLORIDA 34974 • PHONE 13) 763.1189 John E. Hunt & Associates P.U. Box 12909 Tallahassee FL 32308 Re: City Of Okeechobee Policy# PPL810556 Professional Liability Effective February 13, 1989 TO February 13, 1990 Agency/producer code: Gentlemen: Thy: City Police Department asked that we notify you of an incident involving an arrest of an intoxicated woman which they ferel will result in a law suit. I have enclosed the police report�S for Your information, but no suit has been filed as of- this date. On December 16; 1989, Donna Gayle Rucks was stopped by City Police- -officer for excessive speed and reckless driving. Atter giving the woman a physical agility test which she failed, the officer arrested her and took her to the city police dept.. The called her parents and were turning the woman over °' to them when she became angry and ran out of the building and: °..' through the fire escape exit. This exit is on the second floor° of the building. She then attempted to drop herself off of the building when the deputy tried to grab ner jacket, she let_ go:.... She fell to the ground and had to be taken to Raulerson Memorial tor treatment. Her parents are angry, that she fell and they are indicating to the police chief that they may sue. °�� } BEE MS FOR R VOO UR M-SURANCE sold HEAL L ES A4C NEEDS ,I / O O KEECy I a O `, U ::fi•:+k... ,.• • _ • ■ ?.% Cty of Okeechobee • OR %o Now 55 S.E. Third Avenue • Okeechobee, Florida 34974 - 2932.813/763 -3372 January 11, 1991 Berger Insurance Agency 800 South Parrott Avenue Okeechobee, Florida 34974 Dear Lori: These are the medical bills for Donna Rucks I spoke to you about on the telephone this morning. Please file these with insurance per our conversation. Thanks, Lola Parker, Finance Director PHONE 813-763 5544 PATIENT NAME REASON(S) FOR AMBULANCE `41.00KEECHOBEE'COUNTY FIRE •E 301 NW 7ND STREET OKEECHOBEE, FL 34972 Rucks, Donna Arm Pain Leg 'pain Patient fall Allen Rucks re: Donna 485 SE 16tbAnenoe Okee Fl 34974 DESCRIPTION OF CHARGE Base rate Spinal Immobilization TOTAL CHARGES THIS CALL TAX ID 59-6000-768 PATIENT NUMBER 89-12-2751 CALL NUMBER 892751 D3 DATE OF CALL 12/17/89 TIME OF CALL 101 Hrs. CALLER P. D. FROM Okee. City Police Dept. TO HCA Raulerson Hospital F: 262-54 8224 self\Rucks Dairy QUANTITY PRICE PER UNIT FyTFNDED $100.00 $100.00 $25.00 $25.00 DESCRIPTION OF CREDIT RECEIPT PAYMENT DAlE PAYMENTS MADE PRIOR TO THIS MONTH TOTAL CREDITS RECORDED $125.00 ,,, AMOUNt • • PLEASE PAY THIS AMOUNT => $175.00 "DETACH ALONG ABOVE LINE AND RETURN STUB WITH YOUR PAYMENT' PATIENT NAME Rucks PATIENT NUMBER 89 12 2751 CALL NUMBER 892751 D3 AMOUNT $ BILLING DATE 03/01/90 ENCLOSED If payment not received within 10 DAYS, we will be forced to turn your account over for COLLECTION. Thank you. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ OKEECHOBEE COUNTY FIRE RESCUE- 301 NW 2ND STREET OKEECHOBEE, FL 34972 813 /63-5544 • .. • .••••• . ,, ^``^^ . . •••• • • • • • •• • , VLNO ORTHGPAEDIr 1:*00 34TH STREET = "SUIT VE0all BEACH , FL 32960 ;iistiu- tip OIF LAST STAT OFFICE VISIT_LIMITED- EST,PT, X -RAY - PELVIS COP ONLYI . VERO 0 DONNA 'RUCKS VERO BEAD+ . "; k. k►� C/o ALLEN RUCKS ►. PH:. 407 485 S.E. 16TH AVENUE UVEECHGREE, FL 34974(///' L ` J� , VERO ORTHOPAEDICS 1300 36IH STREEI . SUITE 0 YEPO DEA;:fl FL 37960 5911 f. DATE DESCRIPTION CODE DEBTS/CREDITS 07:10/0 i.C.11,7:10/'70 ElhLANGL hS OF LAst SihrlihENT OFIA,,,E. vitAl 1ri1Ef1LD1hTL -ESI,' A i-,:rlY FULL L‘Ir nmu Liir3 ?0060 ...11:14-00 P 3!L 13.1L 1 1 .,-- ACCOUNT NO, . ..;. '..f.' -CURPIENT- . .." .: .- 80-80 DAYS '61.4o. BAYS : . . 90:;:+'--PAYS, -- . -....:' 'BALANCE 014 -.'... ., "f?ii 110.00 0,00 fL)0?-1) 0,.00 110,.00 VERO ORTHOPAEDICS DDNNA RUCKS 1300 36TH STREET - SUITE 0 c'tD nLLEN RUCI-',S T. — _ _ . . _.. ......._....._. 07-16-90 Hi: 4075692330 L OkEECHODEE, FL 34974 HCA`RAbLERSON HOSPITAL' BOX'13O7 OKEECHOBEL FLORIDA 34973�� PATIENT NAME RUCKS DONNA RUCKS ALLEN 45 SE 16TH AVE OKEECHOBEE ACCOUNT NUMBER 3441576 FL 34974 HCA RAULERSON HOSPITAL 89-12-17 89-12-17 89- -17 4W~11-17 89-12-17 89-12-17 89-12-17 89-12-17 89-12-17 89-12-17 RUCKS DONNA E.R. CHARdri �°' 8L0011 ALCOHOL LAB STAT CBC LAB STAT LIMIT�D KNEE COMPLETE ELBOW COMPLETE LUMBAR SPINE - ALL XRAY STAT ACCOUNT BALANCE eco 1. 0 50 77. 16. 55. 16. 35. 82. 80. 123. 16. 550. STATEMENT , OFACCOUNT BILLING DATE 12-22-89 550.00 maroIA 550.00 MINIMUM DUE ^ 550.( HCA RAULERSON HO Ate' OKEECHOBEE, FLORID 34972 (813) 763 -2151 NAPO YT Last 1 7N fl 1 1 YOU HAVE BEEN SEEN BY DR. '_LPL EMERGENCY TREATMErn Middle RcARE INSTRUCTIONS TO THE PATIENT NOTE: The examination, treatment and X -ray reading N*awe received in the Eminency Department have been rendered on an emergency basis only, and they are not intended to be a substitute for or an effort to pttp4e COMPLETE medical cam. X -ray readings done in the Emergency Department are preliminary readings Final readings will be done by the Radiologist and yam 1jIM be nptifed of any other findings. Your follow -up doctor Attained below) can receive a copy of your records and all test reports ft is important that you like .check you again and that you report to him any new or remaining problems at that time, because it is impossible to recognize and treat all elements of or anew in a single Emergency Department visit. Meanwhile, FOLLOW THE INSTRUCTIONS BELOW as indicated for you. PAIN & INJURY INSTRUCTIONS you may gently wash your stitches with peroxide or mild Soap and water and re -cover with a clean dressing use neosporin or similar ointment on the stitches clally keep the dressings clean and dry despite the greatest care, any wound can be infected. if your wound becomes red, swollen, shows pus or red streaks, or feels more sore as days go by, you must report to your doctor right ay jf. use heat or cold on the injured area - whichever seems to help the most. Be careful not to burn yourself. rest as much as possible until you are improved. avoid positions and movements that make the pain worse. relax emotionally -if you are tense the problem will only be worse, and we don't want that.. - elevate the injured part to lessen swelling, if pi cushions with pillows or blankets for comfort. POW, use chair ice packs also help prevent swelling, especially during the twat 48 hours. place ice in plastic or rubber bag, cloth covenng. - if you have an elastic bandage, rewrap it if too tit$ af. top loose. Avoid any use of injured part Allow only limited use of the part - You need not necessarily limit activity Use crutches - Wear soft collar when out of bed May return to work - If you are unable to work in days, you must see a Physician for further evaluation and permission to return ti t, (lf to be out longer. OTHER INSJRUCTIONS GENERAL INSTRUCTIONS use vaporizer take clear liquids by mouth -(weak tea, jello, clear vomiting, diarrhea and abdominal cramps subside, to a normal diet. The sugar content helps, so avoid drink large amount of liquids. use acetominophen (- tylenol -) mg. every fever. mg may be given as a bedtime dose. wu may use ibuprofen mg or aspirin for fever, it may be taken along with acetominophen. call the emergency department on or after pm on for results of X -Ray Lab Tests. Instruction sheet Number soup -) until nausea, then gradually return "Diet" dunks. 4 hours for pain or mg every 4-6 hours HEAD INJURY INSTRUCTIONS Report to your doctor immediately if anything listed occurs (even within several months). Persistent vomiting, stiff neck, fever. - Unequal pupils (one pupil large, one small). - Confusion or unusual drowsiness. ..Convulsions or unconsciousness. Stumbling or other problem with normal use of arms or legs, or areas of skin numbness. NOTE: Waken patient for first night every two hours to be sure patient can be roused. EYE INJURY INSTRUCTIONS Any eye injury is potentially. hazardous. Any increasingly severe discomfort, redness or sudden impairment of vision should be reported immediately to your hysiclan or eye specialist below. RETURN TO THE HCA RAULERSON HOSPITAL EpictirgENCY DEPARTMENT IN DAYS ON AT 9 AM. For[ 1 Suture Removal,[ ] Wound Check,[ : '`1 Redtlessing,[ ] Recheck if problems or signs of infection. F FOR FOLLOW -UP CARE SEE: DR DR. OR DOCTOR OF CHOICE. ❑ CALL AS SOON AS POSSIBLE TO ARRANGE AN MFTTMENT. ❑ CALL IF CONDITION WORSENS TO ARRANGE AN AFIN'TMENT. ❑ CALL OR RETURN IF CONDITION WORSENS ❑ Tetanus Toxoid Given, is good for 5 -10 years, so remember " " as the year of your last dose. I hereby acknowledge receipt of the instructions irdicategliebove. 1 understand that I have had emergency treatment only and that I may be released before all of my medical problems are known or treated. I will an for follow -up care as instructed above. 1 understand that if I have not contacted the above physician within 7 days, he is no longer responsible to see ma (r/3 SPECIALITY SPECIALITY Witness Initial -t rrp r4;1.651;)IREy.4' /8g. E'RICAN PIONEER ?. 30X 3509 LANDO l 75 -02 FL 32302 "1°1265 COMMERCIAL IN" "A ,,,E ~,..• HEALTH INSURANCE CLAIM FORY ii0,60C* READ INSTRUCTIONS BEFORE COMPLETING OR SIGNING THIS FORM ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS [i OTHER Form Approved OMB No. 0938-0008 ria f OF SERVICE AND TYPE OF SERVICE IT .0.S.1 CODES ON THE BACK ,RKS APROVED BY AMA COUNCIL ON MEDICAL SERVICE APPROVED BY THE HEALTH CARE FINANCING ADMINISTRATION 6 CHAMPUS 5.80 Pt ONE% 407- 77e-59C4 Form HCFA-1500 (C1)(10-80) Form CHAMPUS -501 "PENT S NAME (First name, middle Writ. fast name) �)NA RUCKS 3 SE 16TH AVE EECHOBEE FL 34974 _PHONE NUMBER 2. PATIENT'S DATE OF BIRTH 6I 2OI 71 3. INSURED'S NAME (First moms, middle initial, last name) - e PLC."(5 //. i ire �* L 5. PATIENT S SEX 6. INSURED'S LD., MEDICARE - 2618S7- ANm1OR jr-7$ MEDICAID NO. (Include any fetters) .�'<,, �1 i "y��,?`{ MALE( I XXIFEMALE -'- 7 PATIENTS RELATIONSHIP TO INSURED SELF SPOUSE HI OTHER 8. INSURED'S GROUP NO (Or Group Name) I 1 arfej 1 THER HEALTH INSURANCE COVERAGE . Enter Name of tI cyholder and Plan Name and Address and Policy or Medical ssistance Number RE ..CE iti'.f f r^,!' 0 :190 10. WAS CONDITION RE ATED TO A. PATIENT'S EMPLOYMENT 11. INSURED'S ADDRESS (Street, pry, stele, ZIP code) 5 A M E YES I X X NO B. AN ACCIDENT AUTO 1 I OTHER '.TIENT'S OR AUTHORIZED PERSON'S SIGNATURE (Reed back before slgnm9/ enonre the Release of any Medical mtormatIon Necessary to Process the Claim and Request Payment of MEDICARE Benefits e' to Myself or 10 the Party Who Accepts Assignment Below o SIGNATURE O N FILE DATE 13. t AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO UNDERSIGNED P L'S�CLAi get firPPLIER 6 R eRVI C DESCRIBED BELOW 1 ("1 �( ' / 1 SIGNED (Insured or Authorized Person) SICIAN OR SUPPLIER INFORMATION ATE OF. ' 7/05/90 ILLNESS (FIRST SYMPTOM) OR INJURY (ACCIDENT OR PREGNANCY (LMP) 15. DATE FIRST CONSULTED YOU FOR THIS CONDITION 16. HAS PATIENT EVER HAD SAME OR SIMILAR SYMPTOMS? 16a. IF AN EMERGENCY CHECK HERE ■ YES I 1 I NO ATE PATIENT ABLE TO Ei TURN TO WORK 18. DATES OF TOTAL DISABILITY FROM ITHROUGH DATES OF PARTIAL DISABILITY FROM ITHROUGH AME OF REFERRING PHYSICIAN OR OTHER SOURCE (e g.. public health agency) 20. FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION DATES ADMITTED I DISCHARGED AME & ADDRESS OF FACILITY WHERE SERVICES RENDERED at other roan home or office) )IAN RIVER MEMORIAL HDSPITAL 22. WAS LABORATORY WORK PERFORMED OUTSIDE YOUR OFFICE? CHARGES vest, 1 (NO AGNOSIS OR NATURE OF ILLNESS OR INJURY RELATE DIAGNOSIS REFERENCE NUMBERS 1. 2, 3, ETC. OR DX CODE ICC9 -Cp! COCE 7804 TO PROCEDURE IN COLUMN D B EPSDT FAMILY _PLANNING PRIOR AUTHORIZATION NO YES YES NO XX NO A PATE OF ,OM SERVI('E TO • PLACE OF SERVICE C FULLY DESCRIBE PROCEDURES. FURNISHED FOR EACH MEDICAL SERVICES OR SUPPLIES DATE GIVEN (EXPLAIN UNUSUAL SERVICES OR CIRCUMSTANCES) D DIAGNOSIS CODE E CHARGE'), P DAY`; OR UHT', 0 • 1 0 , H LEAVE BLANK PROCEDURE CODE (IDENTIFY I 7/06/90 2 70551 MRI 5RA IN 4464 17500 L NATURE OF PHYSICIAN OR SUPPLIER ernly that the statements on the reverse apply to s bill and are made a pert hereof) ,060 DATE 7/24/90 26. ACCEPT ASSIGNMENT (GOVERNMENT CLAIMS ONLY( (SEE BACK) 27. TOTAL CHARGE �� 2B. AMOUNT PAID 29 BALANCE DUE SII]0 L YES I X X I i I NO 31. PHYSICIAN'S OR SUPP PER'S NAME. ADDRESS, ZIP CODE & PTALEp�ONVO. 3 K A G G S 9 P. C. 2001 19THj`AVEE SUITE 2079 VERO BEACI- FL 32960 w. NO. 31178 30. YOUR SOCIAL SECURITY NO. 264- 76 -79E4 Jr, PATIENT'S ACCOUNT NO 3- 01244704 33 YOUR EMPLOYER I.D. NO. f OF SERVICE AND TYPE OF SERVICE IT .0.S.1 CODES ON THE BACK ,RKS APROVED BY AMA COUNCIL ON MEDICAL SERVICE APPROVED BY THE HEALTH CARE FINANCING ADMINISTRATION 6 CHAMPUS 5.80 Pt ONE% 407- 77e-59C4 Form HCFA-1500 (C1)(10-80) Form CHAMPUS -501 r- ,3 — 76— J2 m. Y. CHAUGHARV, M. D. -- ILL IN j OFFICE -- 1 4c F 7 R C ,,, HILL 3L V D P113 W -ST ?ALm EACH FL 33406 -6013 L_ 5 1-234515 r ALLEN; PUCKS 4` Sr 16 T'-1 AVE L CKFFCHO IFE FL 34974 THIS STATEMENT IS FOR INT= RPRETATICN OF X —RAV SE:, VICES PERFORMED IN H. },. RAULERSON HOSPI TA L Please direct all inquires and payments to our Billing Office at the address above or at Telephone # 813 -4 57 -2 111 o not call the hospital as they coin not help you with this bill. If payment has been sent within the past 10 days your credit will appear on your next statement. Account Number Patient Name 1 —D -)3441:' lONNA PUCKS Please tear off and return upper portion to insure proper credit. If you desire a receipt please return entire statement. Payment Due 1 /1 9/ '3v Balance Due 87 .0r DATE DESCRIPTION 8 -76 -62 1- 003441.57 1 -00 121171PJLUM3AR SPINE .2 11'1 4200 1 y17180EL30W COMPLET 73080 22100 1 211710 iKNF E CnMPLET E 73 564 231100 I R `COL HAVE INSURANCE THAT CAN COVE:, THE SERV ICE 0 9ILLir PLEASE CONTACT OUR OFFICE T0r.';Y. CHARGES t000 Y. Y. ':H.4U')- -14PY• M.O. PLEASE READ OTTER SIDE OF TH: a ATEMENT PAY THIS AMOUNT CREDITS N TH` S ❑ 01 — JAMES L. CAIN, M.D Medicare Provider # 71901 0 02 — DAVID W 'GRIRFIN, M.D. Medicare Prov' Vr s 6 -31126 0 03 — GEORGE K NICIr1DLS, M D. Medicare Provider'* 31160 VERO ORTHOPAEDICS 1300 36th STREET SUITE C VERO BEACH, FLORIDA 32960 (407) 569 -2330 P A GROUP 5 99520 TAX I 5 59- 1651556 S/C OFFICE VISITS CPT FEE S/C X -RAY CONTINUED CPT FEE S/C CASTS CONTINUED CPT FEE 1 Limited -Est. Pt. 90050 37 Shoulder (2 Views) 73030 70 Cast - Cylinder 29365 2 (pre -Op) 90050 38 Humerus 73060 71 Cast Clubfoot 29450 (Pos1 -Op) 90050 39 Elbow AP & Lat. 73070 72 Cast - Bilateral Clubfoot 29455 . r?- n1'ermediate 90060 40 Elbow 3 Views 73080 73 Cast - Short Fiber. Material A4590 5 Intermediate -New Pt. 90015 41 Foreman 73090 74 Cast - Bootwalker L3260 6 Est. Pt. 90080 42 Wrist 73100 75 Cast Removal 29700 7 Comp. -New Pt. 90020 43 Navicular Series 73110 8 2nd Opinion - Intermediate 90651 44 Hand 73130 SUPPLIES 9 2nd Opinion - Extensive 90652 90654 45 46 Finger Chest (2 Views) 73140 71020 76 77 Ace Bandage Air Cast A4460 29799 10 2nd Opinion - Complex 47 Ribs (Unilateral) 71100 78 Jacobi Bunion Splint L3100 X -RAYS 48 Ribs (Bilateral) 71110 79 Cervical Collar L0120 11 Cervical Spine (2 Views) 72040 49 Scanogram 76040 80 Myocollar L0140 12 Cervical Spine (Complete) 72050 Interpretation -26 81 Cervical Traction Unit E0860 13 Cervical Spine (FIex.Ext.) 72052 82 Clavicle Splint L3650 14 Thoracic Spine 72070 INJECTIONS 83 Sling A4565 15 Lumbar Spine (AP & Lat) 72100 50 Injection - Soft Tissue 20550 84 Elbow Pad E0191 16 Lumbar Spine (Complete) 72110 51 Inj.- Arthrocentesis -Int. 20605 85 Heel Cup L3430 17 Scolosis 72090 52 Inj.- Arthrocentesis Major 20610 86 Heel Pad E0191 18 Pelvis (AP Only) 72170 55 Inj. - Tetanus 90703 87 3 -D Knee Splint L1880 19 Sacrum & Coccyx 72220 88 Hinged Knee Splint L1810 20 Pelvis and Both Hips 73520 89 Donjoy Knee Splint L1840 21 Pelvis and One Hip 73510 _ 90 Pateller Knee Splint L1825 22 Femur 73550 CONSULTATIONS 91 Post Op Knee Splint L1830 & Lat) 73560 -, 56 Consultation - Intermediate 90605 92 Spiral Knee Splint L1800 24 .Knee-(AP Knee AP Lat. w /obliques min. 3 view 73562 57 Consultation - Extensive 90610 93 Cartilage Knee Splint L1820 58 Consultation - Comp. 10620 94 Dorsal Lumbar Corset L0974 25 Knee Complete inc. obliques /Tun. 73564 59 Consultation - Complex 90630 95 Lumbar Corset L0976 96 Lumbar Traction Unit E0890 26 Total Knee 76040 CASTS 97 Orthoplast Splint L3906 27 Tibia 73590 60 Cast - Lonq Arm 29065 98 Wooden Shoe Post Op L3260 28 Ankle AP & Lat. 73600 61 Cast - Lonq Arm Splint 29105 99 Wrist Splint L3800 29 Ankle (3 Views) 73610 62 Cast - Short Arm 29075 100 Deluxe Wrist Splint L3805 30 Calcaneus 73650 63 Cast - Navicular 29085 101 Finger Splint 29280 31 Foot 73620 64 Cast - Short Arm Splint 29125 102 Tennis Elbow Splint L3999 32 Toes 73660 65 Cast - Long Leg 29345 103 Tennis Elbow Air Cast 29799 33 Clavicle 73000 66 Cast - Long Leg Splint 29505 104 Unna Boot 29580 34 AC Joints 73050 67 Cast - Short Leq Splint 29515 r�r••y : $ ` 'A.j• ' 35 Scapula 73010 68 Cast Short Leq 29425 TOTAL CHARGE THIS DATE 36 Shoulder (1 View) 73020 69 Cast - PTB 29435 PREVIOUS BALANCE I • • • • ADJUSTMENTS•$ • • DIAGNOSIS: SIGNATURE ON FILE DATE • NEXT APPOINTMENT DATE: DOCTOR NO PATIENT # 37,77 Fee e T tp e : 4 NAME- DI INNfl RUCKS ADDRESS 485 `.'3E 16TH AVENUE DATE. 07 /10/90 #5911 CIF {EECHOBEE FL 34974 HOME PHONE (813)763-3274 WV: -Nor O N FILE- VERO ORTHOPAEDICS GEORGE. k, NII�HOLS, M,D, I.S.0 CASH 0 D,O,Et, 016 /20/71 SEX: F PAYMENT RECD. THIS DATE $ 0CC ID Cash ❑ChI1cJ:. \ NEW BALANCE CUE $ • Code:No•• •••• FINANCIALLY RESPONSIBLE #: gn NAME. ALLEN RUCKS ADDRESS: 485 S , E= , 16TH AVENUE. OKEEC:I IOE%EE FL 34974 (813)763-3274 -NOT ON FILE- EXT: NO INSURANCE /NO I NSURANCE 11111111111 11111111111111 /111111111 1111111111111111111111111 /1111111.11 HOME PHONE. WORK PHONE INS. COMPANY INS. GROUP #: INS. I.D. #. REFERRED 1t\': PHYSICIAN'S SIGNATURE OVER 90 PREVIOUS BALANCE DUE THIS RECEIPT IS FOR INSURANCE FILING AND TAX PURPOSES. ❑ 01 -- JAMES L. CAIN, M.D. Medicare Provider # 71901 ❑ 02 — DAVID W. GRIFFIN, M.D. Medicare *Provider # 6 -31126 ❑ 03 — GEORGE K. NICHOLS, M.D. Medicare Provider# 31160 VERO O1iTHOPAEDICS 1300 36th STREET SUITE C VERO BEACH, FLORIDA 32960 (407) 569 -2330 P A GROUP # 99520 TAX I D. 5 59- 1651556 S/C OFFICE VISITS CPT FEE S/C X -RAY CONTINUED CPT FEE S/C CASTS CONTINUED CPT FEE 1 Limited -Est. Pt. 90050 37 Shoulder L2 Views) 73030 70 Cast - Cylinder 29365 2 (pre -Op) 90050 38 Humerus 73060 71 Cast Clubfoot 29450 3 (Post -Op) 90050 39 Elbow AP & Lat. 73070 72 Cast - Bilateral Clubfoot 29455 4 Intermediate 90060 40 Elbow 3 Views 73080 73 Cast - Short Fiber. Material A4590 5 Intermediate -New Pt. 90015 41 Foreman 73090 74 Cast - Bootwalker L3260 6 Est. Pt. 90080 42 Wrist 73100 75 Cast Removal 29700 7 Comp. -New Pt. 90020 43 Navicular Series 73110 8 2nd Opinion - Intermediate 90651 44 Hand 73130 SUPPLIES 9 2nd Opinion - Extensive 2nd Opinion - Complex 90652 90654 45 46 Finger Chest (2 Views) 73140 71020 76 77 Ace Bandage Air Cast A4460 29799 10 47 Ribs (Unilateral) 71100 78 Jacobi Bunion Splint L3100 X -RAYS 48 Ribs (Bilateral) 71110 79 Cervical Collar L0120 11 Cervical Spine (2 Views) 72040 49 Scanogram 76040 80 Myocollar L0140 12 Cervical Spine (Complete) 72050 Interpretation -26 81 Cervical Traction Unit E0860 13 Cervical Spine (FIex.Ext.) 72052 1 82 Clavicle Splint L3650 14 Thoracic Spine 72070 INJECTIONS 83 Sling A4565 15 Lumbar Spine (AP & Lat) 72100 50 Injection - Soft Tissue 20550 84 Elbow Pad E0191 16 Lumbar Spine (Complete) 72110 51 Inj.- Arthrocentesis -Int. 20605 85 Heel Cup L3430 17 Scolosis 72090 52 Inj.- Arthrocentesis Major 20610 86 Heel Pad E0191 18 Pelvis (AP Only) 72170 55 Inj. - Tetanus 90703 87 3 -D Knee Splint L1880 19 Sacrum & Coccyx 72220 88 Hinged Knee Splint L1810 20 Pelvis and Both Hips 73520 89 Donjoy Knee Splint L1840 21 Pelvis and One Hip 73510 90 Pateller Knee Splint L1825 22 Femur 73550 CONSULTATIONS 91 Post Op Knee Splint L1830 23 Knee (AP & Lat) 73560 56 Consultation - Intermediate 90605 92 Spiral Knee Splint L1800 24 Knee AP Lat. w /obliques min. 3 view 73562 57 Consultation - Extensive 90610 93 Cartilage Knee Splint L1820 58 Consultation - Comp. 10620 94 Dorsal Lumbar Corset L0974 25 Knee Complete inc. obliques /Tun. 73564 59 Consultation - Complex 90630 95 Lumbar Corset L0976 96 Lumbar Traction Unit E0890 26 Total Knee 76040 CASTS 97 Orthoplast Splint L3906 27 Tibia 73590 60 Cast - Lonq Arm 29065 98 Wooden Shoe Post Op L3260 28 Ankle AP & Lat. 73600 61 Cast - Long Arm Splint 29105 99 Wrist Splint L3800 29 Ankle (3 Views) 73610 62 Cast - Short Arm 29075 100 Deluxe Wrist Splint L3805 30 Calcaneus 73650 63 Cast - Navicular 29085 101 Finger Splint 29280 31 Foot 73620 64 Cast - Short Arm Splint 29125 102 Tennis Elbow Splint L3999 32 Toes 73660 65 Cast - Lonq Leg 29345 103 Tennis Elbow Air Cast 29799 33 Clavicle 73000 66 Cast - Lonq Leg Splint 29505 29515 104 TOTAL Unna Boot CHARGE THIS DATE $ 29580 34 AC Joints 73050 67 Cast Short Leg Splint 35 Scapula 73010 68 Cast Short Leg 29425 ••w•• • PREVIOUS BALANCE �'• 36 Shoulder (1 View) 73020 69 Cast - PTB 29435 ADJUSTMEN'TS7 - -' DIAGNOSIS: SIGNATURE ON FILE DATE NAME. ADDRESS HOME PHONE IS.0 NEXT APPOINTMENT DATE DOCTOR NO. PATIENT # PHYSICIAN'S SIGNA TUR DATE 00 NAME ADDRESS HOME PHONE WORK PHONE. INS. COMPANY INS. GROUP # INS.I,D #. PAYMENT RECD. THIS DATE $ ❑ CC ❑ Cash ❑ Chack NEW BALANCE CQTf_"$• • Code iNoy• it • u FINANCIALLY RESPONSIBLE # 31 -60 ' : F8 -75 -02 . UL H. SKAGGS, M. • BILLING CFFIC -- 2C01 9TH AVE SUITE 2373 VERG JEACH FL 32963 L 65- 0179578 r- ALLEN RUCKS L_ 435 SE 15TH AVE OKEECHO3EE FL 34974 _ Y �r .S f %'� i {' i S FOR INTEPPRt TATICN OF X —R:3k S R, ICES PERFORME. IN I\C_A: RIVER M_MCRIMI f4LSPITAL J Please direct all inquires and payments to our Billing Office at the address above or at Telephone # 4c 7_778 -9g94 Do not call the hospital as they can not help you with this bill. If payment has been sent within the past 10 days your credit will appear on your next statement. PAYCC . : C500 PHI 31-3-753-3274 Account Number 3-01244704 Patient Name DC.i'•3A K'J'.'< Payment Due 11/1 5/90 Balance Due 175•CC Please DATE tear oft and return upper portion to Insure proper credit. 11 you desire a receipt 's -7 — ; 2 3- 01'4470 i3 —C please I return entire CHARGES statement. CREDITS DESCRIPTION PLEASE DLJ'.;Y 00 NOT ALLOW TH S ACCOUNT TO 3ECOME SENO YOU1 ?AYMEt T IMYEOIATELY. 175: CELINQUEt 1 T. pAli ° H. SKAGGS, M.D. PAY THIS AMOUNT PLEASE READ OTHER SIDE OF THIS STATEMENT 175100 1 OKEECHOBEE �S�u�� DRUGS 412 N.E. PARK ST. 763-5100 OKEECHOBEE, RA. 412 N.E. PARK ST. 763 -5100 OKEECHOBEE, FLA. 34972 Dr.D.W.GRIFFIN 12/18/89 HYDROCODONE BITRTRATE 3OEA Amt $10.99 RUCKDO- RUCKS, DONNA 485 S.E. 16TH AVE. OKEECHOBEE, = `FL'`` RX #4235008 *PAY CASHIER* NET $10.99 Rx No. 185449 THIS IS YOUR RECEIPT. PLEASE RETAIN FOR TAX OR INSURANCE. PATIENT COUNSELING 4235008 Dr.D.W. GRIFFIN RUCKS, DONNA 12/18 VICODIN TABS HYDROCODONE BITRTRATE May Cause Drowsiness Alcohol Adds Drowsiness Avoid Alcohol THANK YOU FOR SHOPPING A OKEECHOBEE DISCOUNT DRUG HAVE A NICE DAY OKEECHOBEE UR UlGillt 412 mi. PARK sr. 763.5100 a maNW, FLA. 24972 IRRIIH Indian River Memorial .�..�. Hospital PATIENT NO. 1244704 1000 36th Str Vero Bch, rrrorida 32960' TELEPHONE (407) 567 -4311 EXTENSION ADMISSION DATE 7/06/9O BILLING DATE 9122/9'0 PLEASE DISREGARD THIS STATEMENT IF PAYMENT HAS BEEN MADE. KEEP THIS CC FOP YOUR INCG,,,,,.rAX� RECORDT ACCOUNT NO. 1244704 T FC ACCOUNT NO 12.44704 TRANSACTION DATE DESCRIPTION CHARGES & CREDITS DESCRIPTION CHARGES & CREDO S/25/90 9/08/90 9/08/90 9/11/90 BALANCE LASTEMEMT BALANCE TO PATIENT BALANCE TO PATIENT INSURANCE FOLLOWED UP FINAL *** ACCOUNT BALANCE 906.00 'YCN— i 906.00CR 9970019 906.00 9970019 .00 ; 9970004 906,00 946.00 906.00CF? j /06.00 .O0 PATIENT NAME: RUCKS' DONNA 0 BILL TO RUCKS) BEVERLY 465 SE 16TH AVENUE OKEQ4OBEEE FL 34'474 MESSAGE: BILL TO TOTAL AMOUNT DUE-O• TOTAL AMOUNT 906.00 906.00 1 NDICATE HERE THE AMOUNT THAT IS BEING PAID TO ASSURE PROPER CREDIT REMOVE STUB AND RETURN WITH REMITTANCE. a ACCOUNT NO. DATE TEARFiERE L AMOUNT DUE ON RECEIPT PAYMENT ENCLOSED $ PLEASE DETACI-NartID URN TOP PORTION WITH PAYMENT PLEASE CORRECT ANYVFORMATION WHICH IS IN ERROR DATE PROFESSIONAL SERVICES CHARGES/PAYMENT PLEASE RETAIN THIS STATEMENT FOR INCOME TAX PURPOSES. NO OTHER STATEMENT WILL BE RENDERED. DATE OF :..:;:-.../ .i. ] / 3!:?) LAST PAYMENT 0-30 DAYS 31-60 DAYS 61-90 DAYS OVER 91 DAYS TOTAL :;‘.. .7 .. , CURRENTLY DUE .....`'.:,,L,•(-"- , ...;::'!' ..;f::::,,:::::' ,.... ....:;t::.:: CURRENT THIS PORTION OF YOUR ACCOUNT IS PAST DUE