DOCUMENT 2: INITIAL MEDICAL REPORT

ROCK CITY CLINIC, PC 41 Medical Plaza Tel 555-555-6789 Rock City, IA 50700 Fax 555-555-6790 Initial Examination Report Patient: James Sample Date: 8/3/09 DOA: 7/28/09 Subjective History of Present Conditions Mr James Sample is a 35-year-old male who was involved in a motor vehicle accident as a driver, with seat belt. The patient reported no loss of consciousness. His vehicle was struck at the right side while making a left turn at an intersection. The patient treated himself with analgesics before presenting for a consultation on 8/3/09. Previous Medical History No known allergies, non-smoker, non-drinker. No contributory events. Objective Pt is well-developed and well-nourished 35-year-old male with no remarkable masses, deformities, or deficits. Patient appears in moderate distress from the pain and discomfort of cervical/thoracic/lumbar strains and knee strain (R). BP 128/84. P 86, regular. RR 14. Chief Complaints/System Review. Head: Nervousness, irritability, tension, insomnia. Chest: No tenderness or pain on palpation. Cervical spine: Pain 7/10, decreased range of motion, neck pain and stiffness with pain radiating R/L. Spine tenderness at the C2-C7 levels. Increased tone in R/L rhomboid muscles. Compression test positive. Distraction test negative. Thoracic spine: Pain 6/10, tenderness at T2-3-4-5-9-10-11-12 with spasm in R/L paraspinal structures. Lumbosacral spine: Pain 8/10, decreased ROM, lower back pain and stiffness with pain radiating across lower back. Tendnerness at L1, S2 levels with increased R/L paravertebral muscle tone. Spinal percussion test negative. Straight leg raise test positive at 50 on the left. Upper extremities: Normal. Lower extremities: Tenderness over right knee. Active and passive movements are restricted and painful on palpation of the R knee. Varus stress test is positive. Neurological: Unremarkable. Coordination: Unremarkable. Motor systems: Motor muscles test were +5/5 throughout. No muscle atrophy noted. Sensory system: Decreased response to light touch and pinprick sensation in the left hip.

DOCUMENT 2: INITIAL MEDICAL REPORT

Recommendations. – Avoid heavy work until next evaluation – X-ray of R knee, MRI of R knee – MRI of spine – PT evaluation and treatment – Chiropractic – Acupuncturist – Computerized range of motion testing – Prescribed medical supplies for R knee, neck, back – Re-evaluation in 4 weeks Assessment Initial Diagnostic Impression Sprain/strain of C/T/L spine, right knee Rule out: Fracture/tear/herniated disk Plan Analgesics, chiropractic treatment, acupuncture. Physical therapy 3x/week until next re-evaluation. Physical therapy will consist of various modalities such as thermo therapy, electrotherapy/stim, cervical traction, manipulation therapy, assisted active and passive range of motion exercises for the injured area. Additional treatment will include home exercises. Therapeutic equipment has been prescribed. Prognosis At the time, the patient’s prognosis is guarded. Respectfully submitted, B Jones, MD Medical Director License #xxxxx

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Driver’s Name (Last, First, Middle) Gender

Address (Street and Number)

City State ZIP

Birth Drivers License Number State DL CDLDate

Safety Equip. Used Air Bag Ejected Date of Death Injury Type EMS Transport

Summons O�enses Charged to DriverIssued As Result of Crash

CRASH

DRIVER Driver Fled Scene

VEHICLE

PASSENGER (only if injured or killed)

Police Crash Report Page _______ of _______

Crash MM DD YYYY Day of Week MILITARY Time (24 hr clock) County of Crash Of�cial DMV UseDate

City of City or Town Name Landmarks at Scene Town of

Location of Crash (route/street) Railroad Crossing ID no. (if within 150 ft.) Local Case Number

N S E W Location of Crash (route/street) Mile Marker Number Number of Vehicles At Intersection With or ______ Miles Feet of

VEHICLE # DRIVER Driver Fled Scene

VEHICLE

Driver’s Name (Last, First, Middle) Gender

Address (Street and Number)

City State ZIP

Birth Drivers License Number State DL CDLDate

Safety Equip. Used Air Bag Ejected Date of Death Injury Type EMS Transport

Summons O�enses Charged to DriverIssued As Result of Crash

Vehicle Owner’s Name (Last, First, Middle) Same as Driver

Address (Street and Number)

City State ZIP

Vehicle Year Vehicle Make Vehicle Model Disabled CMV Towed

Vehicle Plate Number State Approximate Repair Cost

VIN Oversize Cargo Spill

Name of Insurance Company (not agent) Override

Underride

Speed Before Crash Speed Limit Maximum Safe Speed ALL Passengers Age Count Under Over 8 8-17 18-21 21

VEHICLE #

Investigating Of�cer Badge/Code Number Agency/Department Name and Code Reviewing Of�cer Report File Date

Codes POSITION IN/ON VEHICLE1. Driver2-6. Passengers7. Cargo Area8. Riding/Hanging On Outside9-98. All Other Passengers

SAFETY EQUIPMENT USED1. Lap Belt Only2. Shoulder Belt Only3. Lap and Shoulder Belt4. Child Restraint5. Helmet6. Other7. Booster Seat8. No Restraint Used9. Not Applicable

INJUR Y TYPE1. Dead Before Report Made2. Visible Signs of Injury, as Bleeding Wound or Distorted Member or Had to be Carried From Scene.3. Other Visible Injury, as Bruises, Abrasions, Swelling, Limping, etc.4. No Visible Injury, But Complaint of Pain, or Momentary Unconsciousness.6. No Injury (driver only)

AIRBAG1. Deployed – Front2. Not Deployed3. Unavailable/Not Applicable4. Keyed O�5. Unknown6. Deployed – Side7. Deployed – Other (Knee, Air Belt, etc.)8. Deployed – Combination

EJECTED FROM VEHICLE1. Not Ejected2. Partially Ejected3. Totally Ejected

SUMMONS ISSUED ASA RESULT OF CRASH1. Yes2. No3. Pending

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Vehicle Owner’s Name (Last, First, Middle) Same as Driver

Address (Street and Number)

City State ZIP

Vehicle Year Vehicle Make Vehicle Model Disabled CMV Towed

Vehicle Plate Number State Approximate Repair Cost

VIN Oversize Cargo Spill

Name of Insurance Company (not agent) Override

Underride

Speed Before Crash Speed Limit Maximum Safe Speed ALL Passengers Age Count Under Over 8 8-17 18-21 21

Name of Injured (Last, First, Middle) EMS Transport Date of Death

Position Safety Airbag Ejected Injury Type Birthdate GenderIn/On EquipVehicle Used

MM DD YYYY

MM DD YYYYMM DD YYYY

MM DD YYYY

MM DD YYYY

MM DD YY

Name of Injured (Last, First, Middle) EMS Transport Date of Death

Position Safety Airbag Ejected Injury Type Birthdate GenderIn/On EquipVehicle Used MM DD YYYY

Name of Injured (Last, First, Middle) EMS Transport Date of Death

Position Safety Airbag Ejected Injury Type Birthdate GenderIn/On EquipVehicle Used MM DD YYYY

PASSENGER (only if injured or killed)Name of Injured (Last, First, Middle) EMS Transport Date of Death

Position Safety Airbag Ejected Injury Type Birthdate GenderIn/On EquipVehicle Used MM DD YYYY

Name of Injured (Last, First, Middle) EMS Transport Date of Death

Position Safety Airbag Ejected Injury Type Birthdate GenderIn/On EquipVehicle Used MM DD YYYY

Name of Injured (Last, First, Middle) EMS Transport Date of Death

Position Safety Airbag Ejected Injury Type Birthdate GenderIn/On EquipVehicle Used MM DD YYYY

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NY

Y NNY

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M F

Y N

Y N

Y N

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MM DD YY

MM DD YY MM DD YY

MM DD YY MM DD YY

Revised Report

GPS Lat. GPS Long.

CRASHCrash MM DD YYYY MILITARY Time (24 hr clock) County of Crash City of Local Case Number Date Town of

•

Police Crash Report Page _______ of _______Of�cer Initials________ Badge # __________

Revised Report

CRASH DIAGRAM

Approx. Repair Cost Object Struck (Tree, Fence, etc.) Property Owners Name (Last, First, Middle) Address (Street and Number)

DAMAGE TO PROPERTY OTHER THAN VEHICLES

CRASH EVENTSVehicle # First Event Second Event Third Event Fourth Event Most Harmful Event Vehicle # First Event Second Event Third Event Fourth Event Most Harmful Event

NON-COLLISION28. Ran O� Road29. Jack Knife30. Overturn (Rollover)31. Downhill Runaway32. Cargo Loss or Shift33. Explosion or Fire34. Separation of Units

35. Cross Median36. Cross Centerline37. Equipment Failure (Tire, etc)38. Immersion39. Fell/Jumped From Vehicle40. Thrown or Falling Object41. Non-Collision Unknown42. Other Non-Collision

19. Pedestrian20. Motor Vehicle In Transport21. Train22. Bicycle23. Animal

24. Work ZoneMaintenance Equipment

25. Other Movable Object26. Unknown Movable Object27. Other

1. Bank Or Ledge2. Trees3. Utility Pole4. Fence Or Post5. Guard Rail6. Parked Vehicle7. Tunnel, Bridge, Underpass,

Culvert, etc.8. Sign, Traf�c Signal9. Impact Cushioning Device

10. Other11. Jersey Wall12. Building/Structure13. Curb14. Ditch15. Other Fixed Object16. Other Traf�c Barrier17. Traf�c Sign Support18. Mailbox

First Harmful Event of Entire Crash that Results in First Injury or Damage.

CRASH DESCRIPTION

Indicate North by Arrow

Vehicle # First Event Second Event Third Event Fourth Event Most Harmful Event Vehicle # First Event Second Event Third Event Fourth Event Most Harmful Event

VEHICLE #

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Fill In Impact Area(s). Initial Impact.

Veh Dir of Travel–N/S/E/W

VEHICLE #

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Fill In Impact Area(s). Initial Impact.

Veh Dir of Travel–N/S/E/W

VEHICLE #

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Fill In Impact Area(s). Initial Impact.

Veh Dir of Travel–N/S/E/W

VEHICLE #

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Fill In Impact Area(s). Initial Impact.

Veh Dir of Travel–N/S/E/W

COLLISION WITH FIXED OBJECT COLLISION WITH PERSON, MOTOR VEHICLE OR NON-FIXED OBJECT

DOCUMENT 5: X-RAY REPORT

Rock City Medical Imaging 61 Medical Plaza

Rock City, IA 50700-1234 Ph. 555-555-5555

DOA: 7/28/09 DOB: 11/26/73 DOS: 8/03/09 Patient Name: Sample, James Sex: M Patient Address: 456 Fifth St, Rock City, IA 50700 DOS: 08/06/09 REFERRING PHYSICIAN: Dr. B. Jones RADIOGRAPHS OF THE RIGHT KNEE INDICATION: Pain. FINDINGS: There are no acute fractures or dislocations. The articular surfaces are intact. There is no significant joint effusion. There are no soft tissue abnormalities. IMPRESSION: No acute fractures or dislocations. Thank you for the courtesy of this referral. Electronically Signed Robert Radiologist, M.D. Board Certified Radiologist

DOCUMENT 6: MRI REPORT

Rock City Medical Imaging 61 Medical Plaza

Rock City, IA 50700-1234 Ph. 555-555-5555

DOA: 7/28/09 DOB: 11/26/73 DOS: 8/03/09 Patient Name: Sample, James Sex: M Patient Address: 456 Fifth St, Rock City, IA 50700 REFERRING PHYSICIAN: Dr. B. Jones Study: MRI OF THE RIGHT KNEE Technique: Magnetic resonance imaging of the right knee was performed utilizing multiple imaging sequences. Findings: There is a small knee effusion. No meniscal tears are demonstrated. The cruciate ligaments, patellar tendon, and quadriceps tendon demonstrate no evidence of a tear. There is mild lateral subluxation of the patella. No retinacular tears are seen. No collateral ligament tears are demonstrated. Signal from the visualized osseous and muscular structures is normal. Impression: 1. Small knee effusion. 2. Mild lateral subluxation of the patella. Electronically Signed Robert Radiologist, M.D. Board Certified Radiologist

DOCUMENT 7: DME ORDER

ROCK CITY CLINIC, PC 900 First Avenue Tel 555-555-6789 Rock City, IA 50700 Fax 555-555-6790

Medical Supplies Order from B Jones, MD

License #x-xxxxxx Date: 8/3/09 To: Rock City Medical Supply, PO Box 1234, Rock City, IA, 50700 Patient name: Sample, James Patient address: DOA: 7/29/09 Order: _X__ Orthopedic pillow _X__ Cervical collar ____ Hot/cold pack _X__ Themophore _X__ Lumbar cushion _X__ Lumbosacral support (LSO) _X__ Bed board _X__ Egg crate mattress ____ Car seat ____ Shoulder support __ R __ L ____ Wrist support __ R __ L _X__ Knee support _X R __ L ____ Ankle support __ R __ L ____ Elbow support __ R __ L ____ Arm sling ____ Cane ____ Other: ____ Other: By:__[SIGNATURE]_______ Dr B Jones, MD

DOCUMENT 9: DME RECEIPT

Rock City Medical Supply PO Box 1234

Rock City, IA 50700-1234 Ph. 555-555-5555

Delivery Receipt

DOA: 7/28/09 DOB: 11/26/73 Phone: 555-000-0000 Patient Name: Sample, James Sex: M Patient Address: 456 Fifth St, Rock City, IA 50700 Equipment delivered

1. Orthopedic pillow 2. Cervical collar (2 pc) 3. Thermophore 4. Lumbar cushion 5. Lumbosacral support 6. Bed Board 7. Egg crate mattress 8. Knee support (right) 9. Home cervical traction unit

I have received the medical supplies listed and was instructed in how to use them for my particular condition. Patient signature: [SIGNATURE] Date: 8/06/09

DOCUMENT 10: DME WHOLESALE INVOICE

Al’s Medical Equipment Distributors PO Box 789 Tel 555-555-1235 Chicago IL 60000-0789 Fax 555-555-1234 Date: 7/3/09 Wholesale Invoice #1045 Bill to: Rock City Medical Supply PO Box 1234 Rock City, IA 50700-1234 PO#: Verbal Ship Date: 7/7/09 Patient address: Qty Item

code Description Price Each Amount

25 2120 Cervical foam collar 15.00 375.00 27 1600 Orthopedic cervical pillow 16.00 432.00 7 3015 Ankle support 30.00 210.00 3 2035 Wrist cock-up orthosis 32.00 96.00 3 2020 Elbow orthosis 32.00 96.00 4 2010 Shoulder orthosis 27.00 108.00 25 2400 Thermophore 14.00 350.00 20 1400 Bed board twin size 87.00 1,740.00 20 1450 Foam mattress 65.00 1,300.00 10 1300 Car seat orth. Adjustable 115.00 1,150.00 9 1100 Home cervical traction 337.00 3,033.00 5 2600 Adjustable aluminum cane 8.00 40.00

Total $8930.00

DOCUMENT 11: PT BILL

ROCK CITY REHABILITATION, PC 900 First Avenue Tel 555-555-6789 Rock City, IA 50700 Fax 555-555-6790 Ellen Adams License #x-xxxxxx Itemized Billing of Services Rendered To: Insurco, Insurco Plaza, Des Moines, IA 50500 Patient name: Sample, James DOA: 7/29/09 Patient address: Date Description Treatment

Code Charges

8/19/09 Physical therapy 97010-51 20.00 8/19/09 Physical therapy 97112 30.00 8/19/09 Physical therapy 97110-51 33.00 8/21/09 Physical therapy 97010-51 20.00 8/21/09 Physical therapy 97112 30.00 8/21/09 Physical therapy 97110-51 33.00 8/24/09 Physical therapy 97010-51 20.00 8/24/09 Physical therapy 97112 30.00 8/24/09 Physical therapy 97110-51 33.00 8/26/09 Physical therapy 97010-51 20.00 8/26/09 Physical therapy 97112 30.00 8/26/09 Physical therapy 97110-51 33.00 8/28/09 Physical therapy 97010-51 20.00 8/28/09 Physical therapy 97112 30.00 8/28/09 Physical therapy 97110-51 33.00 8/31/09 Physical therapy 97010-51 20.00 8/31/09 Physical therapy 97112 30.00 8/31/09 Physical therapy 97110-51 33.00 Total charges to date: 528.00

DOCUMENT 12: PT WORKSHEET

ROCK CITY REHABILITATION, PC 900 First Avenue Tel 555-555-6789 Rock City, IA 50700 Fax 555-555-6790 Ellen Adams License #x-xxxxxx Patient name: Sample, James DOA: 7/29/09 Modalities Index HP Hot pack

CP Cold pack

ES Electrical stimulation

TE Therapeutic exercises

TM Therapeutic massage

PB Paraffin bath

US Ultrasound

NE Neuromuscular Edn

August, 2009 Date Signature HP CP US TE TM ES PB NE8/03/09 8/04/09 8/05/09 8/06/09 8/07/09 8/10/09 8/11/09 8/12/09 8/13/09 8/14/09 8/17/09 8/18/09 8/19/09 x x x 8/20/09 8/21/09 x x x 8/24/09 x x x 8/25/09 8/26/09 x x x 8/27/09 8/28/09 x x x 8/31/09 x x x

DOCUMENT 13: CLAIMANT STATEMENT

Insurco Claims Department Des Moines, IA 50300

Recorded Statement with James Sample, 8/15/09 3:15 pm

The insured, James Sample, was driving to work and struck in the

passenger side (front quarter) while making a left turn. This occurred

at about 8:30 a.m. on July 28.The insured says that the accident was

his fault, but that the other driver was not injured and that the

damage to vehicles was minimal. No EMS was called, both vehicles were

drivable. Insured says he was cited for failure to yield right of way.

Advised insured that appraiser would contact him to examine vehicle.

While sleeping the night after the accident, the claimant began to

feel pain in his back and discomfort in his right knee, which had

struck the dashboard during the accident. He visited a clinic several

days later, on 8/3, for an examination. After meeting with the clinic’s manager, the claimant was seen by a doctor whose name he could not

remember. The doctor ordered an MRI and an x-ray of the claimant’s

right knee. Doctor recommended the claimant visit the clinic’s physical therapist.

The same day, the claimant visited the clinic’s physical therapist, who provided lower back electric stimulation for approximately 30

minutes. Before leaving the clinic, the claimant said he received a

car seat cushion from the clinic manager. The claimant does not

recollect receiving further treatment at the clinic, additional DME,

or additional physical therapy on other dates.

(NOTE 8/17. The damage to the claimant’s vehicle was 1 on a scale of 1 to 7; minimal damage from a low speed, low impact

collision, according to the police report.)