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HomeMy WebLinkAboutMINUTES - 04251995 - 1.25 �. VLAjM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA ' April 25, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unknown Section 913 and 915.4. Please note all "Warnings". CLAIMANT: American Seating Company, Inc. 'IM �; .ATTORNEY: _ MAR 2 7 T'95 Michael H. Porrazzo Date received COUNTYCOUNSEL ADDRESS: 96 N. Third St. , #550 BY DELIVERY TO CLERK ON Marrrh 91L 19,95 MARTINEZCALIF. San Jose, CA 95112 BY MAIL POSTMARKED: March 23, 1995 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, ppHH gg DATED: March 27, 1995 BY 1 DeputyLOR, Clerk It 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( u#)0*'This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: J 0�7 Cfs BY: Deputy County Counsel 311. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD ORDER: By unanimous vote of the Superviscrs present (v/) This Claim is rejected in full. ( ) Other: I certify that this is a -true and correct copy of the Board's Order entered in its minutes for this date. Dated: l QS I4I9.S PHIL BATCHELOR, Clerk, By JJ,LD,,4 C.�11J0�� Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. 1'ou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult Bn attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the Jnited States, over age 18; and that today 1 deposited in the United States Postal Service in Martinez, :alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. )ated: Qm 711,395 BY: PHIL BATCHELOR by Deputy Clerk �C: County Counsel County Administrator Claim'to ' BOARD OF SUPERVISORS OF CONTRA COSTA C0UIT7Y INST UCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury ..o person or to per- sonal property or growing crops and which accrue on or before December 31, 1967, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and Mich accrue an or after January 1, 1966, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code 4911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. effs • aa • • e • ee • f • • • aeeefeef • a • eseeeees • ee • fe RE: Claim By ) Reserved for Clerk's filing stamp American Seating Company . Inc. ) -- -� --�- RECEIVES Against the County of Contra Costa ) =2,4 or A.C. Transit District) CLERK BOARD ,E,wO � Fill n name ) c0�c ry c®s1A co. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ indemnity and and in support of this claim represents as follows: contribution 1. When did the damage or injury occur? (Give exact date and hour) October 15, 1993 , Claimaltwas served with Complaint of 10/17/94 . 2. Where did the damage or injury occur? (Include city and county) Contra Costa County 3. How did the damage or injury occur? (Give full details; use extra paper if required) Presently unknown. 4. What particular act oromission on the part of county cr district officers, servants or employees caused the injury or damage? Claimant is making a claim for equitable indemnity for the amount of any judgment returned on the complaint in Contra Costa County Superior Court Action No. C94-04396 , and proportioned to the, amount of judgment caused by the fault of A.C. Transit District . (Over) 5. 'What are the names of county or district officers, servants or employees causing r the damage or injury? Unknown. 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. See response to No. 4 on previous page. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) See response to No. 4 on previous page. B. Names and addresses of Witnesses, doctors and hospitals. Unknown. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT N/A Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SE0 NOTICES TO: (Attorney) or by somepensap on his behalf." Name and Address of Attorney Michael H. Porrazzo Z2�9 THE PORRAZZO LAW FIRM s gnature 96 N. Third Street , #550 n beha f of American Seats Co. San Jose, CA 95112 Address ?el2pnvi �i�. (408) 971-0900 Aelephone No. # ! # ! ! # # 9 IF # ! # ! ! ! # ! ! ! ! NOTICE Section 72 of the Penal Code provides: *Beery person who, With intent to defraud, presents for allowance or for Payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any falx or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($19000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. i 1 JOHNSON V. GILLIG CORPROATION, et al. CASE NUMBER: Contra Costa County Superior Court No. C94-04396 2 3 PROOF OF SERVICE 4 I the undersigned, say: 5 That I am now and at all times herein mentioned a citizen of the United States, over the age of 18 years, a 6 resident of Santa Clara County, California, and not a party to the within action or cause; that my business address is 96 North 7 Third Street, Suite 550, San Jose, California 95112 ; that I served a copy of the attached: 8 - Claim Against Contra Costa County/A.C.Transit - 9 in the following manner: 10 I sent a true copy of said document(s) as follows: 11 R.J. Engel, Esq. Attorney for Henry Johnson 12 Mark C. Peters, Esq. LAW OFFICE OF R. JAY ENGEL 13 44 Montgomery Street, Suite 2000 San Francisco, CA 94104 14 Steven R. Enochian, Esq. Attorneys for GILLIG CORPORATION 15 MOSS & ENOCHIAN P.0 Drawer 994608 16 Redding, CA 96099-4608 17 I am readily familiar with my firm's practice for collection and processing of correspondence for mailing with the 18 United States Postal Service, to-wit, that correspondence will be deposited with the United States Postal Service this same day 19 in the ordinary course of business'. " I sealed said envelope and placed it for collection and mailing on March 23, 1995, 20 following ordinary business practices. 21 I declare under penalty of perjury that the foregoing is true and correct. 22 Executed on March 23 , 1995 a San Jose, lifornia. 23 24 e 'thann Peevw6liT 25 f 26 27 28 1 4 " r r r ♦ .e I ��r�czxo yaw _941:1M 96 North Third Street Suite 550 Facsimile San Jose,California 95112 Phone (408)971-6810 (408)971-0900 TRANSMITTAL MEMORANDUM RECEVED MA ' - l TO: Contra Costa County 2 4 Board of Supervisors 651 Pine Street, Room 106 CLERK S09,Rl3® S�ibrc;s'viSORs Martinez, CA 94553-1293 L CONTRA COC ACO, _ DATE: March 23, 1995 RE: Claim Against Contra Costa County/A.C.Transit Claimant: American Seating Company ----------------------------------------------------------------- XX Please file enclosures. XX Return endorsed filed copies to us. Issue original and deliver to us summons writ subpoena Present order to for signature and return to US. Record Set for hearing on in department Certify copies. Check(s) enclosed for $ XXXXX Stamped, self-addressed envelope enclosed. Enclosures: Claim Against Contra Costa County e thann Pee -.uz Secretary for Mic el H. Porrazzo ! \ } \ } \ 6 . `CO Ric / q # U \0 3 C> k k .12 § � U . 0 U w d . � m . Q � @ . w . � $ . ! $ � � • � V)2/ � ) 0d0 % 2 . 0) ( � � . 2. CLAJ.M *- ► . a BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 25, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements., ) NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government. Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $250,000.00 + Section 913 and 915.4. Please note "Warnings" CLAIMANT: Patricia Allen Burgie, aka Patricia Allen ATTORNEY: Brian P. Evans, Esq. DCOUNTY COUNSEL Date received MARTINEZCALIF. ADDRESS: 2121 N. California Blvd., #1010 BY DELIVERY TO CLERK ON March 2.4-, 1995 Walnut Creek, CA 94596 BY MAIL POSTMARKED: March 230 1995 1. FROM: Clerk of the Board of Supervisors TO: County Counsel " Attached is a copy of the above-noted claim, p gg DATED: March 27, 1995 B�1L OeputyLOR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ) This claim complies substantially with Sections 910 and 910.2. (moi This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send.. warning of claimant's right to apply for leave to present a late claim (Section 911.3). { ) Other: r Dated: ����� " g BY: /�•�..� Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD ORDER: By unanimous vote of the Supervisors present (✓ ) This Claim is rejected in full. { ) Other: I certify that this is a -true and correct copy of the Board's Order entered in its minutes for this date. i Dated: n -- Q , Q , 1q4 5 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov, code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the Jnited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, :alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. )ated: ;L77 19 CUT BY: PHIL BATCHELOR byNJ eputy Clerk :L: County Counsel County Administrator r OFFICE OF COUNTY COUNSEL DEPUTIES: CONTRA COSTA COUNTY PHILLIP S. ALTHOFF •+`- SHARON L. ANDERSON f BRANDON D. BAUM COUNTY ADMINISTRATION BUILDING ANDREA W. CASSIDY VICKIE L. DAWES P.O. BOX 69 MARKE S. ESTIS VICTOR J.WESTMAN MARTINEZ, CALIFORNIA MICHAEL D. FARR COUNTY COUNSEL 94553-0116 LILLIAN T. FUJII DENNIS C. GRAVES SILVANO B.MARCHESI TELEPHONE (510) 646-2041 GREGORY C. HARVEY ARTHUR W.WALENTA,JR. FAX (510) 646-1078 KEVIN T. KERR ASSISTANTS EDWARD V. LANE, JR. MARY ANN M. MASON PAUL R. MUNIZ March 27 , 1995 VALERIE J. RANCHE DAVID F. SCHMIDT DIANA J. SILVER VICTORIA T. WILLIAMS NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Patricia Allen Burgie C/O Brian P. Evans, Esq. 2121 N. California Blvd. , Ste 1010 Walnut Creek, CA 94596 RE: CLAIM OF: Patricia Allen Burgie a.k.a. Patricia Allen Please Take Notice as Follows : The claim you presented against the County of Contra Costa or District governed by the Board of Supervisors fails to comply substantially with the requirements of California Government Code Section 910 and 910 . 2 , or is otherwise insufficient for the reasons checked below: [] 1 . The claim fails to state the name and post office address of the claimant. [] 2 . The claim fails to state the post office address to which the person presenting the claim desires notices to be sent. [x] 3 . The claim fails to state the date, place or other circumstances of the occurrence or transaction which gave rise to the claim asserted. [] 4 . The claim fails to state the name (s) of the public employee (s) causing the injury, damage, or loss, if known. [] 5 . The claim fails to state whether the amount claimed exceeds ten thousand dollars ($10, 000) . If the claim totals less than ten thousand dollars ($10, 000) , the claim fails to state the amount claimed as of the date of presentation, the estimated amount of any prospective injury, damage or loss so far as known, or the basis of computation of the amount claimed. If the amount claimed exceeds ten thousand dollars ($10, 000) , the claim fails to state whether jurisdiction over the claim would rest in municipal or superior court. [] 6 . The claim is not signed by the claimant or by some person on is behalf . [x] 7 . Other: Please identify the date upon which the claimant alleges she was sexually assaulted. VICTOR J. WESTMAN, County Counsel By. Deputy County Counsel CERTIFICATE OF SERVICE BY MAIL (C.C.P. §§ 1012, 1013a, 2015.5; Evidence Code §§ 641, 664) I declare that my business address is the County Counsel's office of Contra Costa County, 651 Pine Street, Martinez, California 94553; I am a citizen of the United States, over 18 years of age, employed in Contra Costa County, and not a party to this action. I served a true copy of this Notice of Insufficiency and/or Non-acceptance of Claim by placing it in an envelope addressed as shown above, sealed and postage fully prepaid thereon, and thereafter was, deposited this day in the U.S. Mail at Martinez, California. I certify under penalty of perjury that the foregoing is true and correct. Dated: March 27, 1995 at Martinez, California. L cc: Clerk of the Board of Supervisors (original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOVT. CODE §§ 910, 910.2, 920.4, 910.8) Claim to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code § 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. ?f the claim is against ,:ore than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * RE: Claim By ) Reserved for Clerk's filing stamp Patricia Allen Burgie, aka ) REGI\JED Patricia Allen ) Against the County of Contra Costa ) MAR 2 41995 or ) CONI'i1UNITY CARE LICENSING ) CLERK BOARD OF SURLRVISORS BAY AREA District ) CONS i'A COSTA CO. .-.- _- (Fill in name) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $excess $250,000 and in support of this claim represents as follows: -------------------------------------------------------------------------------------------------------------- 1. When did the damage or injury occur? (Give exact date and hour) In December, 1994 plaintiff discovered she was HIV positive due to her being raped at a County care facility. --------------------------------------------------------------------------------------------------------------- 2. Where did the damage or injury occur? (Include city and county) 2181 Broadmore, San Pablo, California. ----------------------------------------------—-------------------------------------------------------------- 3. How did the damage or injury occur? (Give full details; use extra paper if required) Claimant was raped by a manager/operator of the Community Care Facility, who at the time was HIV positive and has since died of AIDS. Claimant is now HIV positive. --------------------------------------------------------------------------------------------------------------- 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? Claimant's injury was the result of inadequate and negligent training, supervision, licensing, and control of the patients and (over) operators of the Community Care Facility program, leading to the rape of plaintiff while she was under the care of said program. 5. What are the names of county or district officers, servants or employees causing the damage or injury? Mrs. Luther Wilson, Ray Wilson, others unknown at present time. -------------------------------------------------------------------—-------------------------—------------ 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) Severe emotional distress and physical injuries as a result of acquiring the HIV virus. ------------------------------------------------------------------------------------------------------------- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Medical treatment - excess $500,000; emotional distress - excess $2,500,000. --------------------------------------------------------------------------------------------------------------- 8. Names and addresses of witnesses, doctors and hospitals. Mrs. Luther Wilson, Ray Wilson, Patrcia Allen Burgie. --------------------------------------------------------------------------------------------------------------- 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Claimant has no expenditures to date. These expenditures will primarily occur in the future. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf. Name and Address of Attorney Brian P. Evans, Esq. McCabe, Schwartz, Evans, Levy & Dawe (Claimant's Ste) Brian P. Evans 2121 N. California Blvd. , 41010 0-+JT-0,M&J Walnut Creek, CA 94596 (Address) Telephone No. (510) 934-6082 Telephone No. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents or allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. MCCABE, SCHWARTZ, EVANS, LEVY & DAWE PROFESSIONAL LAW CORPORATION ANTHONY CARY TRACY D. ALEXANDER CALIFORNIA PLAZA OF COUNSEL STEVEN R. CHARNOI DEAN A. CHRISTOPHERSON• 2121 NORTH CALIFORNIA BOULEVARD, SUITE 1010 JAMES N. D AW E WALNUT CREEK,CALIFORNIA 94596 DAVID J. LEVY OF COUNSEL BRIAN P. EVANS TELEPHONE (510) 934-6002 BEVERLY J. LAVIN KENNETH H. LAVIN FACSIMILE 15101 934-1507 MICHAEL P. MCCABE MARCHMONT J. SCHWARTZ OF COUNSEL ARLENE SEGAL LEO J.O'BRIAN 'ALSO ADMITTED IN WASHINGTON STATE March 23, 1995 OF COUNSEL 'ALSO ADMITTED IN CONNECTICUT AND NEW YORK , R E C E�V�E D7 TO: Clerk of the Board of Supervisors LAR ^ Room 106, County Administration Building 4 '" II 651 Pine Street _ Martinez, CA 94553 I CORK 3C'`' D FROM: Tracy D. Alexander, Esq. SUBJECT: Patricia Allen Burgie Our File No. : 801-373 ENCLOSURES: GOVERNMENT CLAIM These are furnished for the purpose designated below: ( ) Your signing and returning the enclosures in the enclosed envelope herewith. ( ) Issuance of process. (X) Filing and returning of the endorsed-filed copies to the undersigned in the envelope provided herewith. ( ) Securing signature of the court, filing of the original, and returning endorsed-filed copies to the undersigned in the envelope provided herewith. ( ) Recording and returning to the undersigned. ( ) For your records and information. ( ) Also enclosed is my check in the amount of $ to cover costs/fees. Kindly return your receipt. ( ) Other: ., C,,_ E, Joyc . Aviles, Secretary l i � NW O � N 4 of - m 14 y Aj N �1 r En •�+ V� 44 0 (�l oAj � V '14U 1 ( 01— 141 W a N � a R4J H u °7' o ri VA .1 o W -t 'n u 4 v yy^^4 u Uj A Y a o m N tJlG�y; N tJF t CLAI114 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 25, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $55,000.00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: Loreen Carabello ATTORNEY: Stephen H. Cornet MAR 2 3 1995 A Professional Corporation Date received COUNTY COUNSEL. ADDRESS: 3521 Grand Avenue BY DELIVERY TO CLERK ON March 22, 1995 MART1NEZr4t,r. Oakland, cA 94610 BY MAIL POSTMARKED: Hand Tial iiTAr®d I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ��IL gATCHELOR, Clerk I DATED: March 23, 1995 : Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors { ✓}r This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( wl" Other: (JG ars. Aok -11%It,C*ACgJ Qw;Atui% . P� t'eo.s� �►,nrnt�v. 14•.�e.. �al. 141 CAS i3s dknd Y-mog c v. 006, g Hari a t 1.61341 tAq 519 �OgAt T/'rxel� {wr�►w.r . Dated: BYDeputy County Counsel Ill. FROM: Clerk of the Board 70: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Superviscrs present (vel) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: CkQ,,,�Q x5. 1900 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that 1 am now, and at all times herein mentioned, have been a citizen of the United States, over age 16; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the Claimant as shown above. .0Dated: T�C1 9�c BY: PHIL BATCHELOR beputy Clerk CC: County Counsel County Administrator STEPHEn H. CORnET RECEIVE'-y;".'' STEPHEN H.CORNET A PROFESSIONAL CORPORATION LYNNE H.OGAWA 3521 GRAND AVENUE AAflp r' In�� BRENDA C. MORRISSEY OAKLAnD. CALIfORnIA 94610.2011 ,. I��h9faa� [ 9 TELEPHONE:(510)465-6264 p -�.N� FACSIMILE:(510)452-9125 CLERK BOARD 01:8UPERVISORS CO!\1YR'a..CC�S�R CO. March 22 , 1994 Via Hand Delivery Clerk, Board of Supervisors 651 Pine Street, Room 106 Martinez, CA 94553 Via Hand Delivery Attention: Ms. Barbara Young Casualty Claims Coordinator Finance Department CITY OF CONCORD 1950 Parkside Dr. Concord, CA 94519 RE: My Client: Loreen Carabello Date of Accident: September 23, 1994 Dear Clerk of the Board of Supervisors and Ms. Young: Enclosed herewith please find an original and two copies of the Claim for Personal Injuries, in reference to the above. Please acknowledge receipt on one of the enclosed copies, and return in the envelope provided. Thank you very much for your courtesies and cooperation. Very truly yours,. STEPHEN H. CORNET A Professional Corporation LYNN H. OGAWA LHO: sp Encl. Claim of Loreen Carabello. CLAIM FOR PERSONAL INJURIES VS. Concord Pavilion, City of Concord, County of Contra Costa To Concord Pavilion, City of Concord, County of Contra Costa: You are hereby notified that Loreen Carabello, whose address is 1542 Berkeley Way, Berkeley, California, claims damages from the Concord Pavilion, City of Concord, County of Contra Costa in the amount, computed as of the date of presentation of this claim, of $45, 000. Should this matter proceed to litigation, the claim would be in the jurisdiction of Superior Court. This claim is based on personal injuries sustained by claimant on or about September 23 , 1994 , on the premises of the Concord Pavilion under the following circumstances: Claimant was leaving the Pavilion premises after a performance, and tripped and fell on the stairs, sustaining injury to her legs. The stairway constituted a dangerous condition and the Pavilion created the condition, and had actual or constructive notice of the danger a sufficient time prior to the injury to have taken protective measures. In addition, there was no warning of the danger. The names of the public employee(s) causing claimant's injuries under the described circumstances is/are unknown at the present time. The injuries sustained by claimant, as far as known, as of the date of the presentation of this claim, consists of severe ankle sprain, and injury to ligaments. Claim of Loreen Carabello, page 2 The amount claimed, as of the date of the presentation of this claim, is computed as follows: Medical and hospital care $ 4, 000 (estimated) Wage Loss $ 7, 000 (estimated) General damages $ 34, 000 Total damages incurred to date $ 55, 000 All notices or other communications with regard to this claim should be sent to claimant c/o Stephen H. Cornet, A Professional Corporation, 3521 Grand Avenue, Oakland, CA (510) 465-6264 . Dated: 3-21-95 STEPHEN H. CORNET A Prof sional C Irporation By: LYN H. O tAWA, k� orney for Cl i ant Loreen a abello CLAIM a-S 4. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 25, 1995 � Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $200,000.00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: Jamie Eberling ATTORNEY: Robert Musante MAR 2 7 e Date received COUNTY COUNSEL BY DELIVERY TO CLERK ON Marr' ')L ADDRESS: 1990 N. California Blvd. , #830 BY BA��iTEZCALIF..,— ,, Walnut Creek, .CA 94596 BY MAIL POSTMARKED: Nanrl rlivexed I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above noted claim. gg r DATED: March 27. 1995 ��ll DeputyLOR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( 6*100 This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: _ ''7 BY: Deputy County Counsel Ill. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: Sy unanimous vote of the Supervisors present ( ✓I This Claim is rejected in full. ( ) Other: I certify that this is a -true and correct copy of the Board's Order entered in its minutes for this date. i Dated: a5,1995 PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov, code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. AFFIDAVIT OF MAILING I derlare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the inited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, :alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to Che claimant as shown above. )aced: a': la 9 S BY: PHIL BATCHELOR by Deputy Clerk :C: County Counsel County Administrator Claim 1o: BOARD OF SUPERVISORS OF CONTRA COSTA OOONTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury --o person or to per- sonal property or growing crops and which accrue on or before December 31, 19870 must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code 5911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553• C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code See. 72 at the end of this orm. face • aaaaaaaaaaaafaaaaaaaaaaaaaaffaasaaaaaa RE: Claim By ) Reserved for Clerk's filing stamp JAMIE EBERLING ) RECEVED Against the County of Contra Costa ) itAR 2 41C_-5) And tt Central Contra Costa County Transit Authority District) CLERK BOAR®OF SUPERVISORS Fill in name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ 2 0 o . o o o_ n o and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 10/21/94 at approximately 12: 35 p.m. 2. Where did the damage or injury occur? (Include city and county) Moraga Way (near School St. ) , Moraga, Contra Costa County 3. How did the damage or injury occur? (Give full details; 'use extra paper if required) See attachment. 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? See attachment. (over) 5. What are the names of coy or district officers, servao or employees causing the damage or injury? Driver of County Connection bus: Glen Clark (#425) (Identification per representation by Perry Wadler of John Glenn Adjusters) 6. What damage or injuries do you claim resulted? (Give full. extent of injuries or damages claimed. Attach two estimates for.b4a damage. (Attached) Severe laceration to inside of right thigh Fractured left wrist requiring multiple pins; Totalled bicycle, 7. How was the amount-claimed above computed? (Include the estimated amount of any prospective injury or damage.) Good faith estimate of the settlement value of the physical injuries (pending additional medical information) and est. medical expenses and past/future wage loss, plus property damage. S. Names and addresses of Witnesses, doctors and hospitals. Dr'. Paul Freitas, John Muir Medical Center, 1601 Ygnacio Valley Rd, Walnut Creek, CA Dr. Dennis Gustafson, ' 2123 Ygnacio Valley Rd, Walnut Creek, CA Dr. Thomas E. Barber, 3010 Colby, Berkeley, CA ----fir- vetrr—p�fti!elrGA ----�_ 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT 10/21/94-present Medical Billings Approx. $6 , 500. 00 (Incomplete) 10/21/94 Bicycle loss_ ;:; Approx. $2 , 500. 00 10/21--41/7/-94, .., Wage loss ` Approx. $4, 200 . 00 • • eeerae • eef • a • • • �ta * aeae • e • ea • e • si • f • efeea Gov. Code Sec. 910.2, provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney �A 5 Robert Musante Cla t'1VSSignature) 1990 N. California Blvd. , #830 Walnut Creek, CA 94596 2096 Ascot Dr. (Address) Moraga, CA 94556 Telephone No. (510) 946-9177 i Telephone No. (510) 631-9923 as �rsf * rt ee • af • • s see NOTICE Section 72 of the Penal Code provides: "Every person who,. With intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or by both such imprisonment and fine. MODEL FRAME SIZE ' ;FRAME TYPE COLOR PROMISED 431.7 � �.,,� �• TIME El A.M. DAY Alm 0 P.M. OWNER'S NAME MAKE / - BUYER'S CHECKLIST 'Tx?_ it, As members of the cycling industry,our staff and management ADDRESS WHEEL SiZE'.- I a' would like to thank you for purchasing your bicycle from us. Jv As in many recreational activities,accidents can and do occa- CITY STATE ZIP sionally occur. It is for this reason,that we specifically bring J the following points to your attention. We ask that you read each point carefully and ask questions of our staff if you do not DAY PHONE j I. , EVENING PHONEr••-' DATE ��<..� ,.;.-. clearly understand any particular point addressed. M� -• 1. I have received the owner's manual and agree to read it, especially the safety warnings, before using the bicycle. I DEALER'S NAME,ADDRESS,CITY,STATE and ZIP understand that all riders(adults and children)should wear SHARP R, ICYCLE a bicycle helmet whenever riding the bicycle. 2800 Hilltop MAII Road Please initial Richmond, CA 94806 2. 1 understand that this bicycle is subject to all the laws of the road, and that many states and localities have additional Phone: (5,10) 227-8004 laws which specifically apply to bicycles. CASH ` JCHAR.GE CHECK SALESPERSON' Please initial, 3. 1 have been instructed in the use of brakes and gear ASSEMBLE oeY LOCATION shifting mechanisms, and in the use of all quick release i �� 1( (40, 2 mechanisms (wheels, seatpost, and brakes) as well as any wheel retention devices on this bicycle. SEMAL rvo.', PRICE LABOR Please initial I s� 4. 1 have been advised of the proper size bicycle for me, but ACCESSORIES t . the final selection of this bicycle has been my Own ? decision. Please initial i 5. I understand that regular maintenance is required to Keep 1 this bicycle operating properly and that failure to maintain may void the manufacturer's warranty and may make the e � ► . .'j r ,,1..-s71r7 �� bicycle unsafe. Regular maintenance includes frequent inspection of all quick release mechanisms and wheel JK ` h retention devices. I also understand that maintaining appropriate tire pressure at all times is essential for the ,/ safe use of this bicycle.The recommended tire pressure is r✓ - �{✓ -;i - marked on the tire.Please initial �, I 77- -j,.�. -- K ., m -, - By initialing each item on the above checklist, I have a, Y indicated m complete understanding of these points, and y p 9 DELIVERY CHECKLIST )TEMS v� I acknowledge my responsibilities regarding the contents. _ ��� I� I also agree to explain the points on this checklist to ❑ GEARS CHECKED AND,; BRAKES CHECKED LABOR fir- anyone besides myself who will be using the bicycle now EASY GEAR SELECTED and in the future. ❑ WHEELS RELEASED AND RETIGHTENED $ALES TAX' ) ❑ TIRE PRESSURE CHECKED _ / .�,.� Buyer's Signature Date r— r r"r—, . 7 ❑ HANDLEBARS AND TOTAL 1. tJ {� SEAT TIGHT �, j✓:� X _ CHECKED BY �DEPOSIT'4"._' Buyer's Name(Print) If Buyer is under 18 years of age,the buyer's guardian must sign. BALANCE' SEE BACK FOR IMPORTANT INFORMATION CUSTOMER COPY JAMIE E$ERLING ATTACHMENT TO CLAIM FOR LOSSES 10/21/94 #3 . & #4 . How did the damage or injury occur? What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? According to witnesses identified in the enclosed police report : Just before the accident, claimant was riding her bicycle, with traffic, eastbound on Moraga Way. In the lane to her immediate left, moving alongside her, was a Central Contra Costa county Transit Authority (County Connection) bus . Approaching the bus from the opposite direction was a pick-up truck which was waiting for the bus to pass it in order for the pick-up truck to make a left turn into a driveway on Moraga Way. The driver of the County Connection bus motioned to the truck driver that it was safe for the latter to proceed with the left turn in front of the bus . The driver of the bus also failed to warn claimant about, and otherwise protect her from, the dangerous situation presented by a pick-up truck turning left in front of the bus . These actions, and inactions, by the County Connection driver were negligent . It was not safe for the truck driver to turn left in front of the bus at that time because the actions of the County Connection driver negligently brought the truck driver into the path of claimant . The bus driver knew or should have known that this accident was likely. As a result of the bus driver ' s negligence the accident did occur, i .e . the pick-up truck struck claimant on her bicycle, as more fully described in the attached police report . �. AW Ar A� C A� 0 Repair Estimate for Trek 5200 frame and fork 1399.99 fork bearings (headset) 54.99 handlebars 44.99 handlebar stem 29.99 handlebar tape 14.99 brake lever rubber grips 325.50 brake lever insignia(right) sis gear cables and housing left brake shift lever Ultegra 600 S.T.T. Shimano 600 crankset and chainrings 139.99 rear derailleur Shimano 600 59.99 seatpost 39.99 saddle 44.99 front wheel 89.99 front tire and tube 29.99 rear wheel (questionable) 140.00 $241.5.39 labor 125.00 tax 199.26 total $2739.65 (includes rear wheel) $2500.00(true rear wheel and fix shifter/brake instead of replacing) 2800 Hilltop Mall Road Richmond,CA 94806 415 222-8004 I I I . ; 1. ,,,., ,,,, . 0,.,! I it- 23 /94 09 : 04 HFS OFFENSE/111CIDENT REPORI 1 . 01 t A A t * t t e I t pvFIF lNJIJF7 COLLISION ( BILE VS TRUCK ) OFFEUSK MFF : M094141C RF l' QFC : H . MAES it (113 REPORT VA10 10 21 14 PISTRICT : 07 REFORTING AREA : Rs GRJV : SHIFT : A DOW : FRI OFFR : 014 ` * * VICTIM IULORMATIOM * * * * ' VICTIM : EVERLING ,JAMIE LVIIN RY9, A : W F 33 Poll : S. .1701 HOME ADD : 2096 ASUOT DR 1 CITY : HORAGA qr : � A WORK ADO : I CYCLOTRON Ell CITY : VERPELIFT fl : CA PHONE : lu ) 510 ,6309923 fW) S1014116 - 441 .1 FNT : 0000 EMPLOYER : tarts RvroPTEE I "VOPMAII010 REPORTEE : CO"SOLIDATRO FIRE PEPT . RYS A : von : ozoo 01, HOME APO : , I T7 - q I WORK ADV : Q11T .- qT : r "OHE : tll � 1w ) wl : 000o * * * * * 01'VENSE IPTnFMATInn * 1 * 11 L%Aflull : MORAGA WY FUSINISS NAME : QVII00L SI PAC : I-Nptiu STREET/ALLEY INVTSTICATOR ASSIGNED : M . MASS Wl: i,101.''IfTiAl I- I P ""MR RR i q 4QO 00 A 4 . lit occ"UPF"I 0 HA 1 F T I ME "CR CODE 1 : 33000 IASI KEnIIF EU 10 - 21 94 Q : It HOUR`, C COVE : THFORMATION ON&V PJACOVITUND 10 71 94 12 : 35 "Oup', STATUS : OPEN IUVESTIGATORS CASE PFIDRITY CS I: : 11 SOLVABILLIT FACTORt . 0000 MARVAUIVE RICTCLIST WAS RIDING If 8 ON MORAWA WAV IN THE BIKE LANE AT 20 "PH APPROAr"10; q1HOOL STFLEF . E R VKHILLE TRAFFIC WAS STOPPED A"P BACKED "F PFCAUNK OF A VITH L I cu r . THF L FG HT T"VMEH GREEN AMP A H% DRI VER FOR COUNTY COVIlunT I ON) WX I 1`10o HF1`01114 FROCIRKPING TO ALLOW A DRA'F'T' OP A OTILIFY TH"Ib TO TNVH ! AFT INTO A arfVKWAY . THk DRIVER OF THE TRUCR MADH THE TURN UNAWARE OF THM P40VI &T . THI: "RIVEP OF THE TRUCK PEAPP A SCREAM AMP AUPPPEP , H" r THE BlUtVISJ CONT ! "0171? ADD 0KIPED WITH THE RIGHU FRONT WHEEL OF THE Tll"vh . THE HTCYCLIST QH9TAIPFH A wQA( TUVFV RIGHT HAND AMP It" LAUKUATIOV ON HER imuER u) unr intun , I'l()VAIA Q ? -- 04 HRS1:' IP1.' II)FI! 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It- 7- it 1: r f. rvm Ir11n Piuir Medic:a r v ff r 0 ti r-,� to Itr , i if i it i- i P, a it 0 m p rl j r,a It:rr , tment. 1; 1 1:1.0 �v q v/i I-,It 1'. -1 F F t, It I T'.),"r I i it i7i r.,i I t ra- 1 0 4 AM t it p r q f a t pitien 1: rt it d a r r a n cr r I t It or, t e p I in,C., r c r 1)(1 1 1'o It t I %q:I� r,o it t,-I c! p I o 7, r ?it (7� S ilii I 1 1 1111 P., a c t T h p POI I F, V f= I: Tri J 11 F,d I, V J 1I. t i i,It i n t)l I? pi !I Z, i r) 1)ll -r 1 1)o In 1-.11. :, h.? 15 it d F, c I'! I-Il OF t It f., w r,q I r r, -1 i a Ef r r r I •,.I I I v?I r 1-1.1 r, I t 11 Ij t-hW r a :i el w i f3 c, , I!r o I e I i c.i i 1o11 o 1 3 0 p e 11 EI., j t 11 fi- 10 7 9i1 all 1)t a i# 11 t a. t e ill v I I C if c- I 1„tC: n w t h 1)p 'i ll i oil ,-lit 1,-,oll(, q on 1. -1115'2 a110IllIll It l .1 fill 9 4 14 : 48: 45 PRIREQUESTED BY TERMINAL MO .it History for: 94283383 DR: $M940247 ref: #F9430792 _ed 10/21/94 12 : 35: 19 BY CDL3 49993 ;patched 10/21/94 12 : 36: 11 BY CDP1 48429 ,nroute 10/21/94 12 : 36: 11 Onscene 10/21/94 12 : 37 : 27 Closed 10/21/94 13 : 29: 31 Initial Type: 11-79 Initial Alarm Level: Final Type: 11-79 (ACCIDENT - FIRE/EMS RESPONDING) Pri: 1 Dispo: AIC Alarm Police 9502 Fire MORA03 Local Govt 85MO Map Page: 073E6 Group: MO Beat: M2 WD: EB SD: CS Base-map: S112890 Loc: MORAGA WY/SCHOOL ST ,MOR Desc: AT INTERSECTION Src: 7 Cont: N Name: CONFIRE Addr: Phone: /1235 (49993 ) TEXT VEIL VS PED / FIRE ADV /1236 (48429 ) DISPER 16X32 #M009 MAES,MICIIAEL /1236 ASST 16W3 #M026 SLOAN,MICHAEL /1.237 ONSCNE 16X32 /1242 ONSCNE 16W3 /1246 ONSC4 16W3 /1246 6NSC4 16X32 /1252 (******) REMINQ 16X32 PERSON, 16X32, FINAU,SIAOSI„M„ 020561., , , , /1301 (48429 ) ASNCAS 16X32 $M9402476 /1301 $PREMPT 16W3 /1329 CLEAR 16X32 D/AIC /1329 CLOSE 16X32 D/AIC ALL MEASUI7EME S AllF AVI'11OXIMATE ANL)NOT TO SCALE UNLESS STATED rSCALE LF- END DoT Ta ScAtr_ O Fo(� LICE ,w n,c wrw you >LE ycLlpl.J 40 PoAawAY r-_oG�r- r rNE 14 V-1 MOR 1 6 g W A Y P�,— -- >, •1 - �- _ 1 / I$� C�_ _ ._-_---- 11-1- - ---- ----- -- UW EA StA ` / 1_N�' 1 PleT I TIZEE cttvp ♦ SNOutrvE2 21 ...__., U (r� FCNCtD Gt�Zt��.r.1 Ago It In 5ctlno 1. S'r-. nwwww w. i.o. www •. r.. � �wrr� �►,. MAEs crrr�,c,c, r;,l,, n ur�� n_Rs►arr o42 . . . . .. .—..._ TIME(2400) IICIC NUMBER OFFICER 10. NUMBER 1 9Y 07/6 9 .2 7 G EXT T OF INJURY ( "X" ONE INJURED WAS( "X" ONE ) .SVIGER AGE SEX PARTY SEAT IAf[TY IJ[CI[0 ONLY FATAL SEVERE OTHER VISIBLE COMPLAINT NLMBER POS. IOU1P. INJURY I'llURY INJURY OF PAIN DRIVER PASS. PEO, BICYCLIST OTHER ❑ 33 F ❑ ® El El 03 ❑ ❑ ❑ 1 W O _ NAME 10.0 B.1 ADDRESS /ElFP11U111 O (INJURED ONLY(TRANSPORTED BY: TAKEN IO; MoaA 'j A F%izE XV [I1 3SILI tt Mu I& MEA\C(-:iI L DESCnIBE INJURIES Ft? Ac'TU2G LC IA f� nl APP('tJXI L L� LAcE�.f1"� lar�! o N IJN EI' k(31 Vk . _ -s 1 VICTIM OF VIOLENT CRIME NOTIFIED ❑" Z M ❑ ❑ ❑ ❑ ❑ ID I ❑ I 3 Ir_ o NAME 1 D.O.B.I ADDRESS IF IEPIIONE M06F-s F Fle-VNuE 5T of Ie-L►ANYI C/ 4.u!; s-(L,9 -30eI (INJURED ONLY(TRANSPORTED BY: IAKEN TO: _DESCRIBE INJURIES VICnM OF VIOLEfIT CRIME NOTIFIED ❑� ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME 1 0 O B,1 ADDni SS IFL[PHONE (FIIJUR10 lHNl Y)TRIANSPOA 1111 BY: TAKEN IO: 'IESCEtl BE INJIInI(S -- — ^— "- — VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ _❑ /NAME 1 D O B 1 ADDn CSS I[I IPI MINE (INJUHED ONL Y(TRANSPORT EO BY: IAKIN TO: Df SC RISE INJURIES ElVICTIM OF VIOLENT CRIME HOTIFIED ❑l" ❑ U ❑ ❑ ❑ U ❑ 10 1 ❑ 1 ❑ NAME.0 OB 1ADDRESS TELEPHONE (INJURED ONLY(IAM45PORTED BY: TAKEN TO: DESCRIBE"JURIES ❑ VICTIM OF VIOLENT CRIME NOTIFIED ❑# ❑ ❑ IQ ❑ ❑ ❑ ❑ ❑ ❑ ❑ NAME 10 0 B.1 AOORI IS I I LF PHONE (INJURID ONLY(IRANSPORTID BY: IAKEN TO: D[SC RI l l INJLIRN I ❑ VICTIM OF VIOLENT CRN[NOTnEO PRf PARfR6 NAME I.D.NUMBER MO. DAY rFAn RFVIFWERS NAME MO DAY Y[A • Ac 9 /o i CNP 555-Page 3(Rev. 7-87)OPI 042 - LJ1 Ir E4 I IJINu • • pFT10N Of DAMAG ..TING POSITION QCCUPAND SAFETY EQUIPMENT MIC BICYCLE-HELMET EJECTED FROM VEH. 1•DRIVER A.NONE.IN VE!ICLE L-AIR BAG OEPI DYED 0-NOT EJECTED 2 TO 0•PASSENGERS B-UNKNOWN M.AIR BAG NOT DEPLOYED DRIVER I•FULLY EJECTED T.STA.WGN.REAR C-LAP BELT USED N.OT14ER V-NO 2•PARTIALLY EJECTED I-RTL OCC.IRK..OR VAN D.LAP BEL T NOT USED P.NOT RECTUIRED W•YES 3.UNKNOWN I.POSI"ON UNKNOWN E•SHOULDER HARNESS USED 1 23 0. OTHER F•8HOULDER HARNESS NOT USED C12LD.AESIIW1,1I PASSENGER 4 5 6 0•LAP I SHOULDER HARNESS USED O.IN VEHICLE USED X•NO H.LAP I SHOULDER HARNESS NOT USED R-IN VEHICLE NOT USED Y.YES 7 J-PASSIVE RESTRAINT USED S•IN VFHICI E USE UNKNOWN K-PASSIVE RESTRAINT NOT USED T•IN VEHICLE IMPROPER USE U.NONE IN VEHICLE ITEMS MARKED BELOW WHICH ARE FOLLOWED BY AN ASIEIIISK I')S14OULD BE EXPLAINED IN 111E NAIIIIAIIVE PRIMARY COLLISION FACTOR TRAFFIC CONTROL DEVICES TYPE OF VE1ICtE ' Z 3 MOVFMI-NT PHOCFDINU UST NUMBER I)OF PARTY AT FAULT 2 3 A VC SECTION VIOLATED: u_*fD[I A CONTROLS FUNCTIONING A PASSENGER CAR I SIA.WGN. COLLISION coo ND B CONTROLS NOT FUNC110FING' B PASSENGER CAR W I TRAILER A SLOPPED I B OTHER IMPROPER DRIVING• C CONTROLS OBSCURED C MOTORCYCLE I SCOOTER B PROCEEDING STRAIGHT D NO CONTROLS PRESENT I FACTOR' D PICKUP OR PANEL TRUCK C RAN OFF ROAD C OTHER THAN DRIVER* TYPE OF COLLISION E PICKUP/PANEL TRK.W I TLR. D MAKING RIGHT TURN D UNKNOWN A HEAD-ON F TRUCK OR TRUCK TRACTOR E MAKING LEFT TURN 0 E FELL ASLEEP* B SIDESWIPE G IRK.I TRK.TRACTOR W/1LR. F MAKING U TURN C REAR END H SCHOOL BUS G BACKING WEATHER MARK 1 10 2ITEMS D BROADSIDE 10114ER BUS H SLOWING I STOPPING A CLEAR E HIT OBJECT J EMERGENCY VEHICLE I PASSING OTHER VEHICLE B CLOUDY F OVERTURNED K HWY.CONS 1.EOUIPMENT J CHANGING LANES C RAINING G VEHICLE I PEDESTRIAN L BICYCLE K PARKING MANUEVER D SNOWING H OIHER•: M01141 R VFIOCLE L ENTERING TRAFFIC E FOG/VISIBILITY FT. MOTOR VEHICLE INVOLVED WITH N PEDESTRIAN M 0111FR UNSAFE TURNING FOIHER-: ANON-COLLISION OMOPFD _ _ NXItK:INI0OPPOSING IANE G WIND B PEDESTRIAN O PARKED LIGHTING C OTHER MOTOR VEHICLE — — — P MF RGING A OAYUG141 D MOTOR VELI.ON 0111ER ROADWAY OILIER ASSOCIATED FACTOR — Q TRAVELING WRONG WAY B DUSK-DAWN E PARKED MOTOR VEHICLE (MARK I TO Z IIEM.S) R OTHER:' C DARK•STREET LIGHTS F TRAIN AVC SECIIONVIOIATION: CITED D DARK-NO STREET LIG141S G BICYCLE Elvis — — ElNO E DARK• STREET LIGHTS NOT H ANIMAL: B VC SFC DON VIOLATION: CITED' FUNCTIONING' O o s ROADWAY SURFACESOBFIIEIY.DRUG ( FIXED OBJECT: CVC SIC11GN VIOIAtION: CITED EDPHYSICAL A DRY Elves (MARK 1 10 2IIFM5) B WET J OTHER OBJECT: _ EI A"AD NOI BEFN DRINKING C SNOWY.ICY D — D B 1100•UNDER INFLUENCE SLIPPERY(MUDDY.OILY.ETC.) E VISION OBSCUREMENT: F INATTENTION' — — C 1480•NOT UNDER INF LU.' ROADWAY CONDITIONS G STOP 6 GO TRAFFIC D 1100-IMPAIRMENT LINK' (MARK I TO 2ITEMS) PEOESIRIANS ACTION _ E UNDER DRUG INFI.U.' A NO PEDESTRIAN INVOLVED H ENIEHING/LEAVING RAMP — I PIIFVIOII$COLLISION F IMPAIRMENT•PHYSICAL' _ A HOLES,DEEP RUTS' CROSSIHIG IN CROSSWALK — — – `--AR— GIMPAIRMENI NOT KNOWN B LOOSE MATERIAL ON RDWV` B AT INTERSECTION J UNFAMILIAR ROAD — - I(DEFECTIVE VEK EFL F EQUIP.: cnFD H NOT APPLICABLE C OBSTRUCTION ON ROADWAY' C CROSSING IN CROSSWALK-NOT ❑res I SLEEPY I FATIGUED D CONSIRUCTION.REPAIR ZONE AT INTERSECTION SPECIAL INFORMATION E REDUCED ROADWAY WIDTH/ D CROSSING.NOT IN CROSSWALK L UNINVOLVED VEHICLE A HAZARDOUS MATERIAL F FLOODED• E IN ROAD-INCLUDES SHOULDER M OINER': G 011IER': F 1401 IN ROAD N NONE APPARENT H NO UNUSUAL CONDITIONS G APPROACH I LEAVING SCHOOL BUS O RUNAWAY VEHICLE oicwri I NAA 1w CIIP 555• Page 2 ( Rev 7 •87)OPI 042 At 4,r In .V.. I.a-. ..1 1 , • C.L PAGE OF NUMBER HIT A R CITY IAL d1 TRICT NIAIBER I/UURCO ifl0 , U A r4WAtNLiT E NUMBER HITS RUNCOUNTY REPORTING DISINCT BEAT KILLED ASSD. / 7 Lam• V ❑ CO TQ.A CL .., A -S COLUSION OCCURRED ON MO. DAY VEAR TIME(2400) NCK• OFFICIA I.D. MrL[POST INFORAIATONDAV OF WEtK TOW AWAY PHOTOGRAPHS BY: S M T W T(FDSEE--I M M A ES U ❑rtS {VINO 0 ❑AT IMIASICI10N WITH $1411 HWT IIFL OA: %O FiET/BBBBB %A 0► c 1A VC3 E E 1 ❑TES ®NO ❑NONE PARTY DRIVER S LiefN51 NUMSFA 1 BIATE CLASS SAFETY VIII VR. MAKE IMOOEL/COLOR UCENS1 NUMBER STATE IOIIIP, AF75c14 F-Q 'y cv`,7oM 3o 'DRIVFA NAME(nRST,MIDDLE,LAST) ' • ' ' ' Pt Q 5M E = A LA wµ 1TE. 0T, , -TY CA PIDES STRIII ADDRESS OWNER S NAME ❑ SAME AS DRIVER TRIAN ❑ U• P,U - MO cov cLv fS HC) A PARx[O CITY I STATE I SIP OWNER S AODAt SS11SAME AS DRIVER VI"ICI! ❑ Mo,a A 61 A G A 9 t4 sc. 1600 s=, ({" to0-EwS pa_ p_A C SICU• S[M HAIN EYES HEIGHT WEIGHT MRTHDATE RACI DISPOSITION or VEHICLE ON ORDERS or: ❑O►AClR DRIVER ❑OTHER C.LIST MO, 1 DAY . VEAR ❑ g�k �an� s-11 zs0 a z 11G/ 10 j),7 v E�� 11 w A Y OTHER HOMO NONE BUSINESS PHONE I ❑ ` �j PRIOR ME CHAHK AL DEFICIT: NONE•►IAREM REFER TO NARRATIVE ❑ (Si v) 37b- 8 9 b�j (51 V )3/b Z Z(>U GNP USE OIILT OISCRIBE VEIRCLE DAMAGE SNAOE 1N DAMAGED ARIA INSURANCE CARRII Rs 10�) Z-2/ '73 POLICY NUMBER ❑VE HICLE TYPB 0(INK INOR Ej ❑ EIMMMAJOR OIALM 1G SPEED 'DIET OF HIGHWAY PCf KC ❑ 'It AVEIlonSTA(ITOR PUC35 SoWvi2AC 14 aII(C CNP ❑ PARTY ORIVIR S LICENSE NUMBER STAT! CLASS SAIFIY VEH.VA. MAKE I MODEL I COLOR UCEN11 NUMBEN 814111E ov1/. 2 C4 c wV_ 5200 nRIV[R T 1 /Vi� k S • NAME(NRST,MIDDLE.IAST 21S. TR� = ❑_ SAM=C Lam( WW �jTe. 11S PEOES STREET ADDRESS OWNER S NAME ❑$AME AS DRIVER TRIAN __❑ ?9r 7- 2 P ARXE� CITY I STATE I TOP OWN[ S An ORE SS El SAM[AS ORIVIR VIIICl I ❑ MOCA6 A GA 9 y s( MCI. SEE HAIR EVES NtlOHi WEIGHT SIFITDAII RACE DISIOSRON or VEIRCLI ON ORDERS 0/: ®Of/ICER ❑DRIVER ❑OTHER C0111MO. I DAY YEAR OINEA I-OM[PHONE SUSINE SS PHONE PRIOR MECHANICAL DEFECTS: NONE APPARENT Q REFER TO HARRAnV! ❑ ❑ (510) 631 - 9923 (5.10) V86- yy33 1'NF 11':E ONLT DESCRIBI V[IDf EE DAMAGE SHAGS IN DAMAGIO MIA INSUNCE CARRIER POUCV NUMBER l'EI,C LE TT►I RA f '1 ❑IMOI ❑NONE ❑MINOR 1 MOO. ❑MAJOR ❑TOIAL DIR OF ON EIRE FT OR HIGHWAY SI[ED PCf ICC c] ` TRAVEL LIMIT PUC ❑ e4,6 35 CHP ❑ PARTY DRIVER S LICENSE NUM$fN STAT( CLAS$ r.A. IY VLH,YR. M­1 MOOII/COLOR LIC,NSt NUM$tR SIATI Coup. 3 nrIIVl1, HAAIE(FIRST.WOOL[,LAS t) __❑ IInIL STREIT ADONIS$ OWN(R B NAME VR:R:11AN El1►M/AS DRIV,R ❑_ _ PARxEO C61 I STAY[I VP OWN(R1 AnI1RtSS ❑IAMF AS DRIVER VI,,CIE ❑ __ -DET SI. NAIET ITfE II[IG111 WI10111 BINIIIDATI RACI (SSWISIIIONOFVEISCU ONOROIRSOP: ❑O//ICER ❑DISVfR ❑OTHER L, DAY_ MO. . OAT . YEAR of"IN NOME PHONE BUSINESS PH01/fI PRIOR M(CnANICAL DEFECT!: NONE APPARENT ❑ RIVER TO NARRATIVE ❑ ❑ ( ) ( , CNP US(ONISHI LY DISCSI VEHICLE DAMA GI w SHADE DAMAGED ARt A -- INSURANCE CARRIER POLICY NUMBER VtHICIE TYPE EJ-- On— ❑MINOR ❑MOO. U MAJOR [JIOTAL DIET OF JONSTAICTOAHIGHWAY SPEED PCF KC ❑ TRAVEL tIMII PUC ❑ CMI ❑ R S NAME RIVIIWtRI NAMEOA1I :ES1,11A.9A � . -( -psi. � /z,.�r Ill' 555•Psge 1 (Rev. M UA:,A 1'01. 09 : 04 P R S N S F., I If f: 1, P F*IH Fit 1.:1't.1{1' F,Af:V" 3 P I A * A x x e < x x 0A A x x x x A t A A IrIjURY (.Of. I 151011 ( PIKE. V"3 TIMCE .1 F F F 11 TA: t I I III r I(.t 1 4 F .jFf M . M A FS 1—WITC 0 0 R RT I?T I I A I E 111 1 '94 7'1 r4 E'13 1,,'IZ L 11.11. . A f I I I.: LYNN P, A W F 1 ,l 17. F. I A IL ft I I AP I?AT I V1; 't A 4 A lk F n r. t n:.1 I. 1! i r a m 1,p r ii:-I F'n , A n I' I. I i Fe of U UP S < ci -hiu ] '.1 1,e m F?Ii t,.; I r t o 11 f. t- If k"ll"(, I tj p l !I r C?DI I I w p I o P) III h F r o t v. l r o r L 1. 11 F, p I 1 0 1, I? t h (1 17 c v m S,oi.nt of r e s; I: IrTl A is h .1, o (d 1- 11 l R lrP s)( iclm i r It V- n C.J 1) 1 -a 17, 11 r P P C F T11 C 11 ra I's 1 0 1 wF t 1 11 d 9 o)I t h I r cr I. n 4. w F. II and d o u 1-11 111-] .1 west. 1 11 1 9 47, t h fl 1)r c! j. 1 0(1 j?F, t-. all d b ?111 100 ' e; t 1111 9 7; 11 f.11 p ro 101 ' :,'est. -1 n(It.h 09204 HRS OFFME/101CIDENT REPORT P A 6 V * * * * * t * * * k ! < * * * k * t * t 1 + A kA I * We INJURY COLLISION AIRE VS TRUCE? WFENSF HUM 14094241F• OFC : M . MASS ("V C ft 1) 1 nEpoRr DATK : 10121 / 94 ATIM : EVERLINGJAMIR LYNN R/Sz& W F 31 DOB : os 1701 A t t * A WARRAmr; Supplemental Report ! 10 94 StntementF : D- T ( Eherting ) was cvntactud Py trtryllone it John Muir "r= pitp .l. it lZZ5 honry . The following i , a Fummary of hqr stitemqnK Sh- -iq IT R oil Norago Was in the hike lane at ZO MPH . Shc noticed 144 i -d light: and lrnffif. , topp-d on hqr left so ihe A-gan Eo qlaw down . When th- liahl- K"rn-d arqpn . - he Rc-qlorated batt: to 20 MPH then 5aw the truck turn in front of hry . 11quirine - f the trifFir nn her 19ft . hp swov -nd right to i -nid th- crIliFirn . Whnn she realized she was going to rptlide with V- 1 , qhv p"I hpl- i - ft hand up to protect hersetf . She said b9c;l"79 of her FpP94 and thenOdry imrn of V- 1 in Ernnt of her that she heal no time to broke . Shr, OpipionF and Conclusions : D- I lFina" , was sLvpped W B on Mpropp rreparing to turn left into the driueway of 01004 School Streak . D- :� Abri ling ) was E "B on Moravia Way in ihp Pike 1pur at TO MPH . Finau was I m- tionqd by a County Connect ion hus dri -nir to mike his turn and he prrnqq4 ­l to rake thp turn not knowing Fberling was apirmaching F:; l! alp"y witly the Yq7 . A ; Fin ; u cros4ed the hihp linp . he and hiF piangilypir Tok- hi hoard .1 77VOR1n ! Finou braked hard to Stop cau5inq thp front wheplq of hjF "Phirle t^ - kid on the dirt/ gravel on the a5phil, L drivoway . Khryling !ii w the 1- nj ir'l right to avoid the co1Jjqirn . "nwr-ar , hnEh -qhiT ! rm wvrp fr ­ llivc! 111 the Fame direction which prevented thum From i"o i ding y i ch a hh- i . I h front whrell of V- 2 ( Trek ) imrActed the right frv" t whrrt of thr ( hr - ,, - iiiinq thy front fork ; of thq bQ- to hrahn . The right fronL brake 7hiFt. Jurpr then impacted the right irent fender of the Cher) oiqni "qi LAq bLkP to f' 'I 'll and rome Lo Y­ t on itv iniylit, ifln . Onume : 0- 1 ( Finau ) rarrspd this vollisiov by hFiry in " iValin" rf TIM011p , Inil "ra to yield right- nF - way while mnhinq 1 - ft Lnr" . Enkibli ; hued by fh- nUnirmants of Finau . Tvketa . Fbprling and thv matching damagF betwppr the two "ehicles . A ? I fho timof report complPtion . I hp "o hrn unable to lvuaty and ­ l- Aligh ' he identity of the County ConiniqrEjon b"; dri "Prni Fervinmendations : None ( inq st;lW : Closed M . fl3es 41 CLAIM '' S S BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 25, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unknown Section 913 and 915.4. Please note all -Warnings". CLAIMANT: Shanti Johnson Ls ATTORNEY: Michael F. Wohlstadter,KAR 2 7 105055. COUNTY Coll NsEbate received ADDRESS: 488 — 7th Street AAARTINEZCALIFBY DELIVERY TO CLERK ON March 27, 1995 Oakland, CA 94607 BY MAIL POSTMARKED: Hand Delivered 1. FROM: Clerk of the Board of Supervisors TOt County Counsel Attached is a copy of the above-noted claim. Bg - DATED: March 27, 1995 q1 Deputy OR, Clerk 11. FROM: County Counsel 70: Clerk of the Board of Supervisors (y]/This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: `it 1 Ts BY: ' Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARDORDER: By unanimous vote of the Supervisors present ( ✓)/This Claim is rejected in full. ( ) Other: I certify that this is a -true and correct copy of the Board's Order entered in its minutes for this date. Dated: PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. fou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. AFFIDAVIT OF MAILING detlare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the lnited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, :alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to :he claimant as shown above. )a ted: I — '1 BY: PHIL BATCHELOR by eputy Clerk :C: County Counsel County Administrator 't. RECEIVE® , t MAR 27 E CLERK BOARD OF SUPERVISORS CLAIMS REPORT FORM CONTRA COSTA CO. (Add sheets if space needed) Date: March 7, 1995 A. Claimant: Shanti Johnson Address: 664 - 6th Street Phone (510) 234-4973 Richmond, CA 94801 Number: B. Address to wkich notices s�oulg be se t: is ae F. Woh sta ter, A torney at Law { 488 - 7th Street Oakland, CA 94607 C. Date of Occurrence: November 26, 1994 Location of Occurrence: 39th Street @ MacDonald Ave. R i r•hmonrl CA Description of occurrence or transaction which givesrise to i your claim: County vehicle impacted claimant vehicle which was parked at time of incident and ogcupied by claimant. If auto accident: Names of Drivers: Roger Richeson (Dept. of Telecommunication: Address: 1619 Shell Ave. Martinez. CA Year Make, Model of Vehicle or Vehicles Involved: White Pic6p CA license E112054; year & make unk. ; 1982 Toyata Starlight 2-door, CA lisence 2PIN668 D. Description of the indebtedness, obligation, injury, damage or loss: Personal injury: strains to cervical and lumbar spine, right shoulder; contusiions (medical report 4E. Amount of claim, including future damage or loss (with basis of computation and bills or estimates to substantiate claim) : Municipal Court Jurisdiction: Personal In 'ur , (billing in amount of $2, 925 is attac ed) . F. Name or names of the public employee or employees causing the injury, damage, or loss, if known: ' Roger Richeson Signed: Date Signed: 3/07/95 (Give relationship if person signing claim is not claimant) i I 1 ATTACHMENT TO CLAIM OF SHANTI JOHNSON 2 The bases for liability against the County of Contra Costa, 3 Roger Richeson and other employees of the County of Contra Costa, 4 are as follows: 5 1 . Negligence in the ownership, maintenance, control, use, 6 entrustment, repair, operation, and securing of the motor vehicle 7 of the County of Contra Costa, causing claimant injury and damage; 8 2. Negligence in the employment, hiring, instruction, 9 training, discipline, and retention, of Mr. Richeson and other 10 employees and/or independent contractors of the County of Contra 11 Costa, causing injury and damage to claimant; 12 3 . Vicarious liability of the County of Contra Costa for the 13 negligence and other improper conduct of Mr. Richeson, other 14 employees and/or independent contractors, who were at all times 15 acting in the course and scope of their employment with the County 16 of Contra Costa. 17 18 19 20 21 22 23 24 25 26 27 28 emc medical ou p orthopaedic, physical & family medicine COMPLETE NARRATIVE MEDICAL/ORTHOPAEDIC REPORT RE: SHANTI JOHNSON January 20, 1995 DATE OF INJURY: November 26, 1994 ATTORNEY- OF RECORD: Michael Wohistadter Attorney-at-Law 488 Seventh Street Oakland, CA 94607 CHIEF COMPLAINTS: 1 ) Neck pain 2) Right shoulder pain 3) Right arm pain 4) Low back pain HISTORY: The above-captioned patient is a 20 year old food service manager at K Mart who sustained injuries in a motor vehicle impact accident on the above date. She was riding as a passen- ger being driven by a friend in the Richmond area. Their car was parked at a corner. Apparently a truck owned by the County made a turn too close to their vehicle. Their car was jerked forward and the bumper was pulled off in the front left area. The patient was jostled quite a bit by the impact. Following this, the patient had increasing pain in the above- noted areas. She did not seek immediate medical attention, hoping the pains would subside. She came into our office for a brief evaluation on 11/28/94 and was given some medication for her pain. She returned the following day for a more complete evaluation on 11/29/94. At that time she stated she was having a persistent pain in the above-noted areas which was rated as between three and four on a visual analogue pain scale of ten. That is a moderate to severe type of pain. She was experienc- ing symptoms of dizziness, nausea, vomiting, increased fatig- ability, difficulty sleeping, nervousness, depression, anxiety and worry. i 2160 vale road san pablo, california 94806 (510) 233-0984 January 20, 1995 Page 2 Re: Shanti Johnson She described the neck pain as radiating into the right shoulder and upper extremity. She described the pain as being continuous and dull in nature. There was a burning quality to it. There was numbness into the upper extremity. She was getting some relief by applying heat, by lying down and resting. Any type of movement, in certain positions, tended to aggravate the pain. The low back pain was described as sharp, intermittent and burning in nature. It was relieved by applying heat. It was aggravated by prolonged sitting, rising from a sitting position, prolonged standing, bending forward, doing any lifting and following sleep. Adverse weather conditions tended to increase the pain. There was also increased pain with coughing or sneezing. There was no problem with urine or bowel control . There was no radiation of the pain into the lower extremities. PAST HISTORY: The patient had sustained an injury on the job on 9/7/94. This involved her right shoulder, right arm and spinal area. She had some treatment following this and was basically recovering . She had not had any previous auto accidents. Otherwise, the patient had been in good health. PHYSICAL EXAMINATION: Reveals a 20 year old normally developed female who appeared to be in moderate distress. She has slow, guarded movements when getting on and off the examining table and does so with some difficulty. GENERAL DATA: Weight: 176 pounds Height : 5 feet 6 inches Temperature: 98.0 Respirations : 20 Pulse rate: 72 Blood pressure: 120/60 January 20, 1995 Page 3 Re: Shanti Johnson I I HEENT: The pupils were equal and reactive to light and accommodation. The extraocular movements were 'full. The tympanic membranes were pearly white. The pharynx was without exudate. LUNGS: The lungs were without rales, rhonchi or wheeze. HEART: The heart showed a normal sinus rhythm and rate without murmur or heave, thrill, 'gallop or friction rub. ABDOMEN: The abdomen was soft and nontender with normal, active bowel tones. PELVIC AND RECTAL: These examinations were deferred. NECK: There is 2+ spasm and tenderness in the paracervical region from C2 down to C7. The tenderness extends laterally into the right shoulder area, the suprascapular area and toward the deltoid. There is also tenderness in the upper paradorsal region from D2 down to D4. There is limited mobility of the cervical spine as follows: ACTIVE RANGE OF MOTION: Flexion: 10 degrees Extension: 20 degrees Right lateral flexion: 25 degrees Left lateral fleixon: 20 degrees Right lateral flexion: 25 degrees Left lateral flexion: 35 degrees 1 January 20, 1995 Page 4 Re: Shanti Johnson f There was 2+ pain elicited with , active and passive movement of the cervical spine in all six planes. There was 2+ pain elicited with resisted movement of the cervical in all six planes. DORSAL SPINE: There was tenderness in the upper paradorsal region of 2+ degree. LUMBAR SPINE: There is limited mobility of the lumbar spine as follows: Forward flexion is possible to 35 degrees with 2+ pain reported. Extension is 10 degrees with 2+ pain reported. Right and left side flexions are 10 degrees with 2+ pain reported. Straight-leg raises are possible to 35 degrees bilaterally with 2+ pain reported at 30 degrees bilaterally. There is 2+ bilateral sciatic notch joint tenderness . There is a negative neck flexion test. There is 2+ to 3+ positive L3 stretch test at 30 degrees bilaterally. There is maximal spinous process tenderness present over this lumbar spinous processes between L1 and S3 of possibly 2+ degree. There is 2+ paravertebral spasm and tenderness present between L1 and L4 . NEUROLOGIC: I Cranial nerves II through XII were intact. The deep tendon reflexes were 2+ and symmetric at the biceps, the triceps, the brachioradialis, patellae and Achilles. January 20, 1995 Page 5 Re: Shanti Johnson s Grip strength was tested using the Jamar dynamometer and the results are as follows: The right side was 2, 3, and 3 pounds. The left side was 20, 10 and 10 pounds. The patient is right handed. EXTREMITIES: Examination of the right shoulder shows marked, limited mobility of the shoulder on internal and external rotation as well as abduction. This is only about 15% of normal . There is 2+ to 3+ tenderness over the deltoid region, the glenohumeral area and the suprascapular area. The tenderness extends inferiorly into the triceps area and the biceps area. The elbow appears fairly normal. The patient reports a marked throbbing sensation in the fourth and fifth digits of the right hand; that is in the C8 sensory dermatomal area. The left upper extremity appears to be within normal limits. SPECIAL STUDIES: X-rays of the cervical spine and right shoulder were obtained on 12/3/94. There were no fractures seen in the cervical spine series . Films of the right shoulder showed a rounded defect in the humeral head consistent with a previous dislocation. There was no evidence of recent fracture or other abnormalities. DIAGNOSES: 1 ) Acute sprain of the cervical spine, post-traumatic. 2) Acute sprain of the lumbosacral spine, post-traumatic. 3) Contusion and sprain of the right shoulder girdle, post-traumatic. 4) Paravertebral myofasciitis with persistent myofascial pain syndnrome. TREATMENT PROGRAM AND CLINICAL COURSE: The patient was initiated on a conservative treatment program utilizing surface electrical stimulation techniques with hertz January 20, 1995 Page 6 Re: Shanti Johnson parameter settings between two and 200 hz. Moist heat was applied utilizing hydrocolator hot packs. She was given appropriate analgesic medication for her symptoms . The patient continued treating on a two to three times weekly basis during December of 1994. She showed gradual and progressive improve- ment with decreased pain and spasm in the cervical spine, and the right shoulder. She had better mobility gradually. Her most recent visit here was on 1/11/95. At that time she was doing significantly better but still had some residual pain in the right shoulder, right upper extremity and in her neck. She had improved significantly. No further visits were planned beyond 1/11/95. The patient was advised to return on an as-needed basis thereafter . PROGNOSIS AND DISCUSSION: The patient is a 20 year old female who sustained injuries to her neck, right shoulder, right upper extremity and low back in a motor vehicle impact accident on the above date. She was quite symptomatic at first but did appear to respond to a course of conservative physical therapy over a period of approximately six weeks. .She was improving by 1/11/95 . With injuries of this type, it should be noted that it is not unusual to have exacerbations of symptoms that can be aggra- vated by ordinary activities of daily living as well as those encountered on the job. Often these injuries are slow to heal and do so poorly and many times incompletely due to poor blood supply to ligaments and fibrous tissues involved. Stretching and tearing of the soft tissues can lead to hemorrhage and hemorrhage can go on to form scar tissue and scar tissue can act as irritable sites causing these areas to be prone to recurrences of pain and spasm. Also, it should be noted in this patient that she had a previous injury to the right shoulder in September of 1994. This injury had healed substantially by the time of 11/26/94 but it appears that the impact in the automobile accident may have exacerbated this previous injury. The x-ray did show evidence of the previous, suspected 'dislocation. There was no evidence of dislocation in this injury, however, the patient did have marked increase in pain following the impact on 11/26/94. January 20, 1995 Page 7 Re: Shanti Johnson We usually find in these cases that precipitating factors leading to recurrence of symptoms are: muscular exertion, holding the spine or upper extremity in a fixed or difficult position for extended periods of time, or increased muscular activity or repeated motions of the affected areas . Probably these are the kinds of activities the patient would encounter in her work as a food service manager. It appears the patient has stabilized at this point and improved significantly but she still has some residual problems in the neck, right shoulder and right upper extremity. She may need some additional diagnostic studies and further physical therapy. If she has persistent symptoms, she may need physical therapy over the next six to twelve months at a cost of $500 to $700 per month. She may need an MRI of the right shoulder and cervical spine. She may need CT scans, repeat x-rays and a high resolution digital infrared imaging examina- tion. If the patient has persistent weakness in the right upper extremity, she may need consultation with a neurosurgeon following appropriate studies to determine if there are any signs of radiculopathy involving the right upper extremity. Consequently, with the above taken into account, the overall prognosis still remains somewhat guarded. If you have any further questions in this matter, please feel free to call or correspond . /Res ctfully submitted, J athan Francis, M. D. i JF:ec 1 ) 1 Ins FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1.PATIENT'S',NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3.INSUR£D'S NAME (LAST,FIRST,MIDDLE) JOHNSON, SHANTI 01 1 12 1 74 JOHNSON, SHANTI 4.PATIENT'S ADDRESS 5.PATIENT'S SEX 6.INSURED'S ID NO. 763 6TH ST MALE ❑ ® FEMALE RICHMOND, CA 94801 '].RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED 236-9473 ® 1:1 1:1 1:10 EMPLOYERIHEALTHOYED PLANANI) COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 1O.WAS CONDITION RELATED TO: ll.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 763 6TH ST YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.236-9473 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ;❑ ACTIVE ❑ DECEASED BRANCH OF SVC STATUS DUTY ❑ RETIRED 12.1 AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13.I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION 14.DATE OF: ILLNESS OR INJURY OR 15.DATE FIRST CONSULTED YOU IF PATIENT HAS HAD SAME OR b.a IF EMERGENCY REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES CHECK HERE 11/26/94 ❑ i ATE PATIENT ABLE .DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH 19. NAME OF REFERRING PHYSICIAN . OR S RVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23,A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, RELATE DIAGNOSIS TO PROCEDURE IN B. COLUMN D BY REFERENCE NUMBERS 1,2,3, ETC. OR DX CODE 1 . 847.9 -- SPRAIN, SPINE ACUTE TRAUMATIC EPSDT YES ❑ ❑ NO 2. 847.0 —" WHIPLASH, (SPINE) FAMILY PLANNING YES ❑ ❑ NO 3. 729 . 1 -- MYOFASCITIS, ACUTE PRIOR--------------------------------------- PRIOR AUTHORIZATION NO. 24. A. B' C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. F. H.LEAVE BLANK DATE OF SERVICE PLA , (EXPLAIN ANY UNUSUAL DIAGNOSIS E. ORDAYG. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES) CODE CHARGES UNITS TOS 11/29/94 3 99212 INITIAL OFFICE VISIT 1 325:00 1 11/29/94 3 64550 SURF.APP.NEURO-STIM. 2 65:00 1 11/29/94 3 97010 HOT PACKS 3 40400 1 12/02/94 3 99212 OFFICE VISIT 1' 55,00 1 12/02/94 3 64550 SURF.APP.NEURO-STIM 2 65:00 1 12/02/94 3 97010 HOT PACKS 3 40100 1 1 1 25.5IGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT PAID 29.BALANCE DUE 590+00 J. FRANCIS, M.D. YES ❑ ❑ NO 31.PHYSICIAN S SUPPLIER'S AND OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30.YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32.YOUR PATIENT'S ACCOUNT NO. 33.YOUR EMPLOYER I.D. NO. SAN PABLO, CA. 94806 7120 I.D. NO. 00A223650 (415 ) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-1500 1 ) 1 Ins �r FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED SUBSCRIBER INFORMATION 1.PATIENT'S NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME (LAST,FIRST,MIDDLE) JOHNSON, SHANTI 01 1 12_ 1 74 JOHNSON, SHANTI 4.PATIENT'S.ADDRESS 5.PATIENT'S SEX 6.INSURED'S ID NO. 763 6TH ST MALE ❑ ® FEMALE RICHMOND, CA 94801 7.RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED 236-9473 ® ❑ 11 1:1EMPLOYERIHEEMP THOYED PLANAND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 10.WAS CONDITION RELATED TO: ll.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 763 6TH ST YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.236-9473 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ;❑ ACTIVE ❑ DECEASED BRANCH OF SVC STATUS DUTY ❑ RETIRED 12.1 AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13.I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION DATE OF: ILLNESS OR INJURY OR .DAT FIRST CONSULTED YOU .IF ATIEN HAS HAD AME OR a IF EMERGENCY REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES CHECK HERE 11/26/94 l< I 1 ❑ 7.DATE PATIENT ABLE 18.DATES OF TOTAL DISABILITY DATES OF PARTIAL—DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH lg.NAME OF REFERRI iYSICIAN MFOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23.A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2,3, ETC. OR DX CODE 1. 847. 9 -- SPRAIN, SPINE ACUTE TRAUMATIC EPSDT YES ❑ ❑ NO 2. 847.0 -- WHIPLASH, (SPINE) FAMILY PLANNING YES ❑ ❑ NO 3. 729 . 1 -- MYOFASCITIS, ACUTE - ------------------------------------------- V PRIOR AUTHORIZATION NO. 24. A. B. C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. F. H.LEAVE BLANK DATE OF SERVICE PLACE D. DAYS OF (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES) CODE CHARGES UNITS TOS 12/03/94 3 99212 OFFICE VISIT 1 55:00 1 12/03/94 3 64550 SURF.APP.NEURO-STIM. 2 65:00 1 12/03/94 3 97010 HOT PACKS 3 40400 1 12/03/94 3 72052 XRAY CERV SP ( 12 VIE 3` , 250;00 1 i 12/03/94 3 73030 SHOULDER, XRAY 1 48100 1 12/05/94 3 99212 OFFICE VISIT 1 55:00 1 25-SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27-TOTAL CHARGE 28.AMOUNT PAID 29.BALANCE DUE 513400 J. FRANCIS, M.D. YES ❑ ❑ NO 31.PHYSICIAN S SUPPLIER S AND/OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30-YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32.YOUR PATIENT'S ACCOUNT NO. 33.YOUR EMPLOYER I.D. NO. SAN PAB LO, CA. 94806 7120 I.D. NO. 00A223650 (415 ) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-1500 1 ) 1 Ins FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1.PATIENT'S NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME (LAST,FIRST,MIDDLE) JOHNSON, SHANTI O1 12 74 JOHNSON, SHANTI 4.PATIENT'S ADDRESS 5.PATIENT'S SEX 6.INSURED'S ID NO. 763 6TH ST MALE ❑ ® FEMALE RICHMOND, CA 94801 7.RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED EMPLOYED 236-9473 ® 1:1 1:10 ElEMPLOYERIHEALTH PLANAND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE IO.WAS CONDITION RELATED TO: ll.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 763 6TH ST YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.236-9473 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ❑ ACTIVE ❑ DECEASED BRANCH OF SVC STATUSDUTY ❑ RETIRED 12.1 AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 3•I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION DATE OF: ILLNESS OR INJURY OR S.DATE FIRST CONSULTED YOU .IF PATIENT HAS HAD SAME OR [6.a IF EMERGENCY 11/26/94 REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES CHECK HERE DATE PATIENT ABLE 18.DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILIT TO RETURN TO WORK FROM THROUGH FROM THROUGH NAME OF REFERRING PHYSICIAN .FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23.A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2,3, ETC. OR DX CODE 1. 847.0 -- WHIPLASH, (SPINE) EPSDT YES ❑ ❑ NO 2. 729 . 1 -- MYOFASCITIS, ACUTE FAMILY PLANNING YES ❑ ❑ NO 3. 847 .9 -- SPRAIN, SPINE ACUTE TRAUMATIC --- ---------------------------- ------------ V PRIOR AUTHORIZATION NO. 24. A. B. C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. F H.LEAVE BLANK DATE OF SERVICE PLACE D• DAYS OF (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES) CODE CHARGES UNITS TOS 12/05/94 3 64550 SURF.APP.NEURO-STIM. 1 65:00 1 12/05/94 3 97010 HOT PACKS 2 40:00 1 12/07/94 3 99212 OFFICE VISIT 3 55400 1 12/07/94 3 64550 SURF.APP.NEURO-STIM. 1' 659: 00 1 12/07/94 3 97010 HOT PACKS 2 40:00 1 12/13/94 3 99212 OFFICE VISIT 3 55:00 1 25.SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT PAID 29.BALANCE DUE 32000 J. FRANCIS, M.D. YES ❑ ❑ NO 3 .PHYSICIAN S SUPPLIER'S AND/OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 3O.YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32.YOUR PATIENT'S ACCOUNT NO. 33.YOUR EMPLOYER I.D. NO. SAN PABLO, CA. 94806 7120 I.D. NO. 00A223650 ( 415 ) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-1500 1 ) 1 Ins �r ** * �r** * FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED (SUBSCRIBER) INFORMATION I.PATIENT'S NAME (LAST,FIRST,MIDDLE) .2.PATIENT'S DATE OF BIRTH 3•INSURED'S NAME (LAST,FIRST,MIDDLE) JOHNSON, SHANTI 01 1 12 1 74 JOHNSON, SHANTI 4.PATIENT'S ADDRESS 5.PATIENT'S SEX 6.INSURED'S ID NO. 763 6TH ST MALE ❑ ® FEMALE RICHMOND, CA 94801 7.RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER EMPLOYED 236-9473 ® ❑ E] E] ❑ EMPLOYERINSUREDIHEALTH PLANAND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 10.WAS CONDITION RELATED TO: ll.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 763 6TH ST YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.236-9473 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ;❑ ACTIVE ❑ DECEASED BRANCH OF SVC STATUSDUTY ❑ RETIRED 12.1 AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13.I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION 14.DATE OF: ILLNESS OR INJURY OR 15,DATE FIRST CONSULTED YOU lb,IF PATIENT HAS HAD SAME OR [b.a IF EMERGENCY REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES CHECK 11/26/94 ElHERE 17-DATE PATIENT ABLE 18.DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH NAME OF REFERRING PHYSICIAN FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATIOND TES ADMITTED ISCHARGED 21-NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23.A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2, ETC. OR DX CODE 1 . 847.0 -- WHIPLASH, (SPINE) EPSDT YES ❑ ❑ NO 2. 729 . 1 -- MYOFASCITIS, ACUTE FAMILY PLANNING YES ❑ ❑ NO 3. 847.9 —— SPRAIN, SPINE ACUTE TRAUMATIC PRIOR--------------------- ----------------- V PRIOR AUTHORIZATION NO. 24. A. pLACE B. C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. p• DAYS F. H•LEAVE BLANK DATE OF SERVICE OF (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES) CODE CHARGES UNITS TOS 12/13/94 3 64550 SURF.APP.NEURO—STIM. 1 65:00 1 12/13/94 3 97010 HOT PACKS 2 40:00 1 12/16/94 3 99212 OFFICE VISIT 3 55400 1 12/16/94 3 64550 SURF.APP.NEURO—STIM. 1' 65,00 1 r 12/16/94 3 97010 HOT PACKS 2 40:00 1 12/19/94 3 99212 OFFICE VISIT 3 55 :00 1 25.SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT PAID 9.BALANCE DUE 3204001 1 J. FRANCIS, M.D. YES ❑ ❑ NO 3 .PHYSICIAN S SUPPLIER'S AND/OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30.YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32-YOUR PATIENT'S ACCOUNT NO. 33.YOUR EMPLOYER I.D. NO. SAN PABLO, CA. 94806 7120 1.D. NO. 0OA223650 (415 ) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-1500 1 ) 1 Ins * * FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED SUBSCRIBER INFORMATION 1.PATIENT'S NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME (LAST,FIRST,MIDDLE) JOHNSON, SHANTI 01 1 12 1 74 JOHNSON, SHANTI 4.PATIENT'S ADDRESS 5.PATIENT'S SEX 6.1NSURED'S ID NO. 763 6TH ST MALE ❑ ® FEMALE RICHMOND, CA 94801 .RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED 236-9473 ® 1:1 ED El El EMPLOYER IHEALTH PLAN S EMPLOYED AND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 1O,WAS CONDITION RELATED TO: ll.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 763 6TH ST YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.236-9473 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ;❑ ACTIVE ❑ DECEASED I BRANCH OF SVC STATUS DUTY ❑ RETIRED 12,I AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13.1 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION DATE OF: ILLNESS OR INJ RY ORDA E FIRST CONSULTED YOU .IF PATIENT HAS HAD SAME OR �b.a IF EMERGENCY REGNANCY POR THIS CONDITION SIMILAR ILLNESS, GIVE DATES CHECK HERE 11/26/94 ❑ ,DATE PATIENT ABLE 8,DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH NAME OF REFERRING PHYSICIA .FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21,NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 3,A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2, ETC. OR DX CODE 1. 847.0 -- WHIPLASH, (SPINE) EPSDT YES ❑ ❑ NO 2. 729 . 1 -- MYOFASCITIS, ACUTE FAMILY PLANNING YES ❑ ❑ NO 3. 847. 9 -- SPRAIN, SPINE ACUTE TRAUMATIC PRIOO-- R- ---------------------------------------- AUTHORIZATION NO. 24, A. PLACE B. C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. D, DAYS H.LEAVE BLANK DATE OF SERVICE OF (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES) CODE CHARGES UNITS TOS 12/19/94 3 64550 SURF.APP.NEURO-STIM. 1 65:00 1 12/19/94 3 97010 HOT PACKS 2 40: 00 1 12/21/94 3 99212 OFFICE VISIT 3 55400 1 12/21/94 3 64550 SURF.APP.NEURO-STIM. l ' 65.1: 00 1 i 12/21/94 3 97010 HOT PACKS 2 4000 1 12/29/94 3 99212 OFFICE VISIT 3 55:00 1 25.SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT PAID 9.BALANCE DUE 320400 J. FRANCIS, M.D. YES ❑ ❑ NO 31.PHYSICIAN S SUPPLIER'S AND OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30.YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32.YOUR PATIENT'S ACCOUNT NO. 33,YOUR EMPLOYER I.D. NO. SAN PABLO, CA. 94806 7120 1 I.D. NO. 0OA223650 (415 ) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-15500 Ins FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1.PATIENT'S NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3•INSURED'S NAME (LAST,FIRST,MIDDLE) JOHNSON, SHANTI 01 1 12 74 JOHNSON, SHANTI 4.PATIENT'S' ADDRESS 5.PATIENT'S SEX 6.INSURED'S ID NO. 763 6TH ST MALE ❑ ® FEMALE RICHMOND, CA 94801 '].RELATIONSHIP TO INSURED &INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED EMPLOYED 236-9473 ® 1:1 1:1 1:1 ElEMPLOYERIHEALTH PLANAND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 10.WAS CONDITION RELATED TO: ll.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 763 6TH ST YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.236-9473 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ❑ ACTIVE ❑ DECEASED BRANCH OF SVC STATUS DUTY ❑ RETIRED 12.I AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13.I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION DATE OF: ILLNESS OR INJURY OR 15.DATE FIRST CONSULTED YOU I6.IF PATIENT HAS HAD SAME OR 6.a IF EMERGENCY REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES CHECK HERE 11/26/94 < El]. DATE PATIENT ABLE .DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH NAME OF REFERRING PHYSICIAN .FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23.A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2,3, ETC. OR DX CODE 1. 847.0 -- WHIPLASH, (SPINE) EPSDT YES ❑ ❑ No 2. 729 . 1 -- MYOFASCITIS, ACUTE FAMILY PLANNING YES ❑ ❑ NO 3. 847. 9 -- SPRAIN, SPINE ACUTE TRAUMATIC PRIOR--------------------------------------- PRIOR AUTHORIZATION NO. 24. A. PLACE C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. p, DAYS H.LEAVE BLANK DATE OF SERVICE OF (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR FROM" TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES CODE CHARGES UNITS TOS 12/29/94 3 64550 SURF.APP.NEURO—STIM. 1 65:00 1 12/29/94 3 97010 HOT PACKS 2 40:00 1 12/30/94 3 99212 OFFICE VISIT 3 55+00 1 12/30/94 3 64550 SURF.APP.NEURO-STIM. 1 65;00 1 12/30/94 3 97010 HOT PACKS- 2 40:00 1 01/03/95 3 99212 OFFICE VISIT 3 55:00 1 25.SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT PAID 29.BALANCE DUE 320100 J. FRANCIS, M.D. YES ❑ ❑ NO 3 •PHYSICIAN S SUPPLIER'S AND/OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30.YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32.YOUR PATIENT'S ACCOUNT NO. 33.YOUR EMPLOYER I.D. NO. SAN PABLO, CA. 94806 7120 1 I.D. NO.00A223650 (415) 233-0984 REMARKS: JF Form HCFA-1500 C-2) (1-84) Form OWCP-1500 C 1 ) 1 Ins * * * * FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED SUBSCRIBER INFORMATION 1.PATIENT'S NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME (LAST,FIRST,MIDDLE) JOHNSON, SHANTI 01 1 12 1 74 JOHNSON, SHANTI 4'.PATIENT'S ADDRESS 5.PATIENT'S SEX 6.INSURED'S ID NO. 763 6TH ST MALE ❑ ® FEMALE RICHMOND, CA 94801 '].RELATIONSHIP TO INSURED S.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED 236-9473 ® El 1:1 1:1 1:1EMPLOYERIHEALTHOPLANYED AND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE lO.WAS CONDITION RELATED TO: ll.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 763 6TH ST YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.236-9473 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ;❑ ACTIVE ❑ DECEASED BRANCH OF SVC STATUSDUTY ❑ RETIRED 12.1 AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13.I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION DATE OF: ILLNESS OR INJURY OR 15.DATE FIRST CONSULTED YOU lb.IF PATIENT HAS HAD SAME OR a IF EMERGENCY REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES CHECK HERE 11/26/94 <1 1 ❑ DATE PATIENT ABLE 18.DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH NAME OF REFERRING PHYSICIA .FOR SER CES RELATED TO HOSPITALIZAT 0 GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23.A DIAGNOSIS-OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2,3, ETC. OR DX CODE 1. 729 . 1 -- MYOFASCITIS, ACUTE EPSDT YES ❑ ❑ NO 2. 847.0 -- WHIPLASH, (SPINE) FAMILY PLANNING YES ❑ ❑ NO 3. 847. 9 -- SPRAIN, SPINE ACUTE TRAUMATIC PRIOR--------------------------------------- PRIOR AUTHORIZATION NO. 24. A. B. C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. F H.LEAVE BLANK DATE OF SERVICE PLACE ��• DAYS OF (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES) CODE CHARGES UNITS TOS 01/03/95 3 64550 SURF.APP.NEURO-STIM. 1 65:00 1 01/03/95 3 97010 HOT PACKS 2 40:00 1 01/07/95 3 73130 HAND X-RAY 3 44400 1 01/07/95 3 73110 WRIST, COMP. XRAY 2, 1 \ 48;00 1 01/11/95 3 99212 OFFICE VISIT 3 55:00 1 01/11/95 3 97010 HOT PACKS 2, 1 40:00 1 25.SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT PAID 9.BALANCE DUE 292;00 J. FRANCIS, M.D. YES ❑ ❑ NO 31.PHYSICIAN S SUPPLIER'S AND/OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30-YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32.YOUR PATIENT'S ACCOUNT NO. 33.YOUR EMPLOYER I.D. NO. SAN PABLO, CA. 94806 7120 I.D. NO. 0OA223650 (415 ) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-1500 r 1 ) 1 Ins FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED SUBSCRIBER INFORMATION 1.PATIENT'S NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME (LAST,FIRST,MIDDLE) JOHNSON, SHANTI 01 1 12 74 JOHNSON, SHANTI 4.PATIENT'S ADDRESS 5.PATIENT'S SEX 6.INSURED'S ID NO. 763 6TH ST MALE ❑ ® FEMALE RICHMOND, CA 94801 7.RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED 236-9473 ® El 1:1 El ElEMPLOYERIHEALTHOYED PLANAND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 10,WAS CONDITION RELATED TO: ll.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 763 6TH ST YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.236-9473 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ,❑ ACTIVE E3 DECEASED BRANCH OF SVC STATUSDUTY ;❑ RETIRED 12.1 AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13.I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION DATE OF: LLNESS OR INJURY OR S.DATE FIRST CONSULTED YOU .IF PATIENT HAS HAD SAME OR .a IF EMERGENCY REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES CHECK HERE 11/26/94 ❑ 7.DATE PATIENT ABLE 18.DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH 19.NAME OF REFERRING PHYSICIAN FOR S RVICES RELATED TO OSPITALIZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23.A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2,3, ETC. OR DX CODE 1. 847 . 9 -- SPRAIN, SPINE ACUTE TRAUMATIC ePSDT Yes ❑ ❑ No 2. 729 . 1 -- MYOFASCITIS, ACUTE FAMILY PLANNING YES ❑ ❑ NO 3. 847.0 —— WHIPLASH, (SPINE) --------------------------------------------- V PRIOR AUTHORIZATION NO. 24. A. B. C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. F' H.LEAVE BLANK PLACE D• DAYS DATE OF SERVICE OF (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES CODE CHARGES UNITS TOS 01/23/95 3 99080-22 MEDICAL REPORT 1, 2, 3 250:00 1 25-SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT PAID 9-BALANCE DUE 250{00 J. FRANCIS, M.D. YES ❑ ❑ NO 31.PHYSICIAN S SUPPLIER S AND OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30-YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32.YOUR PATIENT'S ACCOUNT NO. 33-YOUR EMPLOYER I.D. NO. SAN PABLO, CA. 94806 7120 1I.D. No. OOA223650 ( 415 ) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-1500 -'CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA -- April 25, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unknotan Section 913 and 915.4. Please note all "War rsDmm CLAIMANT:Valerie Jones MAR 2 7 5995 ATTORNEY:William C. Johnson, Esq. ` COUNTY COUNSEL Date received MARTINEZ CALIF. ADDRESS: 1901 Harrison St. , Ste 1650 BY DELIVERY TO CLERK ON March 27, 1995 Oakland, CA 94612 BY MAIL POSTMARKED: March 24, 1995 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pp gg DATED: March 2.7, 1995 e�IL DeputylOR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ✓''rThis claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying Claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: �'�j—Z� - C1 S' BY: Deputy County Counsel Ill. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOAR/ ORDER: By unanimous vote of the Superviscrs present (v) This Claim is rejected in full. ( ) Other: I certify that this is a -true and correct copy of the Board's Order entered in its minutes for this date. r Dated: PHIL BATCHELOR, Clerk, ByCa;�. Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 16; and that today I deposited in the United States Postal Service in Martinez, California, Postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: o�`� . 1 q�J� BY: PHIL BATCHELOR by9.0 ,Deputy Clerk �C: County Counsel County Administrator 7MAR DED 2 7 I 1 CLERK BOAR®OE SUPER ISOR 2 CERTIFIED MAIL - RETURN RECEIPT REOUESTEOWRA COSTA CO. �------ 3 NOTICE OF CLAIM FOR DAMAGES 4 AGAINST THE COUNTY OF CONTRA COSTA 5 6 TO: County of Contra Costa Board of Supervisors 7 651 Pine Street, Room 106 Martinez, California 94553 8 CLAIMANT'S NAME: VALERIE JONES 9 CLAIMANT'S TELEPHONE 10 NUMBER: (510) 516-7684 11 CLAIMANT'S ADDRESS: 2405 Santa Cruz Byron, California 12 ADDRESS TO WHICH 13 NOTICES ARE TO BE SENT: WILLIAM C. JOHNSON, ESQ. 14 BENNETT, JOHNSON & GALLER 1901 Harrison Street 15 Suite 1650 Oakland, California 94612 16 AMOUNT OF CLAIM: In excess of the jurisdictional 17 limits of the Municipal Court 18 DATE CLAIM ACCRUED: September 24, 1994 19 PLACE CLAIM ACCRUED: Merrithew Memorial Hospital 2500 Alhambra Avenue 20 Martinez, California 94553 21 CIRCUMSTANCES OF CLAIM: Claimant, VALERIE JONES, presented 22 to Merrithew Memorial Hospital on September 22, 1994 , and was 23 diagnosed with a tubal pregnancy. Claimant was examined and treated 24 by medical practitioners at Merrithew Memorial Hospital who she 25 is informed and believes were 26 1 1 agents and employees of the COUNTY OF CONTRA COSTA; Thereafter she was 2 released without any follow-up care and instruction. 3 On September 24 , 1994 , Claimant 4 suffered a ruptured ectopic pregnancy. Claimant was diagnosed 5 on September 24 , 1994, at Delta Memorial Hospital and underwent 6 emergency surgery on September 25, 1994, to correct her condition. 7 On or about September 22 , 1994 , the 8 COUNTY OF CONTRA COSTA, by and through its agents, servants and 9 employees so negligently and carelessly examined, treated, 10 tested, diagnosed, prescribed and cared for the Claimant, and 11 provided medical, surgical, nursing and laboratory care and treatment 12 in a negligent and careless manner, and negligently and carelessly 13 failed to properly diagnose and manage Claimant' s condition and 14 negligently and carelessly failed to provide adequate or any follow- 15 up care, instruction or advice and negligently caused and permitted 16 aggravated increased injuries to said Claimant . 17 Claimant did not discover the 18 alleged malpractice of the COUNTY OF CONTRA COSTA, its agents and 19 employees, until subsequent to September 25, 1994 , when she was 20 alerted for the first time by other medical practitioners that the care 21 and treatment she received at Merrithew Memorial Hospital was 22 below acceptable standards of care. 23 ITEMIZATION OF 24 INJURIES: Claimant, VALERIE JONES, suffered severe and permanent injuries and 25 damages including, but not limited to, a ruptured ectopic pregnancy, 26 2 1 emergency surgery loss of blood, loss of a fallopian tube, extreme 2 mental and emotional distress and other injuries, the full extent of 3 which is presently unknown. 4 DATED: March 24, 1995 BE T JO ON & GALLER 5 6 By 7 L OHNSON ttorne s or Claimant 8 i 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 3 6, M Ln w ul O d r-4 aN uom0 (s O ?4 O -r q U 0 tx r. rtS -r•-1 O �4 > 4-) 44 4-3 f4 () -r i oaK (13 U U) 4-) U 44 :r O44 N O N >1 ri ° r� ?4 -N u� :I It r4 p O O «S r•9 U 6Q +� �, w a c� z � o0) O a O � z >4 -4 F � oxm occ Hyo 0 H W z _ z w as CLAIM 7 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA 4 April 25, 1995 -C) Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unknown E; f Section 913 and 915.4. Please note all "Warnings". CLAIMANT: Charles Harris PEAR 2 7 1,9S5 ATTORNEY: Michael R. Wohlstadte]COUNTYCOUNSEL MARTINEZ CALIF. Date received ADDRESS: 488 — 7th Street BY DELIVERY TO CLERK ON March 27, 1995 Oakland; CA 94607 BY MAIL POSTMARKED: Hand Delivered--- 1. elivered-:1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: March 27, 1995 all Bep�tyLOR+ ClerkIj 11. FROM: County Counsel TO: Clerk of the Board of Supervisors (This claim complies substantially with Sections 910 and 910.2. { ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.6). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). { ) Other: i Dated: -a-1 -C75 BY: Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD ORDER: By unanimous vote of the Superviscrs present ( ✓) This Claim is rejected in full. ( ) Other: I certify that this is a Z rue and correct copy of the Board's Order entered in its minutes for this date. Dated: S PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, Postage fully prepaid a certified Copy of this Board Order and Notice to Claimant, addressed to She claimant as shown above. Dated: � ���q S BY: PHIL BATCHELOR bydeputy Clerk CC: County Counsel County Administrator ,. RECEIVED 4R 2 7 19°5 CLERK BOARD OF SUPERVISORS CLAIMS REPORT FORM CONTRA CO.�iTA CO. (Add sheets if space needed) Date: March 7, 1995 A. Claimant: Charles Harris Address: 664 - 6th Street Phone Richmond, CA 94801 Number: (510) 234-4973 B. Address to wMichaeltF. Wohlstadter, Attorney at Law 488 - 7th Street Oakland, CA 94607 C. Date of Occurrence: November 26, 1994 Location of Occurrence: 39th Street @ MacDonald Ave. Richmond, CA Description of occurrence or transaction which gives rise to your claim: County vehicle impacted claimant vehicle which was parked at time of incident and occupied by claimant. (copy of police response card attached) If auto accident: Names of Drivers: Roger Richeson (Dept. of Telecommunication Address: 1619 Shell Ave. Martinez, CA Year, Make, Model of Vehicle or Vehicles Involved: White Pickup CA license E112054; year & make unk. ; 1982 Toyata Starlight 2-door, CA lisence 2PIN668 D. Description of the indebtedness, obligation, injury, damage or loss: Property damage to front end,: bumper, etc.. ..-._(.est.attached) ; personal injury (contusions and soft-tissues; medical report attached) E. Amount of claim, including future damage or loss (with basis of computation and bills or estimates to substantiate claim) : Property damage $ 494. 74 per estimate attached. par�nnalTn3ij=y - $ 9, 500 (billing in amount of$3 , 010 attached) (Municipal Court Jurisdiction) F. Name or names of the public employee or employees causing the . injury, damage, or loss, if known: Roger Richeson Signed: lag 4. Date Signed: 3/07/95 (Give relationship if person signing claim is not claimant) y 1 ATTACHMENT TO CLAIM OF CHARLES HARRIS 2 The bases for liability against the County of Contra Costa, 3 Roger Richeson and other employees of the County of Contra Costa, 4 are as follows: 5 1. Negligence in the ownership, maintenance, control, use, 6 entrustment, repair, operation, and securing of the motor vehicle 7 of the County of Contra Costa, causing claimant injury and damage; 8 2 . Negligence in the employment, hiring, instruction, 9 training, discipline, and retention, of Mr. Richeson and other 10 employees and/or independent contractors of the County of Contra 11 Costa, causing injury and damage to claimant; 12 3. Vicarious liability of the County of Contra Costa for the 13 negligence and other improper conduct of Mr. Richeson, other 14 employees and/or independent contractors, who were at all times 15 acting in the course and scope of their employment with the County 16 of Contra Costa. 17 18 19 20 21 22 23 24 25 26 27 28 NON-YWOMABIE ACCIIF+N'r DRIVERS '—,E4 �. IE'�rlff scyl ADDRESS IGa 54/&u Aw, ' YZ�� _ PHONE # r . �t/ .S"1 -- DRIV LIN TMIM CD. 5fa- A ZA,540r'to IWIS C W NER CY e'&&,v _ A DFESS f, PHONE ACD.I= I ^ TICN eoy-�J' Y 3� SEC 16000 CVC: mcOf `S THAT ANY DR_TVER INVOLVED IN AN ACXSL'ENr RESULTl% IN DkwAG 3 CF $500 OR ME TO THEIR VEEIIC IE MUST SLEIT A RE.POt. WITHIN 15 MYS TO THE STATE. USE FORM SR-1, AVAILABIE AT.ANY axi. OF MOTOR VEHICIES OFFFICE. NOTE: NO REPORT WILL BE ON FI.LE AT THE POLICE LEPARIM4T Cg'F'ICER _ �. - uta- "�_ /a . � RPD 26 ........... �A,MAGE REPORT AR Rl a P 252 44- 0'001 P ZEY "T `ARANTE' CUSTOMER '4-N F 251 24TH STREET RIC'AuCND , C-A ?4&D4-r_ C 2 3'2' '2�-,2 3 r ts; c t t C, levo c e 348 .67 L,a b 0 2 .3 h s 51 .00/hr 11.7 .3'0 SUBTOTAL $ 465 .97 Tax on 348 .67 at i .25ccol- 28 .77 -------------------- GRAM) TOTAL. 14; 494 .74 ' N S'­'r AN C E R A.Y S 94 7� AX 0510-233-9761 E�'%"Amate based OR MQT^VR :RASH ESTItATIKS' GUIDE. !"M a',8 deTiV?G frv, '-,'Ile L,'6de HLEM6208. 'Vatabas? Date 1/95 itu* 4".d.1cat? pa-l" by d SV;P.'*:fr Other thda the QrAJi5d1 eqJiPMen, mfwfaCtUreT A PTodict of IlAc. 17:57 FROM 'JOSS PRINTING TO 8394250 P.01 1AGE REPORT H KRIS ::;/',S 244-000019(, 133 822 E By SC 3 CS-{TELES HARRIS D,:;y Phonc dress : 664 6THI STREET 0"--h N/A R.7'-14MONO C-A '34P-," Ded1Ac c- ; zsurancc Co . :C,:*'L1F0RNIA ST A'" A'-`0M'v'811.LE claim No . C!J 2`;�' c/ 0 cdom�t Tv- '10�;.ngs seatz Hiback buckat seat-- sty, ed wheels I lie/ A. R E rP R RAFT PAINT QTY P,- E:15 C R P-1 1 C F DA Mi A G E- CVS T FIRS HR-0 M,i lc;" ------------------- I FRONT &JMiPER Recond Fuc;: ba-.- asst 1 " 27 .00 1 .6 R�cond cove-, 4 GRIL-LE & LAMPS Repl LT a a o c 0 C-. Repl Aim (�eadlamps 0 .5 0 .0c SL,bto"a!:�s /4 80 7 2 V .0 emc medical STQU12 orthopaedic, physical & family medicine COMPLETE NARRATIVE MEDICAL/ORTHOPAEDIC REPORT i I RE: CHARLES HARRIS January 20, 1995 DATE OF INJURY: November 26, 1994 ATTORNEY OF RECORD: Michael Wohlstadter Attorney-at-Law 488 Seventh Street Oakland, CA 94607 j . CHIEF COMPLAINTS: 1 ) Neck pain 2) Right shoulder pain 3) Right back pain 4) Right facial pain 5) Right-sided headache HISTORY: The above-captioned patient is a 21 year old security guard who sustained injuries in a motor vehicle impact accident on the above date. He was parked in his own car in the Richmond area. He was restrained with a seat belt. Another motor vehicle pulled alongside and started to make a turn. Appar- ently the turn was too tight and the side of the truck caught on the bumper of the patient ' s car and pulled his car suddenly forward . There was damage to the left front of his vehicle and his bumper was pulled forward. ' Following this, the patient had increasing pain in the above- mentioned areas. He continued to try to work as a security guard on a part-time basis, 25 to 30 hours per week. He did not seek immediate medical attention and was hoping the pain , would subside with conservative care at home. He continued symptomatic and presented at our office for an initial evaluation on 12/2/94. At thit time he had persistent pain in the above-mentioned areas. He was still working on an as-tolerated basis but was having some difficulty doing so. 2160 vale road san palo, callfornia 94806 (510) 233-0984 ,I January 20, 1995 Page 2 Re: Charles Harris f He underwent an. evaluation on 12/2/94. He stated he was having a pain that was variable; from one to eight on a visual analogue pain scale of ten. That is a mild to intensely severe pain. He was having headaches. He was having difficulty sleeping and he was having right neck pain,, right shoulder pain, and right upper back pain. He described .the pain as being continuous and burning in nature. There was a throbbing quality to it. It was relieved by having his wife massage it and by taking aspirin. Any type of movement tended to aggravate the pain. PAST HISTORY: There have been no previous traumatic incidents involving the head, neck, mid, low back or upper back. There have been no previous auto accidents. PHYSICAL EXAMINATION: Reveals a 21 year old normally developed male who is alert and oriented to time, place and person. GENERAL DATA: Weight: 175 pounds Height: 6 feet 3 inches Temperature: 97 .4 Respirations : 12 Pulse rate: 80 Blood pressure: 120/72 HEENT: Examination of the head, eyes, ears, nose and throat revealed the pupils to be equal and reactive to light and accommodation. The extraocular movements were full. The tympanic membranes were pearly white. The pharynx was without exudate. LUNGS: The lungs were without rales, rhonchi or wheeze. I i I January 20, 1995 Page 3 Re: Charles Harris HEART: The heart showed a normal sinus rhythm and rate without murmur, heave, thrill, gallop `or friction rub. v ABDOMEN: -The abdomen was soft and nontender with normal, active bowel tones. NECK: : There is 2+ spasm and tenderness in the paracervical region from C2 down to C7, greater on the right than on the left. The tenderness extends laterally into the right trapezius area, the right suprascapular area and towards the right deltoid. There was limited mobility of the cervical spine as follows: ACTIVE RANGE OF MOTION: Flexion, extension: 3D degrees Right lateral flexion: 210 degrees Left lateral flexion: 2;5 degrees Right rotation: 30 degrees Left rotation: 35 degrees PASSIVE RANGE OF MOTION: Flexion, extension: 35 degrees Right lateral flexion: 2,5 degrees Left lateral flexion: 30 degrees Right rotation: 35 degrees Left rotation: 40 degrees There was 2+ to 3+ pain elicited with active movement of the cervical spine in all six planes . There was 2+ pain elicited with'; passive movement of the cervical spine in all six planes . There was 2+ pain elicited with resisted flexion and extension and there was 1+ to 2+ pain elicited with resisted right and left side flexions and right and left rotations. i January 20, 1995 Page 4 Re: Charles Harris f DORSAL SPINE: There is paravertebral tenderness and spasm in the paradorsal region from D2 down to D8; greater on the right than on the left . There is no deformity or swelling noted. LUMBAR SPINE: i - There is no specific tenderness, swelling or deformity noted in the lumbar spinal area. There is no sciatic notch tender- ness. There is good mobility in the lumbar spine on forward flexion, extension and side flexion. EXTREMITIES: The right shoulder has significant, limited mobility being only 60% of normal on internal and external rotations as well as abduction. There is no crepitus noted at the glenohumeral joint. There is no evidence of clavicular disruption or AC joint separation. The ' left shoulder moves fairly normally. NEUROLOGIC: Cranial nerves II through XII were intact. The deep tendon reflexes were 2+ and symmetric at the biceps, the triceps, the brachioradialis, patellae and Achilles. i Grip strength was tested using the Jamar dynamometer and the results are as follows: i The right side was 70, 45 and 35 pounds. The left side was 105 , 90 and 75 pounds. The patient is right-handed. SPECIAL STUDIES: An X-ray of the cervical spine was obtained on 12/3/94. This showed evidence of a compression fracture of the left lateral mass of C2; possibly recent. DIAGNOSES: 1 ) Acute sprain of the cervical .spine, post-traumatic. 2) Acute sprain of the dorsal spine, post-traumatic. i January 20, 1995 Page 5 Re: Charles Harris Diagnoses continued: 3) Acute sprain of the right shoulder girdle, post- traumatic. i 4) Multiple contusions involving the right face, right shoulder and right upper back. 5) Evidence for possibly recent fracture of the left lateral mass of C2, post-traumatic. 6) Post-traumatic headaches secondary to surface contusion of the cerebral hemispheres in the cranial vault. 7) Paravertebral myofasciitis with persistent myofascial pain syndrome. TREATMENT PROGRAM AND CLINICAL COURSE: The patient was initiated on a treatment program utilizing surface electrical stimulation techniques with hertz parameter settings between two and 200. Moist heat was applied utilizing hydrocolator hot packs. He was advised to try to continue to work on an as-tolerated basis. He was given appropriate anal- gesic medication for his symptoms. He was seen initially two to three times weekly during December of 1994. During that time he continued to improve gradually and progressively with j the conservative therapy given. By early January 1995, he was doing significantly better. He was using the Philadelphia-type collar which had been given to him for treatment of the cervical spinal fracture earlier. He was down to using it only three to five hours per day. He was having increased mobility in the cervical spine with decreased pain and spasm and he was sleeping better. His most recent visit here was 1/11/95. At that time he still had some residual pain in the right shoulder and right arm and some residual pain in the cervical spine. It was felt that he was coming along fairly well and that no further conservative therapy would be indicated as of that date. The patient was advised to return on an as-needed basis, depending on the level of his symptoms. He , "s still working on an as-tolerated basis. He was no longer using the Phil- adelphia-type collar to any extent. i January 20, 1995 Page 6 Re Charles Harris f PROGNOSIS AND DISCUSSION: The patient is a 21 year old male security guard who sustained injuries in a motor vehicle impact accident on the above date. He probably sustained a fracture of the lateral mass of C2 as a result of this trauma. He remained symptomatic, particularly j in the right neck, the right shoulder and the right upper back - for a number of weeks but did respond to a course of conserva- tive therapy and was doing better at the time of his most recent visit here on 1/11/95 . The patient could have some additional problems as a result of this type of injury. He may develop premature degenerative osteoarthritic changes at the C2 level as a result of this type of trauma. He may have recurrence of symptoms, aggravated by ordinary activities of daily living as well as those en- countered on the job. Often these injuries heal slowly, poorly and many times incompletely due to poor blood supply to the ligaments and fibrous tissues involved in these areas. Stretching and tearing of the soft tissues occurs, leading to hemorrhage. Hemorrhage can go on to form scar tissue and scar tissue can act as irritable sites causing these areas to be prone to recurrences of pain and spasm. We usually find in these situations that factors leading to precipitation of symptoms are: muscular exertion, holding the spine in a fixed or difficult position for extended periods of time, increased muscular activity or repeated motions of the spine. Probably these are the kinds of activities the patient could encounter in his work as a security guard. It appears the patient has stabilized at this point and recovered from the significant extent of his injuries but he could have additional problems over the next six to twelve months. He may need additional physical therapy at a cost of $500 to $700 per month. He may need some repeat x-rays, CT scan, MRI scan, EMG studies and high resolution digital infrared imaging examination especially if he has any signs of radiculopathy into the right upper extremity. He may need an additional work-up and possibly consultation with a neuro- surgeon. i i Consequently, with the above taken into account, the overall prognosis should still remain somewhat guarded. January 20, 1995 Page 7 Re: Charles Harris Should you have any further questions regarding this matter, please feel free to call or correspond. Res ectfully submitted, i nathan Francis, M. D. JF:ec i 1 ) 1 Ins * ** ** ** FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1.PATIENT'S NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME (LAST,FIRST,MIDDLE) HARRIS, CHARLES 03 1 28 1 73 HARRIS, CHARLES 4.PATIENT'S ADDRESS 5.PATIENT'S SEX 6.INSURED'S ID NO. 664 6TH STREET MALE ® ❑ FEMALE RICHMOND, CA 94801 '].RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED 234-4973 ® 1:1 ED 1:1 1:1EMPLOYERIHEALTHOPLANYED AND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 10.WAS CONDITION RELATED TO: 11.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 664 6TH STREET YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.234-4973 B.ACCIUENT 11.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ;❑ ACTIVE ❑ DECEASED BRANCH OF SVC STATUSDUTY ❑ RETIRED 12.I AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13.1 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION ATE OF: LLNESS OR INJURY OR 5.DATE IRST CONSULTED YOU .I PATIENT HAS HAD SAME OR �b.a IF EMERGENCY REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES CHECK HERE 11/26/94 O ].DATE PATIENT ABLE .DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH lg.NAME OF REFERRING PHYSICIAN .FOR SERVICES RELATED TO HOSPITAL ZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23.A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2,3, ETC. OR DX CODE 1. 847.9 -- SPRAIN, SPINE ACUTE TRAUMATICEPSDT YES El ❑ NO 2. 847.0 -- WHIPLASH, (SPINE) FAMILY PLANNING YES El ❑ NO 3. 729 . 1 -- MYOFASCITIS, ACUTE - ------------------------------------------- V PRIOR AUTHORIZATION NO. 24. A. B. C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. F' H.LEAVE BLANK DATE OF SERVICE PCE (EXPLAIN ANY UNUSUAL DIAGNOSIS E. ORS G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES) CODE CHARGES UNITS TOS 12/02/94 3 99212 INITIAL OFFICE VISIT 1 325:00 1 12/02/94 3 64550 SURF.APP.NEURO-STIM. 2 65:00 1 12/02/94 3 97010 HOT PACKS 3 40400 1 12/03/94 3 99212 OFFICE VISIT 1' 554100 1 i 12/03/94 3 64550 SURF.APP.NEURO-STIM. 2 65 :00 1 12/03/94 3 97010 HOT PACKS 3 40:00 1 25.SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT,PAID 9•BALANCE DUE 59000 J. FRANCIS, M.D. YES ❑ ❑ NO 31.PHYSICIAN S SUPPLIER'S AND OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30-YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32-YOUR PATIENT'S ACCOUNT NO. 33.YOUR EMPLOYER I.D. NO. SAN PABLO, CA. 94806 7127 I.D. NO. 0OA223650 (415 ) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-1500 1 ) 1 Ins * ** * ** * FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1.PATIENT'S NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME (LAST,FIRST,MIDDLE) HARRIS, CHARLES 03 1 28 1 73 HARRIS, CHARLES 4.PATIENT'S ADDRESS 5.PATIENT'S SEX 6.INSURED'S ID NO. 664 6TH STREET MALE ® ❑ FEMALE RICHMOND, CA 94801 '].RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED 234-4973 ® El 13 11 13 EMPLOYER IHEALTH PLANS EMPLOYED AND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 10.WAS CONDITION RELATED TO: ll.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 664 6TH STREET YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.234-4973 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER --,[:] ACTIVE ❑ DECEASED BRANCH OF SVC STATUS DUTY ❑ RETIRED 12.I AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13.I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION DATE OF: LLNESS OR INJURY ORDATE FIRST CONSULTED YOU .IF PATIENT HAS HAD SAM OR a IF EMERGENCY REGNANCY - T'FOR THIS CONDITION SIMILAR ILLNESS. GIVE DATES CHECK HERE 11/26/94 ❑ DATE PA IENT ABLE 18.DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH NAME OF REFERRING HYSICIAN .FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 3.A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2,3, ETC. OR DX CODE 1 . 729 . 1 -- MYOFASCITIS, ACUTE EPSDT YES ❑ ❑ NO 2. 847. 9 -- SPRAIN, SPINE ACUTE TRAUMATIC FAMILY PLANNING YES ❑ ❑ NO 3. 847.0 -- WHIPLASH, (SPINE) PRIOR--------------------------------------- PRIOR AUTHORIZATION NO. 24. A: PLACE C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. p, DAYS H.LEAVE BLANK DATE OF SERVICE OF (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES) CODE CHARGES UNITS TOS 12/03/94 3 72052 XRAY CERV SP ( 12 VIE 1 250:00 1 12/05/94 3 99212 OFFICE VISIT 2 55:00 1 12/05/94 3 64550 SURF.APP.NEURO-STIM. 3 65400 1 12/05/94 3 97010 HOT PACKS 11 ' 401: 00 1 12/07/94 3 99212 OFFICE VISIT 2 55:00 1 12/07/94 3 64550 SURF.APP.NEURO-STIM. 3 6500 1 25.SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT PAID 29..13ALANCE DUE 530400 J. FRANCIS, M.D. YES ❑ ❑ NO .PHYSICIAN S SUPPLIER'S AND/OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30.YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32.YOUR PATIENT'S ACCOUNT NO. 33-YOUR EMPLOYER I.D. NO. SAN PABLO, CA. 94806 7127 I.D. NO. 0OA223650 (415 ) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-1500 ,1 1 ) 1 Ins FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1.PATIENT'S NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME (LAST,FIRST,MIDDLE) HARRIS, CHARLES 03 1 28 1 73 HARRIS, CHARLES 4.PATIENT'S ADDRESS 5.PATIENT'S SEX .6.INSURED'S ID NO. 664 6TH STREET MALE ® ❑ FEMALE RICHMOND, CA 94801 '].RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED 234-4973 ® El El ❑ ❑ EMPLOYERIHEALTHOPLANYED AND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 10.WAS CONDITION RELATED TO: 11.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 664 6TH STREET YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.234-4973 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ;❑ ACTIVE ❑ DECEASED BRANCH OF SVC STATUS DUTY ❑ RETIRED 12.I AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13.I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION DATE OF:' LLNESS OR INJURY OR 15.DATE FIRST CONSULTED YOU lb.IF PATIENT HAS HAD SAME OR [b.a IF EMERGENCY REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES CHECK HERE 11/26/94 < I ❑ 17-DATE PATIENT ABLE ITDATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH lg.NAME OF REFERRING PHYSICIAN 20.FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23.A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2,3, ETC. OR DX CODE 1 . 729 . 1 -- MYOFASCITIS, ACUTE EPSUT YES ❑ ❑ NO 2. 847. 9 -- SPRAIN, SPINE ACUTE TRAUMATIC FAMILY PLANNING YES ❑ ❑ NO 3. 847.0 -- WHIPLASH, (SPINE) --------------------------------------------- PRIOR AUTHORIZATION NO. 24. A. B.PLACE C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. p• DAY6 H.LEAVE BLANK DATE OF SERVICE OF (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES) CODE CHARGES UNITS TOS 12/07/94 3 97010 HOT PACKS 1 40:00 1 12/13/94 3 99212 OFFICE VISIT 2 55 :00 1 12/13/94 3 64550 SURF.APP.NEURO-STIM. 3 65j00 1 12/13/94 3 97010 HOT PACKS 1` 401:00 1 i 12/15/94 3 99212 OFFICE VISIT 2 55:00 1 12/15/94 3 1 64550 1 SURF.APP.NEURO-STIM. 3 65 00 1 25•SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT PAID 9.BALANCE DUE 320+00 J. FRANCIS, M.D. YES ❑ ❑ NO 3 •PHYSICIAN S SUPPLIER'S AND/OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30-YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32.YOUR PATIENT'S ACCOUNT NO. 33.YOUR EMPLOYER I.D. NO. SAN PAB LO, CA. 94806 7127 I.D. NO. 00A223650 (415) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-1500 1 ) 1 Ins * * ** ** * * FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1.PATIENT'S NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME (LAST,FIRST,MIDDLE) HARRIS, CHARLES 03 1 28 1 73 HARRIS, CHARLES 4.PATIENT'S ADDRESS 5.PATIENT'S SEX 6.INSURED'S II) NO. 664 6TH STREET MALE ® ❑ FEMALE RICHMOND, CA 94801 7.RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED 234-4973 ® 11 El 11 11EMPLOYERiHEALTHOYED PLANAND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 10.WAS CONDITION RELATED TO: ll.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 664 6TH STREET YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE N0.234-4973 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ;❑ ACTIVE ❑ DECEASED BRANCH OF SVC STATUS DUTY ;❑ RETIRED 12.1 AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. 1 3•I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION DATE OF: ILLNESS OR INJURY OR 5.DATE FIRST CONSULTED YOU .1F PATIENT HAS HAD SAME OR 11b.a IF EMERGENCY REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES CHECK HERE 11/26/94 < 7 ❑ 7.DATE PATIENT ABLE .DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH lg.NAME OF REFERRING PHYSICIA . OR S R ICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23.A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2,3, ETC. OR DX CODE 1. 729. 1 -- MYOFASCITIS, ACUTE EPSDT YES ❑ ❑ NO 2. 847. 9 -- SPRAIN, SPINE ACUTE TRAUMATIC FAMILY PLANNING YES ❑ ❑ NO 3. 847.0 -- WHIPLASH, (SPINE) ---PRIOR------------------------------------------ AUTHORIZATION NO. 24. A. B.PLACE C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. D. DAYS H.LEAVE BLANK DATE OF SERVICE OF (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES) CODE CHARGES UNITS TOS 12/15/94 3 97010 HOT PACKS 1 40:00 1 12/16/94 3 99212 OFFICE VISIT 2 55:00 1 12/16/94 3 64550 SURF.APP.NEURO-STIM. 3 65400 1 12/16/94 3 97010 HOT PACKS 1' 401: 00 1 t 12/19/94 3 99212 OFFICE VISIT 2 55:00 1 12/19/,94 3 64550 SURF.APP.NEURO-STIM. 3 65:00 1 25.SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT PAID 9.B LANCE DUE 320400 J. FRANCIS, M.D. YES ❑ ❑ NO 3 PHYSICIAN S SUPPLIER S AND OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30.YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32.YOUR PAT.IENT'S ACCOUNT NO. 33-YOUR EMPLOYER I.D. NO. SAN PABLO, CA. 94806 7127 I.D. NO.00A223650 (415) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-.1500 1 ) 1 Ins * * **** *** * ** FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE Cl MEDICAID ❑ CHAMPUS Cl CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1•PATIENT'S NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME (LAST,FIRST,MIDDLE) HARRIS, CHARLES 03 1 28 1 73 HARRIS, CHARLES 4.PATIENT'S ADDRESS 5.PATIENT'S SEX 6.INSURED'S ID NO. 664 6TH STREET MALE ® ❑ FEMALE RICHMOND, CA 94801 7.RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED 234-4973 ® ❑ ❑ El 1:1EMPLOYERIHEALTHOYED PLANAND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 10.WAS CONDITION RELATED TO: ll.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 664 6TH STREET YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.234-4973 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ;❑ ACTIVE [:] DECEASED BRANCH OF SVC STATUS DUTY ❑ RETIRED 12.I AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13.I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION DATE OF: ILLNESS OR INJURY OR WR FIRST CONSULTED YOU .IF PATIENT HAS HAD SAME OR .a IF EMERGENCY REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES I CHECK HERE 11/26/941:17.DATE PATIENT ABLE .DATES OF TOTAL DISABILITY DATES OF PART AL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH NAME OF REFERRING PHYSICIAN 1 .FOR SEH ICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23.A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2,3, ETC. OR DX CODE 1. 729 . 1 -- MYOFASCITIS, ACUTE EPSDT YES ❑ ❑ NO 2. 847. 9 -- SPRAIN, SPINE ACUTE TRAUMATIC FAMILY PLANNING YES ❑ ❑ NO 3. 847.0 -- WHIPLASH, (SPINE) PRIOR--------------------------------------- PRIOR AUTHORIZATION NO. 24. A. B' C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. F. H.LEAVE BLANK DATE OF SERVICE P OFE (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES CODE CHARGES UNITS TOS 12/19/94 3 97010 HOT PACKS 1 40:00 1 12/21/94 3 99212 OFFICE VISIT 2 55:00 1 12/21/94 3 64550 SURF.APP.NEURO-STIM. 3 65400 1 12/21/94 3 97010 HOT PACKS 1' 401: 00 1 12/29/94 3 99212 OFFICE VISIT 2 55:00 1 12/29/94 3 64550 SURF.APP.NEURO-STIM. 3 65 , 00 1 25.SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT PAID 29.BALANCE DUE 320j00 J. FRANCIS, M.D. YES ❑ ❑ NO 3l.PHYSICIAN S SUF'f'LIER'S AND/OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30-YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32.YOUR PATIENT'S ACCOUNT NO. 33-YOUR EMPLOYER I.D. NO. SAN PABLO, CA. 94806 7127 1 ll..D. NO. 0OA223650 (415 ) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-1500 1 ) 1 Ins FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED SUBSCRIBER) INFORMATION l.PATIENT'S NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME (LAST,FIRST,MIDDLE) HARRIS, CHARLES 03 1 28 1 73 HARRIS, CHARLES 4.PATIENT'S ADDRESS 5.PATIENT'S SEX 6.INSURED'S ID NO. 664 6TH STREET MALE ® ❑ FEMALE RICHMOND, CA 94801 .RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED 234-4973 ® 11 El 1:1 1:1 EMPLOYER IHEALTH PLAN S EMPLOYED AND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 1O.WAS CONDITION RELATED TO: ll.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 664 6TH STREET YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.234-4973 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ;❑ ACTIVE ❑ DECEASED BRANCH OF SVC STATUS DUTY ;❑ RETIRED 12.I AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13.1 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION DATE OF: ILLNESS OR INJURY OR 15.DATES O S LTE YOU .IF AT E T HAS HAD SAME OR .a IF EMERGENCY REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES CHECK HERE 11/26/94 ❑ 7.DATE PATIENT ABLE 18.DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH 19.NAME OF REFERRING PHYSICIA OR S ICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23.A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2,3, ETC. OR DX CODE 1. 729 . 1 -- MYOFASCITIS, ACUTE EPSDT YES ❑ ❑ NO 2. 847. 9 -- SPRAIN, SPINE ACUTE TRAUMATIC FAMILY PLANNING YES ❑ ❑ NO 3. 847.0 -- WHIPLASH, (SPINE) PRIOR-------- ------------------------------ PRIOR I AUTHORIZATION NO. 24. A. B' C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. F H.LEAVE BLANK DATE OF SERVICE PLACE D. DAYS OF (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES CODE CHARGES UNITS TOS 12/29/94 3 97010 HOT PACKS 1 40:00 1 12/30/94 3 99212 OFFICE VISIT 2 55:00 1 12/30/94 3 64550 SURF.APP.NEURO-STIM. 1 65400 1 12/30/94 3 97010 HOT PACKS 3 ' 40:00 1 i 01/03/95 3 99212 OFFICE VISIT 2 55:00 1 01/03/95 3 64550 SURF.APP.NEURO-STIM. 1 65:00 1 25.SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27,TOTAL CHARGE 28.AMOUNT PAID �9.11A ANCE DUE 320+00 J. FRANCIS, M.D. YES El El NO 3 •PHYSICIAN S SUPPLIER S AND OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30-YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32-YOUR PATIENT'S ACCOUNT NO. 33-YOUR EMPLOYER I.D. NO. SAN PABLO, CA. 94806 7127 I.D. NO. 00A223650 (415 ) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-1500 1 ) 1 Ins FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED SUBSCRIBER INFORMATION 1.PATIENT'S NAME (LAST,FIRST,MIDDLE) 2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME (LAST,FIRST,MIDDLE) HARRIS, CHARLES 03_1 28 1 73 HARRIS, CHARLES 4.PATIENT'S ADDRESS 5.PATIENT'S SEX 6.INSURED'S ID NO. 664 6TH STREET MALE ® ❑ FEMALE RICHMOND, CA 94801 .RELATIONSHIP TO INSURED B.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED 234-4973 ® ❑ El El EMP OYERIHEALTHOYED PLANAND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 10.WAS CONDITION RELATED TO: ll.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 664 6TH STREET YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.234-4973 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ;❑ ACTIVE ❑ DECEASED BRANCH OF SVC STATUS DUTY ❑ RETIRED 12.1 AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13-1 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION DA E OF: ILLNESS (5-R-10 uiiy RI JURY OR . )ATE FIRST CONSULTED YOU lb I PATIENT HAS HAD S EOR .a F EMERGENCY REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES I CHECK HERE 11/26/94 4 -7 ❑ DATE PATIENT ABLE .DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH lg.NAME OF REFERRING PHYSICIAN .FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23.A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1.2,3, ETC. OR DX CODE 1. 847 .9 -- SPRAIN, SPINE ACUTE TRAUMATIC EPSDT YES ❑ ❑ NO 2. 729 . 1 -- MYOFASCITIS, ACUTE FAMILY PLANNING YES ❑ ❑ NO PRIOR AUTHORIZATION NO. 24. A' PLACE B. C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. D DAYS H.LEAV£ BLANK DATE OF SERVICE OF (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES) CODE CHARGES UNITS TOS 01/03/95 3 97010 HOT PACKS 1 40:00 1 01/09/95 3 99212 OFFICE VISIT 1 55:00 1 01/09/95 3 64550 SURF.APP.NEURO-STIM. 2 65 ; 00 1 01/09/95 3 97010 HOT PACKS 1 401: 00 1 01/11/95 3 99212 OFFICE VISIT 1 55:00 1 01/11/95 1 3 64550 SURF.APP.NEURO-STIM. 2 65:00 1 25.SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT PAID 29.BALANCE DUE 3204001 1 J. FRANCIS, M.D. YES ❑ ❑ NO 31.PHYSICIAN S SUPPLIER'S AND OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30.YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DBA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32.YOUR PATIENT'S ACCOUNT NO. 33-YOUR EMPLOYER I.U. NO, SAN PABLO, CA. 94806 7127 I.D. NO. 0OA223650 (415) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-1500 a 1 ) 1 Ins * *** **** * ** FORM APPROVED OMB NO. 0938-0008 HEALTH INSURANCE CLAIM FORM (CHECK APPLICABLE PROGRAM BLOCK BELOW) ❑ MEDICARE ❑ MEDICAID ❑ CHAMPUS ❑ CHAMPVA ❑ FECA BLACK LUNG ❑ OTHER PATIENT AND INSURED (SUBSCRIBER) INFORMATION 1.PATIENT'S NAME (LAST,FIRST,MIDDLE) .2.PATIENT'S DATE OF BIRTH 3.INSURED'S NAME (LAST,FIRST,MIDDLE) HARRIS, CHARLES 03 1 28 1 73 HARRIS, CHARLES 4.PATIENT'S ADDRESS 5.PATIENT'S SEX 6.INSURED'S ID NO. 664 6TH STREET MALE ® ❑ FEMALE RICHMOND, CA 94801 7.RELATIONSHIP TO INSURED 8.INSURED'S GROUP NO. SELF SPOUSE CHILD OTHER INSURED 234-4973 ® 1:1 13 El El EMPLOYER IHEAL�TH PLAN PLOYED AND COVERED BY 9.OTHER HEALTH INSURANCE COVERAGE 10.WAS CONDITION RELATED TO: 11.INSURED'S ADDRESS A.PATIENT'S EMPLOYMENT 664 6TH STREET YES ❑ ® NO RICHMOND, CA 94801 TELEPHONE NO.234-4973 B.ACCIDENT ll.a CHAMPUS SPONSOR'S AUTO ® ❑ OTHER ;❑ ACTIVE ❑ DECEASED BRANCH OF SVC STATUS DUTY ❑ RETIRED 12.1 AUTHORIZE RELEASE OF MEDICAL INFORMATION NEEDED TO PROCESS THIS CLAIM. I 13.1 AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO REQUEST PAYMENT OF GOVT BENEFITS TO MYSELF OR PARTY WHO ACCEPTS ASSIGNMENT BELOW. UNDERSIGNED PHYSICIAN. SIGNED SIGNATURE ON FILE DATE SIGNED PHYSICIAN OR SUPPLIER INFORMATION DATE OF: ILLNESS OR INJURY OR 15.DATE FIRST CONSULTED YOU .IF PATIENT HAS HAD SAME OR .a IF EMERGENCY REGNANCY FOR THIS CONDITION SIMILAR ILLNESS, GIVE DATES CHECK HERE 11/26/94 1 1 ❑ ].DATE PATIENT ABLE 18.DATES OF TOTAL DISABILITY DATES OF PARTIAL DISABILITY TO RETURN TO WORK FROM THROUGH FROM THROUGH NAME OF REFERRING PHYSICIAN 2 .FOR SERVICES RELATED TO HOSPITALIZATION GIVE HOSPITALIZATION D TES ADMITTED ISCHARGED 21.NAME & ADDRESS OF FACILITY WHERE SERVICE RENDERED 22.WAS LAB WORK PERFORMED OUSIDE YOUR OFFICE? YES❑ ❑ NO CHARGES 23.A DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. RELATE DIAGNOSIS TO PROCEDURE IN B COLUMN D BY REFERENCE NUMBERS 1,2,3, ETC. OR DX CODE 1. 847. 9 -- SPRAIN, SPINE ACUTE TRAUMATIC EPSDT YES ❑ ❑ NO 2. 729 . 1 -- MYOFASCITIS, ACUTE FAMILY PLANNING YES ❑ ❑ NO 3. 847. 0 -- WHIPLASH, (SPINE) PRIOR -------------------------------------- V PRIOR AUTHORIZATION NO. 24. A. B. C.FULLY DESCRIBE PROCEDURES FOR EACH DATE GIVEN. F. H.LEAVE BLANK DATE OF SERVICE PLACE D• DAYS OF (EXPLAIN ANY UNUSUAL DIAGNOSIS E. OR G. FROM TO SERVICE PROCEDURE CODE SERVICES OR CIRCUMSTANCES CODE CHARGES UNITS TOS 01/11/95 3 97010 HOT PACKS 1 40:00 1 01/23/95 3 99080-22 MEDICAL REPORT 1, 2, 3 25000 1 I 25.SIGNATURE OF PHYSICIAN OR SUPPLIER 26.ACCEPT ASSIGNMENT 27.TOTAL CHARGE 28.AMOUNT PAID 129.BALANCE DUE 290100 J. FRANCIS, M.D. YES ❑ ❑ NO 31.PHYSICIAN S SUPPLIER S AD U OR GROUP NAME, ADDRESS, ZIPCODE AND TELEPHONE NO. 30.YOUR SOCIAL SECURITY NO. JONATHAN FRANCIS,M.D SP DHA/EMC MEDICAL GROUP 01/27/95 A22365 108-30-7587 2160 VALE RD. 32.YOUR PATIENT'S ACCOUNT NO. 33-YOUR EMPLOYER I.D. NO. SAN PABLO, CA. 94806 7127 I.D. NO. 0OA223650 (415 ) 233-0984 REMARKS: JF Form HCFA-1500(C-2) (1-84) Form OWCP-1500 ����*a k"fir.°a i r•1,���"�'�--•..�..,�.� _ -- 3 ^J j SF n2J+ 4 4 �u ���"'�.; r � ysr ��:„ wN'.��9.s� "t�`l�.+A.r� � •,Y,+'"•c ✓ .f.�� * + t 'ate '".+ti fiy •fir � 3 ll, "k6 � ter'. _ r r A'�� Jf r h }}�� ., ... ` /�*r,�p r 3�� �t k� `�JJ 4 •NF1 j i l � ��,ty�'� �#1 }-• x �j `�^:.� '� ,p'�v ti�Sr ;i ~,.N 6 �� t ti-n.tl .z {"p�r:4 q ! � q T,� �w� )� r��'i� !3, +� �,, , f •' . 'd�.� '�s "tK,•.���i'hra.y � `� ,�, },d�� 4,' S 3 fF '�S+°.. t�A Y S v:,?+a1 +a.,, •*`k a5 r, :.y`jt ." }�� �, , . Y•vt` '"'s.. r % e{ ,•l k �' ,t'•t �J Sy^:41 "'�;P� �+ „r U� i�F�+ f!t ��,�k''L.SfN � ��`, F�J F�'� _ „`� �F +E,µ "g♦ .�y�1: �'Y 4 +. f �,.1 °s S,r,s� 4y u y a,�jy� �{ �� y t t� 'i.'•v �t 5�-t {"-`i��k t + +YY "�}"�+,Y. «`� a. Y.• • k �� s� si �V .{ � " r rl�i.��� ��`f, "«� PF�"'��, .a �i'ti*� z�E�•,� k� a,:, i k i is r s �t x TOYOTA . t' k s wv y #. ... � c.'e•»; �,�`�',..t.. r r'�' ,d- 7•:�- i„ :�,� ' '�� to t f 4t f•' •��1 �K `` r } �q..,�� 'ji;' t yR i r � t ` �, $ � r f"�, j P `,���s rf, ' �v ti t_ `� �y'�r„ .j�`i' 1, r- n- ""•` r.S. b'jh ! % i r..n j� ��� {SS ti 9 L'4 •-; J} ., . "�t A, n�f i �tt ��• w }� „ .r rT f tlH',"� '� 1� , F Ym � � r ;. ;� � 7�1ts�,' �rr•, ; ��+' ♦rys,m �, y�'. •� +.yq�'r �r`. ,f f, SX �i 4� ��t,"4 { r`�'}�,p'�,P { ''`#�x��'�� k. P{k - it��{�,.t,� �::'�* �.qt�.�{"tb F •`.. c °ts� , �F;, is��'� 'F f' 'x i � H �Y��`�^h� t * �Nk` i k?k �' ♦4{�n._4� �� '�.�5.•. -m + 1 ! y, .,F� �'.� t t lL tF;h f�y'.t ��� i �.»e�m r>♦�n s�v11k � ,`r r4r.+ BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 25, 1995 Claim Against the County, or District governed by) BOARD ACTION the'Soard of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $721.65 Section 913 and 915.4. Please note all "Warnings" CLAIMANT: Catherine E. Jovanovich ' ATTORNEY: MAR 2 9 1995 Date received COUNTYCOUNSEL BY DELIVERY TO CLERK ON March 29 1 RTINEZCALIF. ADDRESS: 737 Palm Ave. • Martinez, CA BY MAIL POSTMARKED: Hand D 1 iyereci I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: March 29, 1995 gq?L aep�tyLOR, Clerk ` CA A 11. FROM: County Counsel TO: Clerk of the Board of Supervisors {v4'This claim complies substantially with Sections 910 and 910.2. { ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: CJ BY: Deputy County Counsel I11. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Superviscrs present ( J) This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. ,` Dated: �„p�,�� oto PHIL BATCHELOR, Clerk, By Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only Six (6) months from the date this n6tice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the united States, over age 16; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: BY: PHIL BATCHELOR b Deputy Clerk CC: County Counsel County Administrator Claim.`io: BOARD OF SQPERYISORS OF C Y6-7RA COSTA COMM 7 INSIRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury -�o person or-to per- sonal property or growing crops and which accrue on or before December 31, 1987, must be presented not later than the 100th day after the accrual of the cause of action. Claims relating to causes of action for death or for injury to person or to personal property or growing crops and which accrue on or after January 1, 1988, mu; t be presented not later than six months after the accrual of the cause, of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code 6911.2.) B. Claims must be filed with the Clerk of t`:+e Board of Supervisors at its office in Room 106, County Administration Building," 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the. name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. "Fraud._ See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this TF-M. RE: Claim By ) Reserved for Clerk's filing stamp V t t.A) NMI Against the County of Contra Costa ) MAR 29 i�L;5 or ) District) CLERK BOAR®OF SUPERVISORS Fill in name ) I CONTRA COSTA CO. The undersigned claimant hereby makes clai inst the ty of Contra Costa or the above-named District in the sum of $ • and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) 2. Where did the damage or injury occur? (Include city and county) 3. How did the damagg or i,pjury occur? (Give full details; use extra pa if required) (Z,�i co �� .fib �► ��� • - "t . ' . What particular act or omission on the part of countbu strict officers, servants or employees caused the injury ci, damage? 1- u,. V rr• a0M46 4 uut.. lg. �b /a,• Z l Y 5. What are the names ��f count or distric5. officers, servants or employees causing" :Y: the damage or Wlz7? CO CO U k 5. What damags or injuries do you claim resulted (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. r 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) Be Names d ddress!/e\s�ow witnesses, doctors and hospitals. 9. List the e,Penditures you made on account cf this accident or injury: DATE ITEM AMOUNT 1W , C*T Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some perspa,,on his behalf." Name and Address of Attorney NP V rA Claiman s Signature Ad ss Telephone No. Telephone No. NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city or district board or offices, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ( 1,000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($109000, or by Doth such imprisonment and fine. y - - -�- ; ----� --�r�-mac_-- � --=------ ---- T7 _ o Aft- rw ;a Cly rtoll 7G0'9 �- mss 4 05 R c A i , ����/ , ��r, .� i� � , /.� y .� ,. ,. ..� ._ � ,, S � � a % `` � n � � ,/ 9 Nr �' � '` P ' � ' � �.��� e _��> ���� �Id� i _��,�,, � ��, / i, � � � ����� � � .� ' .� � � �, � t 1 /% � %� ' � 1 � .•i i ESTIMATE OF REPAIRS AS LISTED FOROf AND MATERIA -VERBAL AGREEMENTS NOT BINDING-ESTIMATES FREE . (V'u� 8001 OW ER �� DATE .� Q,,c t2)i '34 �Y1J AD SS PHONE EST,NO, INSURANCE CO. ORDER NO. ADDRESS �<: PHONE LNSE NUMBER / YEAR-MAKE MO L MILEAGE MOTOR NO. l`/✓SfEE-RIAL NO. QUAN. DESCRIPTION OF LABOR OR MATERIAL PART NO. MATERIAL LABOR mow'` t4O co O cQ3 00 PARTS PRICES BASED ON STANDARD CATALOG PROCUREMENT PRICE LISTS SUBJECT TO CHANGE WITHOUT NOTICE. TOTAL PROCUREMENT AND DELIVERY CHARGES MAY BE ADDED FOR SPECIAL SERVICE ON ITEMS NOT AVAILABLE LOCALLY. MATERIAL OLD PARTS REMOVED FROM CARS WILL BE JUNKED UNLESS OTHERWISE INSTRUCTED IN WRITING. THE ABOVE IS AN ESTIMATE BASED ON OUR INSPECTION AND DOES NOT COVER ADDITIONAL PARTS OR LABOR WHICH 6690),A 6 TOTAL LABOR Q MAY BE REQUIRED AFTER THE WORK HAS BEEN OPENED UP.OCCASIONALLY AFTER WORK HAS STARTED WORN PARTS ARE TOTAL MATERIAL DISCOVERED WHICH ARE NOT EVIDENT ON FIRST INSPECTION.BECAUSE OF THIS THE ABOVE PRICES ARE NOT GUARANTEED. ESTIMATE TAX � �y ESTIMATED BY NakAPPROVED BY AUTHORIZED AND ACCEPTED PAID OUT-TOW&STORAGE ��cc��, SUBLET REPAIR L.J W BY OWNER YOTA OR AGENT DATE PdFQttWim 4L429 JAN-13-1995 15:51 FROM PG&E CONCORD COST SUC TO CONCORD T&D P.01 Ticket 4: B74090 01V13/95 14:53 CUSTOMER ASSISTANCE FORM Sent to: JG CONCORD FAX: 0-441-4511 Type of Item: COMPLIMENTS/COMPLAINTS FAX Status: AUTO -------------------------------------------------------------------------- Account Number: 036621.8505 G Schad: G IX E Schad: E 1XB Name: BERNARD W TAYLOR Contact: Service Address, 737 PALM AVE X-Street: City; MARTINEZ ST: CA ZIP; 94553 Mailing Address: City: ST: ZIP Home Phone; 510/372-5509' Work Phone: 510/000-1194 Contact Phone: 510/372-5569 Problem: GUST IS COMPLAINING ABOUT POT HOLES & RUBBLE IN FRONT OF HER HOUSE ON HER HOUSE, WE DID NOT PUT UP WARNING SIGNS, CUST- S CAR GOT TORN UP BY DRIVING OVER POT HOLES. PLEASE SEE IF THIS CONSTRUCTION JOB ZS OURST & CONTACT CUSTOMER. Comments & Commitments: -----------------------------------------------------------L- ------------- Originating Call Center; FRESNO Phone Number: 8-877-5401 Taken By: I-GF2 LARRY FRISBY r me TOTAL P.01 � 1 I f 1^ ��. �� ` , ' \\./� V ��,r�`� . yam" �� v . _ � , . . _ _ _ �� Al- 4- =m` e a W � C t � SAAR , r _ 'Yl y}k s � nk u s sy F d P' � r ^s M Yal yrs, aw / k 3 � ^d x, IN, 4. r rl` i ' S Y JI wLN d y+� �x Ab..f s v y,• "" r bs a e 7 w h•• .�. �.w �, �•,�. va r+..� s� ( �� P`'."a - c3 '='scat '✓� y � .'r i � 4 Y �mP ^=c .�., v, •'' '� ria"�' .: of y y",5 `4 � ,��"'`'y-u.'• . w�``�.t%,�,s•",My3' :�. 4 4 k$ r i r, i �t ti• f ttJit�' �,�A ,�4y` Y 7y� y, i "M•1�jY p ,3 $�A9,,r POP t�;�`�. 'y'�3 3��;e,�¢^ t- ,y�,.,•!ra e." �' fir. .. t f eft - �... gip. d y. . ' � � .. kyr ✓, �k�"a x i ' r P� -52 K .-,k1 ms� g i. .} �� :� ��•*.. »„. d CLAIM . as BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 25, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $10,000.00+ Section 913 and 915.4. Please note all "Warnings". CLAIMANT: Mobert McIntyre ATTORNEY: Michael D. Thamer MAR 2 3 1995 Attorney at Law Date received COUNTYCOUNSEL ADDRESS: 210 Fourth St. BY DELIVERY TO CLERK ON Marct Marc--h 23, 1944ATINEZCAtp Yreka, CA 96097 BY MAIL POSTMARKED: Hand Delivered via- Rick Mgmr= I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim, ppH gg DATED: March 23, 1995 BIL DepuiylOR, Clerk 11. FROM: County Counsel TO: Clerk of the Board of Supervisors {o< This claim complies substantially with Sections 910 and 910.2. { ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send �l warning of claimant's right to apply for leave to present a late claim (Section 911.3). \. Other: (yoga lel 9 g5$•� jg5(0 "til Dated: BY - Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (✓) This Claim is rejected in full. ( ) Other: I certify that this is a -true and correct copy of the Board's Order entered in its minutes for this date. , J Dated: J S PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or ieposited in the mail to file a court action on this claim. See Government Code Section 945.6. fou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. AFFIDAVIT OF MAILING detlare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the lnited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, ;alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to :he claimant as shown above. iated:_� oZ7 :> BY: PHIL BATCHELOR bXALL C,1410Deputy Clerk ;C: County Counsel County Administrator .Michael D. Thamer RECEIVED Attorney at Law d�oMd � 210 Fourth Street 2 31995 Yreka, CA 96097 (916) 842-9000 -'1 CLERK BOARD OF Sr;P-RVISORS Attorney for Claimant, MOBERT McINTYRE _rnNTPA COSTA CO. Claim of Mobert McIntyre ) CLAIM FOR DAMAGES [Governmental Code §910] against ) MERRITHEW MEMORIAL HOSPITAL ) AND CLINICS ) TO MERRITHEW MEMORIAL HOSPITAL AND CLINICS: 1. Claimant, MOBERT McINTYRE, whose address is 2921 Bay Village Circle, Apt. 1023, Santa Rosa California 96403, claims damages from Merrithew Memorial Hospital and Clinics in an amount that exceeds $10,000. 00. [Governmental Code 5910(f) ] 2 . Jurisdiction over this claim would rest in Contra Costa County, Superior Court and/or U.S. Federal Court, Eastern District. 3. This claim is based on the facts and circumstances surrounding the diagnosis performed by certain employees of Merrithew Memorial Hospital and Clinics on or about September 25, 1994 which led to a conclusion that Claimant was a danger to herself or others and/or otherwise qualified to be held pursuant to the provisions of Welfare and Institutions Code §5150. By wrongfully diagnosing and restraining Claimant's movement, the conduct amounted to a false imprisonment and/or unlawful arrest which resulted in damages to Claimant, including general damages for, among other things, humiliation, emotional upset and stress, loss of freedom, loss of ability to move freely and communicate with third parties, loss of funds associated with same, as well as expenses associated with retaining counsel for purposes of advising Claimant concerning her rights, and other damages in amounts which will be established at a later date. 4 . The names of the public employee(s) causing Claimants damages are currently unknown. All notices and communications concerning this claim should be sent to Michael D. Thamer, Attorney at Law, 210 Fourth Street, Yreka, California 96097. DATED: March , 1995. c MICHAEL D. THAMER Attorney for Claimant Son Harvey, errithew VAR 2 31995 emorial T4 O�p�4Lad AND C LI N IC S March 20, 1995 To: Contra Costa County Counsel From: Mark Finucane,Health Services Director Re: Mobert Mdntyre Enclosed please find a Claim for Damages sent by certified mail to Patient Accounting and transmitted to Merrithew Memorial Hospital and received 3/21/95 regarding the above-named patient. enc. cc: Ron Harvey �7 o cin gra Costa 'County `�,; - j CLAlk ' • IO. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA April 251 1995 � • a-.S Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $705,185.00 + Section 913 and 915.4. Please note all "Warnings". CLAIMANT:Dr. Daniel Merrill and Mrs. Tamaki Merrill ATTORNEY:Robert L. Grant, Esq. MAR 2 3 1995 Grant & Sternberg Date received COUNTYCOUNSEL ADDRESS: 540 Lennon Lane BY DELIVERY TO CLERK ON March 23, 199514AR INEZCAUF= Walnut Creek, CA 94598"- BY MAIL POSTMARKED: Hand Delivered 3. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ��1L BATCHELOR, Clerk ' DATED: March 23, 1995 : Deputy I]. FROM: County Counsel TO: Clerk of the Board of Supervisors ( ✓f'This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). f ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: BY: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 9]1.3). IV. BOARD ORDER: By unanimous vote of the Superviscrs present ( V,� This Claim is rejected in full. ( ) Other: I certify that this is a -true and correct copy of the Board's Order entered in its minutes for this date. Dated: 39,5—PHIL BATCHELOR, Clerk, Bya'� 0--- 0AAJ0 Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or iepcsited in the mail to file a court action on this claim. See Government Code Section 945.6. fou may seek the advice of an attorney of your choice in connection with this matter. If you want to consult in attorney, you should do so immediately. AFFIDAVIT OF MAILING declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the )nited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, ;alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant. addressed to :he claimant as shown above. )ated: 01� • 19� BY: PHIL BATCHELOR bA&dQQAy eputY Clerk ;C: County Counsel County Administrator A. Claims relating to ezau,ses of action for death or for Wv*' •.a person or to per- sonal, property or growing Crops and which aocr e on or before December •3x, 19877 must be prriesented not deter than the 1,QOth day after the &,OcMal,,Of the Cause of action. Claims relating to causes cit co;tlon for death or for Injury to person: : ,' : or to personal property or growing amps and which accrue sea or anter January lo 1988, must be presented riot later that six t the after the Accrual of the cause of action., Claims slating to only:other cause of action must be presented not later,than One year after the aeoru of the oause of action. (Govt. Code 5911.2. ., • ,r B. Claims mmt be filed with the Clerk of the Board of Supervisors At 1t3 Office in Roam 106, County Administration Duildingo 851. pine Street, wrtinezo CA 94553* Co if claim is against a distrietga verned by the Board of Supervisors, rather than . the County, the rAme of the Di3trict should be filled in. D. if the claire is against taore than one public entityp separate claims must be filed against each public entity. E. Fraud. See penalty for fmwdulent claims, Penal Code Sec. 72 at the end of this car +� aaaararrraraaraeaaaaa +� raaaaaaa * aa • aaa F.r.s Claim By ; Reserved for Cl.erk'a filing stamp DR. DANIEL MERRILL MRS . TANIAKI MERRILL } RECEIVED` > ffMA!R} ad- 66 ga nsthe ny o ntra ossa or 2 9 9 5 District) CLERK BOARD OF SUPERVISORS Fill n rkame ) CONTRA COSTA CO. ne undersigned claimant hereby makes claim against the County of Contra Costa or sa the above- =d District in the sum of $ 7os,1 5.00* and In support of this claim represents as f011OWS2 *plus additional amounts not yet determined. 1. MGn did the damage or injury occur?. .(Give exact date and hour) This claim has arisen over time, as set forth in the attached Claim for Damages Against Contra Costa County. Claimants did not discover their claim until sometime after the receipt of a ,letter dated September 23, 1994. 2. W. ere did the damage or injury occur? (Include City and oaunty) Lot 9, Subdivision," #6443, Contra Costa County, California: 3. Row did the damage or Injury Occur? (Give full det&113; use extra paper If required) . See attached Claim for Damages Against Contra Costa County. +a. what particular,act or .=433ion ion ;the Part of county or district offfoera, servants or ezployees tauaed the . z�jui-y or ? Approval of Final Subdivision Map for Subdivision 46443 in contravention to mandafo:Yy`, :. requirements of the County Code and Contra Costa County Health Services Department related to individual sewage (septic) systems. See attached Claim for Damages Against Contra Costa County. (over) 5, 1 ,a: athe n =s of Or diS-riot Q4Siccrs, Berm'%tz or ��.oyees ca re using the da=ge of C r injury? The Board of Supervisor as of July 28, 1990, W.L.. Grossi, George Nakamura, Joseph Doser� and others not yet determined. 6. What da=se or injuries do you claim resulted? (Give full extent of in juries or damps claimed. Attach two estimates for auto damage. Purchase price, money expended in attempting to develop property, attorneys, fees expended in rescission of purchase litigation and related damages as outlined in the attached Claim for Damages Against Contra Costa County. 7. Now was the amount claimed above. oamputed?, (Include the estiMted 8=1iu t of any prospective injury or damage.) See itemization in the attached Claim for Damages Against Contra Costa County. I S. Names and addresses of witnesses, doctors and hospitals. Claimant's; County officials listed in response to item #5, Dantotten, Alhambra Valley Ranch, a California Limited Partnership, Flett & Assoc. , Dan Bergman, Nancy Fanden, and'.Mark Ross. 9. List the ex;)Pnditures you made On iccoUnt, of this A cent or injury: DATE ... EM See itemization in the attached Claim for Damages Against Contra Costa County. a r a a r a r r r +: r a r a :► r a a a e a f a a a a a �r a s r: N �t a a a •' a a a r Gov. Code Sec. 910.2 provides: "The claim wmra wast be signed by the claint SE 'J NOTICES T0: (Attorney) some person on his behalf." Naze and Address of Attorney NT & STS ERINBERG By: az Robert L. Grant, Esq. (Claimant'sgnature GRANT & STERNBERG Robert L. Grant, Esq. 540 Lennon Lane 540 Lennon Lane ' Walnut Creek, CA 94598 Ad SS Walnut Creek, CA 94593 (Attorney for Claimants) Teleph. OM No. (510) 946-1400 Telephone No. (510) 946-1400 1� aaea00 T 0 0 � � • NOTICE Section 72 of the Penal Code provides: *Every person who, with intent to defrauds prewta for ally or for . payment to any state bow-d or officer, or to any Oounty, City or d,istriot board or affi*tr, Uthorixed to ILUow or pay the same if genuine, any Wee or fraudulent claim, bill, account, vouoher, or writing, iR punishable either by Inprriseanment in the aaunty Ail for a period of no mar t= 00e year, by a fine of not meeding ane thousand 41 DOp?, or bar both . ivah mprx30nment and fine, or by imprimor�m nt in the state prison' by a fine of phot' ex4,;. tern thousand dol�,M OlOj s�:6r k►yi both Ruch fmprisdnment and fire. CLAIM FOR DAMAGES AGAINST CONTRA COSTA COUNTY March 22 , 1995 Name and Address of Claimants and Claimants' Attorneys: Dr. Daniel C. Merrill Ms. Tamaki Merrill 2127 Danville Blvd. Walnut Creek, CA 94595 (510) 228-6800 Acting on behalf of Dr. and Mrs. Merrill: Robert L. Grant, Esq. Grant & Sternberg 540 Lennon Lane Walnut Creek, CA. 94598 (510) 946-1400 The law firm of Grant and Sternberg, acting on behalf of its clients, Dr. Daniel C. Merrill and Ms. Tamaki Merrill, (hereinafter "Claimants") , hereby submits the following claim against Contra Costa County, and/or its subdivisions ("the County") , for any and all liability resulting from. its acts and omissions described below. General Circumstances This claim arises from the approval of subdivision # 6443 . A tentative subdivision map was first prepared in January of 1984 and submitted to the County for checking in February of that year along with an application for approval thereof. In March of 1984 , the Contra Costa County Health Services Department Environmental Health Division ("Environmental Health Division") notified the developer of the requirement to pay certain fees to determine feasibility of individual sewage disposal, and possible percolation tests which may be required. This was in compliance with County Code 420-6. 3 which requires that there be sewer connection, unless the Environmental Health Division determines that connection to a sanitary sewer is unavailable, in which event an application may be filed for a permit to install an individual septic system. In August of 1984 the tentative subdivision map was revised, and thereafter in the' same month the Contra Costa Planning Department notified the County's subdivisions and other agencies that Septic tank approval was required for each development site. On December 4 , 1984 , the County Planning Commission approved the negative declaration and the revised tentative subdivision map. County Code Chapter 420-2 et seq. , and specifically 420- 6. 511 require that the tentative map show, among other things, proposed provisions for sewage disposal, number of lots, size of each lot, and contour lines at intervals of five feet or less. That provision further requires that the health officer review the filed tentative map for compliance with the sewage disposal requirements and report his conclusions thereon, together with any conditions recommended to inure compliance to the planning department and advisory agency. Finally that provision imposes a mandatory duty that "Final Maps shall not be recorded unless the conditions recommended by the health officer and established by 2 the advisory agency on approval of the tentative maps have been satisfied. " §420-6. 511 (c) . In addition to the requirements in the County Code discussed above, pursuant to Chapter 420-6 of the County Code, detailed Regulations have been adopted by the County Health Officer Governing Installation of Individual Sewage Disposal Systems. Regulation Article 420-1. 6 then defines the requirements of individual systems. These include, among other things: 1) a building sewer; 2) a septic tank; 3) an acceptable absorption system; and 4) an area for 100% expansion of the absorption system available and reserved for future use. 420-1. 601. A site evaluation is conducted and "the ground slope of the portion of the lot in the area designated for the individual system shall not be greater than 20 percent. " The system also shall not be installed in an area known to be subject to erosion or landslide. " Reg. 420-1. 603 . Installation in swampy areas, areas of high water table, standing water are subject to flooding more often than ten years "shall not be acceptable" and the water table must be more than five feet below the bottom of the proposed absorption system. Id. Furthermore, "no portion of the lot in which there is ledge rock, hard pan, heavy tight clay soil, or other impervious functions will be acceptable for expansion of the individual sewage disposal system and "minimum soil depth immediately below the bottom of the leaching device shall not be less than five (5) feet. " Reg. 420. 1603 . Percolation tests are conducted "with the health officer" in 3 test holes he designates. Reg. 420-1. 604. This regulation also specifies the specific means for doing the test. The percolation rate is the time "in minutes" for water to drop (1) inch. If the percolation tests exceed 1/2 of specified times for different sized gravel packed test holes "an individual system shall not be allowed. " 420. 1-604 . Specific requirements also exist for how to construct the system, including the materials, piping, location, septic tank and absorption system. Inspections are also required to ensure compliance. In December of 1984, the Contra Costa County Health Service Department, reported to Supervisor Nancy Fanden that each lot area meets slope requirements, but essential percolation test data has not yet been accumulated. The Health Department further informed Supervisor Fanden that the County Code "prohibits filing of the final map" unless conditions recommended by the Health Officer and established by the advisory agency on approval of the tentative map have been satisfied. In March of 1987, the Environmental Health Division reported to the Community Development Department that the subdivision was approved following satisfactory percolation tests. In fact, based on later test results reported later, it is clear that such satisfactory percolation tests never occurred. Nor did the subdivision ever satisfy the conditions recommended by the Health Officer and established by the advisory agency on approval of the tentative map. 4 Nevertheless, based upon the incorrect report made in 1987 that the septic requirements were met, on July 28 , 1989, the Board of Supervisors approved the Final Subdivision Map. This was in direct contravention to the mandatory duties imposed for approval of the Final Map by the County Code and regulations adopted by the Health Officer. In 1992, Claimants purchased lot 9 in the subdivision. The purchase price was $379, 000. 00. At the time Claimants purchased the lot they intended to build their dream home, which was to be approximately 4200 - 4500 square feet and have 4 bedrooms plus a den. In purchasing the lot, Claimants relied on the fact that the final subdivision map had been approved by the County and that the lot could be developed for their home, as it met all of the requirements for an individual septic system. However, before construction on the Claimants' home could proceed, Claimants had to obtain a permit for the septic system which would be constructed when their home was built. Accordingly, in September and October of 1993, percolation tests and a site evaluation were conducted by the County. Thereafter, the County and claimants exchanged a series of correspondence regarding conditions that would be imposed by the County to install a septic system, and how such conditions might be satisfied. Those letters culminated in a letter dated September 23 , 1994 from George Nakamura of the County Health Department to Dan Totten, in which the County granted conditional approval of a 5 site waste disposal requirement, and documented certain deficiencies in the ability of the site to meet the requirements imposed by the County Code and regulations for septic systems. The conditions imposed by the County are such that Claimants cannot feasibly build their dream home which they intended when they purchased the property. Furthermore, the deficiencies listed with respect to mandatory requirements for septic systems, are items that can never be satisfied. These include insufficient rates of percolation, soil which is too shallow, insufficient soil over bedrock, slope that is too steep, and inadequate space to locate required replacement leachfield lines. Nature of Claimants' Claim: Claimants' claim that the final subdivision map should never have been approved because of the failure to meet mandatory County requirements, and that the County Health Department wrongfully advised the County Planning Department that the subdivision, and specifically Lot 9, complied with the Health Department's regulations. Had the subdivision never been approved, or the Health Department not declared the subdivision compliant with County Health Department regulations, innocent purchasers such as claimants, who were the intended beneficiaries of the statutes imposing minimum requirements for septic systems, and regulations specifying standards of compliance, would not have purchased lots and now have essentially undevelopable property. Claimants seek to recover in this claim all damages which they have incurred arising from the purchase of their lot 6 in this subdivision. Damages Claimed. Claimants seek to recover in this claim all amounts which they expended in connection with the purchase and attempts to develop the lot because the lot would never have been created had the County followed its own codes and regulations. Those damages are as follows: $379, 000 - purchase price of Lot 9 $ 26,835 - engineering and related costs. $ 32, 000+/- - moneys lost in paying down principal balance of refi loan on existing home. Amount unknown - interest differential. $15, 000 - $25, 000 - tax penalty for failure to reinvest refi funds in new residence within two years. $75, 000 - loss in value of Danville residence during delay. $127, 350 - Stigma damage. $50, 000 - Attorney's fees. Conclusion: For the reasons stated above, Claimants hereby submit the within claim pursuant to California Government Code Section 905 et seq. Claimants claim that Contra Costa County is legally responsible for all damages incurred by Claimants arising from the purchase of their lot, which should never have been allowed to be created. This claim includes claims for attorneys' fees and costs incurred in prosecuting a case to rescind the purchase 7 against Alhambra Valley Ranch, which is currently ongoing and would never have occurred, but for the Third Party tort of the County. Please send all communications to the Attorneys for Claimants at the address noted above. Dated: March 22, 1995 GRANT & STERNBERG By Robert L. Grant Attorneys for Claimants Daniel and Tamaki Merrill 8 CLAIM ' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA Appril 25, 1995 Claim Against the County, or District governed by) fOARD ACT10N the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: Unknown Section 913 and 915.4. Please note all "Waren s;':+ CLAIMANT: Olive Nkherean e ATTORNEY: Priscilla S. Winslow HAR 405 Fourteenth St. Ste 1100 Date received Cc�u1�MARTINEZ FL MARTINEZ CALF. ADDRESS: Oakland, CA 94612 BY DELIVERY TO CLERK ON March 24, 1995 BY MAIL POSTMARKED: Hand Delivered via: County Counsel 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. . ppHHIL BATCHELOR, Clerk DATED: March 27, 1995 B1 : eputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors (� This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: tJ—,a-7 —S BC � �t�e Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Superviscrs present ( This Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated:(24&661190f5 PHIL BATCHELOR, Clerk, By0_AAA.QJ2&,:L�, Deputy Clerk WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. if you want to consult en attorney, you should do so immediately. AFFIDAVIT OF MAILING 1 declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the Jnited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, :alifornia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. J )ated: a �q Q, _ BY: PHIL BATCHELOR by Deputy Clerk :C: County Counsel �-�—�--+ County Administrator Law offices of Priscilla S. Winslow-PERSOINEEL DEPT 95 FEB -9 Pli 1: 13 405 FOURTEENTH STREET.SUITE 1100 95 SOUTH MARKET STREET.SUITE 300 OAKLAND.CALIFORNIA 94612 SAN JOSE,CALIFORNIA 95113 (510)839-2543 (408)995-3238 FAX(510)839-7839 Reply to: PRISCILLA S.WINSLOW Oakland CATHERINE A.PORTER San Jose p 3 � ,,AFt7,1�;'= .G" ;;;February 7, 1995 Q Merit Board `s t 3 1995 Contra Costa County MERIT BOARD OFFICE 651 Pine Street, 3rd floot RECEIVED CONTRA COSTA COUNTY Martinez, CA 94553-1292 EMAR1995 Re: Olive Nkhereanye, R.N. CLERK BOARD OF SUPERVISORS Dear Merit Board Members: CONTRA COSTA CO. This firm represents Olive Nkhereanye , R.N. , whose employment at the Merrithew Hospital and Clinics, Detention Facilities, was terminated on or about December 16, 1994. We believe that her termination was discriminatory based on her age and her national origin and accent (African--Lesotho) . In anticipation of Ms. Nkhereanye's appearance before the Merit board on February 28, 1995 and pursuant to Part 14 of the Personnel Management Regulations of Contra Costa County, please consider this a complaint of discrimination to supplement Ms.. Nkhereanye's original complaint submitted to you on or about December 22, 1994. - I. The elements of a prima facie case of discriminatory termination based on age and national origin and accent: In order to establish a prima facie case of discriminatory termination based on age or national origin, Ms. Nkhereanye need only show that: 1) she was a member of a protected class (i.e. age, national origin) ; 2) she was qualified for the job she was performing and was satisfying the normal requirements in her work; 3) despite her qualifications and her performance being at least comparable to co-workers, she was terminated from her nursing position; 4) after her discharge, the County assigned persons younger than her and not of her national origin, including accent, to perform the same work. See McDonnell Douglas Corp. v. Green (1973) 411 U.S. 792; Texas 1 Dept. of Community Affairs v. Burdine (1981) 450 U.S. 248, 252- 256; Flowers v. Crouch-Walker Corp. (7th Cir. [Ill. ] 1977) 552 Fed. 2d 1277, 1281,1282. Moreover, the California Fair Employment and Housing Commission ("FERC") which administers the California employment discrimination statutes finds discrimination if a preponderance of all the evidence demonstrates a causal connection between the complainant's protected status and the adverse employment action. II. Facts upon which tis. Nkhereanye claims discrimination establish a prima facie case of discrimination. A. Ms. Nkhereanye is a member of protected groups based on her age, 64 years old, and her national origin and accent, African--Lesotho. B. Ms. Nkhereanye was, and continues to be, qualified to fill the position of Registered Nurse ("R.N.") and assistant to the charge nurse for the County hospital facilities and absent discriminatory criticisms by Director Rael, performed her job satisfactorily. 1. Ms. Nkhereanye first obtained her California nursing license in October, 1960. She is a highly-trained and educated nursing professional, having had extensive nurses' training in South Africa, specializing in Medical/Surgical nursing and midwifery. In 1981, she obtained her Master of Arts Degree in Human Resource Management from the University of Redlands in San Bernardino County, California. She has taught seminars on organizational skills and team-building effectiveness. From the 1970's to the present, she has taken various classes and seminars at least every two years. 2. Ms. Nkhereanye first filled the position of R.N. at the detention facilities in November, 1987, and was promoted to the position of assistant to the charge nurse in 1991. 3 . From November, 1987 to approximately_ November, 1994, Ms. Nkhereanye received no complaints concerning her job skills or performance. 4. Doctors with whom she has worked for several years at the hospital . detention facilities highly recommend her job skill and performance. (Please see enclosed letters of recommendation. ) C. Criticisms Ms. Nkhereanye may have received concerning her job skills or performance arose out of age or accent bias: 2 1. In a conversation between Ms. Nkhereanye and Director Rael in or about August, 1994, Ms. Nkhereanye explained a patient's symptoms and recommended that the inmate receive emergency medical care. Director Rael responded that he could not understand her and that he wanted to speak with another nurse. After he spoke with another nurse with whom he was familiar, who was in her 201s, and who had no African accent, he ordered that the inmate receive emergency care. (See Ms. Nkhereanye's original complaint. ) Up to this time, no one at the County had 'in any way indicated that her accent interfered with her effectvely communicating. 2. In a conversation with Medical Director Rael in November, 1994, Nurse Nkhereanye, after evaluating a patient's vital signs, recommended that a patient receive emergency medical care. Again, Director Rael complained that he could not understand her and that he wanted to speak with another nurse. The nurse with whom he spoke and with whom he was familiar was in her 30's and did not have an African accent. After he spoke with this second nurse, Dir. Rael recommended that the inmate in question be admitted to emergency. (See Ms. Nkhereanye's original complaint. ) Other than the incident described above, up to this time, no one at the County had in any way indicated that her accent interfered with her effectvely communicating. D. The nursing staff predominantly comprises persons who are at least 20 to 25 years younger than Ms. Nkhereanye. Out of approximately 30 employees, she was the only person who was 60 years old or older. There are only approximately two nurses working for the County hospital detention facilities who are as old as in their 501s. This may reflect a bias in hiring as well as discharge practices as far as age. E. In December, 1992, Ms. Nkhereanye applied for the vacant position of charge nurse. She received no response to her application. Moreover, the position was filled by another per diem nurse with less seniority who was no more qualified than Ms. Nkhereanye and who was in her late 301s. F. Ms. Nkhereanye has been given no reason for her termination other than she failed "to meet Per Diem contract requirements. " (See attached termination letter dated December 16, 1994. ) E. Persons who have no African accent and who are much younger and who are predominantly in their 30's or 40's continue to be employed -as nurses for the detention hospital facilities and to be treated with professional respect and confidence by the County and Director Rael. 3 III. Based on the facts, the County's termination of Olive Rkhereanye was discriminatory. The only conclusion that can be drawn from the above facts is that Ms. Nkhereanye's termination was the product of an age and accent bias by the County and Mr. Rael. Ms. Nkhereanye had been working with the County as an R.N. since 1987 free of criticisms. According to several doctors with whom she worked, she is very capable, skilled, and dedicated to her job and patients. In 1992, she evidently was skipped over for the charge nurse position which was given to a person in her 301s. What little criticism she has received, occurred only in the last six months and appears to have arisen out of an age and accent bias. Even though she had been working for the County for over seven years, Dir. Rael made no effort to aid her in improving any alleged performance deficiencies--a fact which further questions his motive concerning Ms. Nkhereanye and whether he had any interest in seeing Ms . Nkhereanye improve any alleged deficiencies and continue her employment. IV. The Remedy Ms. Nkhereanye seeks: The remedy that Olive Nkhereanye seeks is compensation for loss in wages and compensation for attorneys' fees she has had to incur to defend against her termination by the County. Ms. Nkhereanye's hourly wage was approximately $ 33/hour; she worked approximately 40 hours/week. Her yearly income was approximately $62,000/year. Although she is seeking employment as a nurse at other health facilities, she remains unemployed. Thus, Ms. Nkhereanye requests $ 10,560 for an 8 week loss in wages to date and $2,500 to compensate her for the attorney fees she incurred. Additionally, she requests front pay for two years. Having had worked at the County for over seven years, there is no doubt that, absent discrimination, she would have continued working there for at least two more years. Ms. Nkhereanye and I look forward to our opportunity to further state her case at your February 28 meeting. If you have , any questions regarding this matter, please call me at the above Oakland address. Sincerely, C�ne Ams'`-Porter J`,_" LAW OFFICES OF PRISCILLA S. WINSLOW 4 errithew emorial o�CPi1st'Q�, AND CYNICS To: Cecil Patmon, RN. Date: December 22, 1994 - From: Dirk Van Meurs, M.D. ^ � Subject: OI.1VE NKHEREANYE I am writing in regard to "Nurse Olive,"with whom I have worked at the jail for six years. lam very concerned about the termination of employment that is apparently occurring as, from my perspective over the past six years, she has consistently been one of the most reliable and diligent nurses at MDF. I reviewed several charts that she said had been identified as problems, with particular emphasis on Charts 9621006-6,4301037-8, and 043582-6. From my perspective, these represent nothing more than trivial irregularities and certainly do not indicate a lapse in nursing care or judgment. I believe that Olive's intent was always to promote good health care for the inmates, and this is well demonstrated by Case 4621006-6,where her concern led her to send the patient to the Emergency Department despite the on-call doctor's inclination to begin treatment by offering the patient an anti-hypertensive medication. As the patient was subsequently hospitalized for six days, it would seem that her judgment was correct. Under the circumstances, most on-call physicians realize that they are at a disadvantage having not actually seen the patient, and hence, relying on the nurse's judgment is inherent in our role"on ca1L" In summary,I feel that the termination of nurse Olive is very ill advised. In discussing this situation with many of her co-workers, no one could understand the rationale for such a drastic, "out-of-the-blue" move. The prevailing sentiment is that"personalities"were somehow involved, but if this is true, perhaps it could have been dealt with in a less drastic manner- cd: Anita Duckett,RN.,Director of Nursing James ltael, M.D., Medical Director Steve Tremain,M.D., Director;Medical Staff Affairs L Contra Costa County sE L Health Services Department MENTAL HEALTH DIVISION Martirm Datention amity Dwmbr 13, 1994 Steve ZYm3rairm, ltiD Me of Staff, h'T'E-I Dear Dr. Treinin, R--: ?rape rung Tenmiraticn of RN Olive Myzeanye It is with mxh distress and earn m d7at I an writing dais letter to you after I heard dr- shoddng ras of the bpadug ternrinatim of N se Olive's duties at HF. In my egxrierne, workug with R1 olive at MF, sizmce mmmy working at this facility, has always been a pleasure mainly tecaof her pleasant and oourteous attitude; op , oonoern and respect she. du,7s hard not only hrr co--�s & R mss but also towanl both the #ysically and the mrermtally ill patient in-nates. I have faurd Clive to be extra»sly courteous, l-nwledgwble, alert, canpetent and also inspiring to others mu rd her. I have farad hex not cnly gable of adequately diaosing situations thrt reed trcgazt medical attezticn and bring to my attention burse she recoguzes the possible psyd-nat nc inpucati(m, but also follow-W any mm adicaticn or treatment orders appropriately & prarptly. I do mer one.tine scat'months ago Nhen she questioned aie of nmy medication orders. I leas glad that her irritiation of tar-qnzy led to my dmrgirg the orders for that patient. It is easy to feel offienled scmatinns vb m sore staff nterbeis point out saTe questionable orders but with Olive it has always been a pleasure tie way sire brir>gs it up ar)d it becomes a valuable learning eaperienoe for both IN and W. Ste has, at the sane time, shown eagenmess to sbow appreciation whim discission leads to clarification of certain issues regarding certain problem patients. I have neer ford Olive say aydiug to disrespigct any of her colleagues or Hrysiciais. I have observed ter to mrmxxW her duties with earpetence, a-d deligenoe to maintain d-e high-est ethical standards daT=hd of her as a W. Ser seam to gpin a same of fulfilJmrermt, devotion, axd pride fran the way she oaTlicts hrrself in the aeartion of her daily work. It is my firm belief that this action contemplates against RN Olive is unjustified . 9r has been a dedicated N zee valued rut anly by me but all of ber Clinicians and Riysicians I have talked with. the deputies are also rrnplussed aboat this unforeseen situation. I feel that i.i the interest of fainr>ess, a full inTary stu d'be mrducted on thds natter before any adverse action is tale ag hist tdus FN. I an eonfLdmt that you will hanRe this matter justly and above board. In carrlxsinm I must say that Niglmtingple wand be very proud to have otters."Olives" of her nature and omwtene. l7marmhcirg you and mr_hm obliged. may, �- Riaard r , ham, staff Psydiiatrist, WF o: a- Van rr ,rn; C. tarn=,,M,1; J. Ra--I,U); rd Scuth,r); A. Ott, 03C (2/92) Contra Costa County s _ t Health Svices Department MENTAL HEALTH DIVISION r� covK� December 1531994 Steve Tremain, M.D. Chief of Staff, Merrithew Memorial Hospital Dear Dr. Tremain, I am surprised, sadden and extremely appalled to hear the Nurse Olive is being asked to terminate her affiliation with the medical unit at the Martinez Detention Facility. In my 7 years of service at the detention facility, I have found Nurse Olive to be one of the most dedicated, sensitive and caring nurses I've had the priviledge of working with. Her sense of patient care and professionalism is to be admired. She has on countless occasions gone above and beyond her duties to be helpful to inmates and other staff members. She is the epitome of teamwork and conscientiousness. To lose Nurse Olive ' s talents and skills would be a terrible loses to the detention facility and to the medical profession in general. incerely y u Sg and MoskoviCz, Ph. . ,MFCC Me al Health Clinical Specialist :',303C (2,92) Contra Costa County Health .services Department MENTAL HEALTH DIVISION 00f T 7o- : M CIS,- Ct. ZC.L,! f �icr`.t/7`"�..,_../•-•� .� � J' J06— ./'i�t..l.»w.!.. . � ( ,,�.s •e,.�-kms ,W3C (2192) Contra Costa County y errithew emodat AND CLINICS 2500 Alhambra Avenue Martinez, CA 94553 December 16, 1994 olive Nkhereanye, RN 4363 Hillview Drive Pittsburg, CA 94564 Ms. Nkhereanye: Effective December 16, 2994 your services are no longer required at i Merrithew Memorial Hospital due to failure to meet Per Diem contract requirements. Sincerely, Anita Duckett, RN, MSN Director of Nursing cc: Personnel File AD.svh 121694.AD o. �ls � Contra Costa Cou A-301A '3`E') CONFIDENTIAL COUNTY COUNSEL'S OFFICE CONTRA COSTA COUNTY MARTINEZ, CALIFORNIA MEMORANDUM Date: March 23, 1995 TO: Jeanne Maglio, Clerk of the Board of Supervisors FROM: Victor J. Westman, County Counsel By: Gregory C. Harvey, Deputy County Counsel RE: Claim of Olive Nkhereanye, R.N. Please treat the attached letter as a claim. CLAIM /Z BOARD OF SUPERVISO"S,OF CONTRA COSTA COUNTY, CALIFORNIA, March 17, 1995 Claim Against the County, or District governed by) BOARD ACTION the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to you is your notice of California Government Codes. ) the action taken on your claim by the Board of Supervisors (Paragraph IV below), given pursuant to Government Code Amount: $424.90 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: Henry Rick Palumbo ATTORNEY: MAR 2 7 1995' Date received COUNTY COUNSEL ADDRESS: 1166 Lea Drive BY DELIVERY TO CLERK ON March 27, 1995 MARTINSZCALIF. Novato, CA 94945 BY MAIL POSTMARKED: March 24, 1995 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppH BATCHELOR, , DATED: March 27, 1995 B IL DeputylOR, ClerkJA JJ 1,4 �-A-d-4 11. FROM: County Counsel TO: Clerk of the Board of Supervisors (46-�This claim complies substantially with Sections 910 and 910.2. ( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: �"-Zg `cj 8Y Deputy County Counsel 111. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). 1V. BOARD ORDER: By unanimous vote of the Superviscrs present ( ✓j This Claim is rejected in full. ( ) Other: r I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: PHIL BATCHELOR, Clerk, By Deputy Clerk Y WARNING (Gov. code section 913) Subject to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim. See Government Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult en attorney, you should do so immediately. AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the Jnited States, over age 18; and that today I deposited in the United States Postal Service in Martinez, :alifornia, Postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. )ated: a.. ..— BY: PHIL BATCHELOR by. eputy Clerk :C: County Counsel County Administrator Clam: to: BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person orto per , sonal property or growing crops and which accrue on or before December 311 19871 must be presented not later than the 100th day after the accrual of the cause'of action. Claims relating to causes of action for.death or for injury to person or to personal property or growing crops and which accrue on or after January,l,, , 1988, must be presented not later than six months after the accrual of the cause of action. Claims relating to any other cause of action must be presented not later than one year after the accrual of the cause of action. (Govt. Code §911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. j E. Fraud. See penalty for fraudulent claims, Penal. Code Sec. 72 at the end of this Form RE: Claim By ) Reserved for Clerk's filing stamp III--A.'12 geiex PA.Lu,,wBa ) RECEIVED Against the County of Contra Costa ) g 2.7.1995 or - ) District) CLERK BOARD OF SUPERVISORS Fill in name ) CONTRA COSTA CO. The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ and in support of this claim represents as follows: l. When did the damage or injury occur? '(Give exact date and hour) ---- 2. Where did the damage.or injury occur? (Include city and county) t, ,'-,v rn q Cos T,9 ee,M V rx 3. How did the damage or injury occur? (Give full details; use extra paper if required) -7- W,17-.47 Woo,`-6`V r3�.vr AW `-i2e it Ri6slT Ws,�EE� .q.vD ?oRE Zzaa 4. What particular- act or omission on the part of county or district officers, servants or employees caused the injury or damage? /'"A/c tsRE To i(//�Yillr9�•tt T,V-- PRo01 -AU y 4kA//asLK uAiS.yfE eoivairioiyu e7F TjoVbvv, . ROAD CO1VD 1TiOif/ k.Voy /=0 l 2lwAil oiYTI-iS .VR10R T /WG,a,�•uT �! L�D�iti77�/ Of �D.VTRf.J lA5Ti9• �. wnat are t.ne names of county or district officers, servants or employees 'eausin, g he c --age or in jury' i ------------------------- -------------------- 6. What damage or. injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) B. Names and addresses of witnesses, doctors and-hospi*.als, 9. List the expenditures you made on account of this accident or injury: DATA, ITEM AMOUNT IAIWlee ts/65'J6 ¢y-2 o1,90 Gov. Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by some person on his behalf." Name and Address of Attorney Claimant's Signature //6 6 F l7lt r vE Address Telephone No. Telephone No. Cy s) 89.2•2 qe y ' N O T I C E Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer; or to any county, city or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account, voucher, or writing, is punishable either by imprisonment in the county jail for a period of not more than one year, by a fine of not exceeding one thousand ($1,000), or, by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000, or,by both such i.mprisonrjent and fine. 24 WOODLAND AVENUE, SAN RAFAEL, CA 94901 (415)459-7378 ARD# AC086328 INVOICE FOR SERVICES INVOICE NUMBER:: Z ext505 63 ------------------------------------------------------------7-77---7---------- R/O Date Invoice Invoice Date: 0,_1/24/9-9 ------------ MARIN VOLVO/SAAB RICK PALUMBO Work: 459-7178 24 WOODLAND AVE. Home: 892-2704 SAN RAFAEL, CA 94901 ------------------------------------------------------------------------------ Year: 89 Make: SAAB Model : 9000T CD License #: N 060T VIN: YS3CT45L9K1008165 Unit#: BLACK Odom: 66518 ------------------------------------------------------------------------------ Farts: All parts are NEW unless otherwise specified Qty Part Number Description List Price _Total 2.0 50 400 W/WASHER::...,, ..4 1 a 2. 50 5.00 1 .0 CAT000613943 ENVIROMENTALWASTE 2.00 2.0.,',*) 1 .0 40 2026 DRAIN PLUG G S::A 1 .00 1 .00 .. i i•l i FILTER .a.: 1 I C89 170.00 170.00 ', 1 .0 i 200 ..if.,a 6.95 Labor Performed: BRAKE CONDITION:: REAR 190%) 67, 500 MILE€. E SE:.4'.VIt.:E ::0+,0y, 3AND CHECKED (::4••iA#:i:::a:f:S, t:::€••4AN1a}:::D OIL it OIL F:€:f..."f'4i I:,,' .- PCV VALVE ,.: a� i. t.;4••4f::.t.:fa;4::..i1 4'`t.:':! '.:•=sL..:?4::. _... I:'4'';4::.A.f.4..;f::.R 4•• .4.4... 44::.!'.,1 t.;4"•44::.1.;i;4::..t? !"'tf...€... 4"4...€.7.4.D l...4ii:�,14i::f...<:� !�?+I'•-€:�:? 'I'-:Cf�,l::: 4��'4��'€:::'•i:if: E.l4��:F:::;:�„ Sublet Labor;: Slt44 " , REPOPCElE11T OF 4 'R ?4fRIGHT € € € 44AND TIRE 24a „ „ BALANCED FRONT TIRE PIRELLI P600 205/55VRI5 [;Hfi:a:;k:4:ia:) i7,4f••IEE::€... !^)f...:4:G4•"'44•'4f..:f'•'3'T' Recommendations: Pslsrie :4. , ~ . ` M f=W F=<- X M WC31 ���_���� , ~ . . . INVOICE FOR SERVICES INVOICE NUMBER: -1 4EP�_i Z!5 4f 3. ______________________________________________________________________________ MARIN VOLVO/SAAB RICK PALUMBO 89 SAAB 9000T CD License#: N3060T ______________________________________________________________________________ 1 1 0 Taxable parts: 204.35 Labor Charges: 272.57 Tax: 14.82 Nom—Taxable Parts: 2.00 Misc. Shop Supplies: 0.00 Total : 493.74 ____________________—_______________________________________________________— A buyer of this product in California has the right to have this product serviced or repaired during the warranty period. The war- ranty period will be extended for the number of whole days that the product has been out of the buyer's hands for warranty re- pair. If a defect exists within the warranty period, the warranty will not expire until the defect has beer, fixed. The warranty period will he extended if the warranty repairs did not remedy the defectandthe buyer notifies the manufacturer or seller of the failure of the repairs within 60 days after they were comp}eted, If, after a reasonable number of attempts the defect has not been fixed' the buyer may return the product for a replacement or a refund subject, in either case, to deduction of a reasonable charge for usage. This time extentinn does not affect the protection or remedies the buyer has under other laws. I have been advised of possible California or federal emission warranty coverage and agree to have MVS complete the repairs. Estimate Totals: Orig. Est; $54.52 Additional Cost; $0.00 Revised Est./ �8Q Customer S � 4 \Q96igoatore 0f Acceptance Date '^^` � Charge, Cash, Check 8 Credit Card Card # Exp. Date Authorization Page 2 t 12 o Cl z b 60 o � � a y L.. �i o © tea v s � Av ` tz