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HomeMy WebLinkAboutMINUTES - 03121996 - C9 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA MARCH 12, :.1996 Claim Against the County, or District governed by) BOARD AC-T 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: TEN MILLION Section 913 and 915.4. Please note a1`1 "Warnings". CLAIMANT: LLOYD HELDRIS Ry��II�g� ATTORNEY: FEB 2 2 1996 Date received OUN SEL ADDRESS: 3072 VALLMOOD COURT BY DELIVERY TO CLERK ON FEBR jQ�icA@I�6 SAN JOSE CA 95148 BY MAIL POSTMARKED: FEBRUARY 16, 199 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. FEBRUARY 22 1996 PpHHIL BATCHELOR, Clerk DATED: BY: Deputy II. 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: `c 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 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present ( X This Claim is refected 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:-=r� �� 1971,PHIL BATCHELOR, Clerk, B 14 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. *For additional warning see reverse side of this notice. 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 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 the claimant as shown above. Dated i,p�L / ��9 / BY: PHIL BATCHELOR by_. Deputy Clerk CC: County Counsel County Administrator t OFFICE OF COUNTY DEPUTIES: COUNSEL PHILLIP S. ALTHOFF SHARON L. ANDERSON !" CONTRA COSTA COUNTY BRANDON D. BAUM µ ANDREA W. CASSIDY COUNTY ADMINISTRATION BUILDING VICKIE L. DAWES MARKE S. ESTIS P.O. BOX 69 MICHAEL D. FARR MARTINEZ, CALIFORNIA LILLIAN T. FUJII DENNIS C. GRAVES VICTOR J. WESTMAN 94553-0116 GREGORY C. HARVEY COUNTY COUNSEL TELEPHONE (510) 646-2041 KEVIN T. KERR FAX (510) 646-1078 EDWARD V. LANE, JR. SILVANO B. MARCHESI MARY ANN M. MASON ARTHUR W. WALENTA, PAUL R. MUNI Z JR. VALERIE J. RANCHE ASSISTANTS February 23, 1996 DAVID F. SCHMIDT DIANA J. SILVER VICTORIA T. WILLIAMS NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Lloyd Heldris 3072 Valleywood Court San Jose, CA 95148 RE: CLAIM OF: Lloyd Heldris 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 I , 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 . [] 7 . Other: 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: February 23, 1996 at Martinez, California. CC: Clerk of the Board of Supervisors (original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOVT. CODE H 910, 910.2, 920.4, 910.8) Memorandum OFFICE OF COUNTY COUNSEL DATE: February 21, 1996 TO: Jeanne Maglio, Clerk of the Board FROM: VICTOR J. WESTMAN, COUNTY COUNSEL By: Gregory C. Harvey, Deputy County Counsel RE: Claim of Lloyd Heldris Please treat the attached document as a claim. Thanks. CONFIDENTIAL ATTORNEY CLIENT DOCUMENT Memorandum OFFICE OF COUNTY COUNSEL DATE: March 4, 1996 TO: JEAN MAGLIO, CLERK OF THE BOARD FROM: VICTOR J. WESTMAN, COUNTY COUNSEL By: Gregory C. Harvey, Deputy County Counsel RE: CLAIM OF LLOYD HELDRIS Please treat the attached letter as a Government Tort Claim. Thanks. ,...: ; RECEIVE® x. 1996 CLERK BoETFtC Cr_p�SVA C©150RC CO �MP CONFIDENTIAL ATTORNEY CLIENT DOCUMENT February 15, 1995 Mr. Mark Finucane, Ms. Velma Berry, Deputy Ms. Anne Hause, Deputy Public Guardian Office Public Guardian Office Public Guardian Office Contra Costa County Contra Costa County Contra Costa County 624 Ferry Street 624 Ferry Street 624 Ferry Steet Martinez, CA 94553 Martinez, Ca 94553 Martinez, Ca 94553 SUBJECT: DEMAND FOR DAMAGES Violation of Penal Code Violation of Federal Statue Dear Mr. Finucane and Contra Costa County Board of Supervisors. This is a DEMAND FOR DAMAGES OF TEN MILLION DOLLARS ( $10, 000,000) PURSUANT TO 42 USC SECTION 1983 . If you or the Attorneys at the District Attorneys Office or at the County Counsel Office, feel there is anything to talk to me about regarding this law suit, please feel free to contact by mail at my home address. This will be the only demand letter you will receive. The reasons for these demands are CORRUPT AND INEPT actions of your staff of Contra Costa County Public Guardian Office Employees. Government Code Sect. 815 . 6 requires that you or any employee"FULLY DISCHARGE YOUR MANDATORY DUTY" . A Failure to Fully Discharge youfMandatory Duty, eliminates yougimmunity under Government Code 818 . 2 and 818 . 4. Plus you are never immune from charges of FRAUD, MALICE, OR OPPRESSION. Listed below are charges of violations committed by Anne Hause, Velma Berry, and others as agents of the Public Guardian Mark Finucane and the Contra Costa County Department of Health. 1 ) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris by ILLEGALLY invading the PRIVACY OF HER KAISER PERMANENTE MEDICAL RECORDS WITHOUT PERMISSION. 2 ) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris by violating Mrs. Heldris Fourth and Fourteenth Amendment Civil Rights by ILLEGALLY searching and seizing Mrs. Heldris Medical Records located at Kaiser Permanente Hospital, Richmond, CA. 3 ) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency -known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris by violating Mrs. Heldris Fourth and Fourteenth Amendment Civil Rights by searching and seizing Mrs. Heldris' body from the Acute Hospital known as Kaiser Permanete Hospital, Richmond. 4) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank. of America Branch Located in San Jose by ILLEGALLY violating Mrs. Heldris and Mr. Heldris Privacy Right and the theft of Mrs. Heldris Electronically Deposited Federal Pension. 5 ) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians Office violated the Civil Rights of Mrs. Gladys Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by ILLEGALLY interfereing with Mrs. Heldris and Mr. Heldris Economic Business Dealings and Violating the rules of the Electronic Funds Transfer Act (EFTA) and purpetrating Wire Fraud upon Bank of America. 6) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris and Lloyd Heldris, who 'are Joint Depositors on an Account at Bank of America Branch Located in San Jose by violating Mrs. Heldris and Mr. Heldris Fourth and Fourthteen Amendment Civil Rights by ILLEGALLY Searching and Seizing the assets of that Bank of America Joint Deposit Accoupjjw' ithout any LEGAL Authorization. 7 ) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Glenda Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by violating Mrs. Heldris' and Mr. Heldris' Privacy Right. 8 ) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Glenda Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by ILLEGALLY violating Mrs. Heldris and Mr. Heldris Privacy Right. 9) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Glenda Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by violating Mrs. Heldris and Mr. Heldris Fourth and Fourthteen Amendment Civil Rights by ILLEGALLY Searching and Seizing certain assets of that Bank of American Joint Deposit Accout without any Authorization. PLEASE DO NOT DESTROY ANY RECORDS RELATED TO MRS HELDRIS CASE. Sincerel , FEB 2 01996 Lloyd eldris CONTRA COSTA COUNTY CALIF. 3072 Valleywood Court DISTRICT ATTORNEY'S OFFICE San Jose, CA - 95148 cc: Phillip Batchelor, County Administrator Victor Westman, Contra and Clerk Contra Costa County Costa County Legal Board of Supervisors Counsel Gary Yancy, Contra Costa County District Attorney MID-3:Q9�7R R NS7EE i February 15 , 19,95 T1 FEB 2 0 19SIS Mr. Mark Finucane, Ms. Velma Berry, Deputy Ms. Anne Had&?,-,,,Be,puty Public Guardian Office Public Guardian Office Public GuaffU-4AEMae Contra Costa County Contra Costa County Contra Costa County 624 Ferry Street 624 Ferry Street 624 Ferry Steet Martinez, CA 94553 Martinez, Ca 94553 Martinez, Ca 94553 SUBJECT: DEMAND FOR DAMAGES Violation of Penal Code Violation of Federal Statue Dear Mr. Finucane and Contra Costa County Board of Supervisors. This is a/DEMAND FOR DAMAGES OF TEN MILLION DOLLARS ($10,000,000 ) PURSUANT TO 42 USC SECTION 1983 . If you or the Attorneys at the District Attorneys Office or at the County Counsel Office, feel there is anything to talk to me about regarding this law suit, please feel free to contact by mail at my home address. This will be the only demand letter you will receive. The reasons for these demands are CORRUPT AND INEPT actions of your staff of Contra Costa County Public Guardian office Employees. Government Code Sect. 815 . 6 requires that you or any employee"FULLY DISCHARGE YOUR MANDATORY DUTY" . A Failure to Fully Discharge yougMandatory Duty, eliminates yougimmunity under Government Code 818.2 and 818.4. Plus you are never immune from charges of FRAUD, MALICE, OR OPPRESSION. Listed below are charges of violations committed by Anne Hause, Velma Berry, and others as agents of the Public Guardian Mark Finucane and the Contra Costa County Department of Health. 1) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris by ILLEGALLY invading the PRIVACY OF HER KAISER PERMANENTE MEDICAL RECORDS WITHOUT PERMISSION. 2) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris by violating Mrs. Heldris Fourth and Fourteenth Amendment Civil Rights by ILLEGALLY searching and , seizing Mrs. Heldris Medical Records located at Kaiser Permanente Hospital, Richmond, CA. 3 ) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris by violating Mrs. Heldris Fourth and Fourteenth Amendment Civil Rights by searching and seizing Mrs. Heldris, body from the Acute Hospital known as Kaiser Permanete Hospital, Richmond. 4) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by ILLEGALLY violating Mrs. Heldris and Mr. Heldris Privacy Right and the theft of Mrs. Heldris Electronically Deposited Federal Pension. 5) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County. Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by ILLEGALLY interfereing with Mrs. Heldris and Mr. Heldris Economic Business Dealings and Violating the rules of the Electronic Funds Transfer Act (EFTA) and purpetrating Wire Fraud upon Bank of America. 6) . Ms. Velma Berry and Anne Hause and other persons unknown of the .Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by violating Mrs. Heldris and Mr. Heldris Fourth and Fourthteen Amendment Civil Rights by ILLEGALLY Searching and Seizing the assets of that Bank of America Joint Deposit AccouVrwithout any LEGAL Authorization. 7) . Ms. Velma Berry and Anne Hause. and otherpersons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Glenda Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by violating Mrs. Heldris, and Mr. Heldris' Privacy Right. 8) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Glenda Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by ILLEGALLY violating Mrs. Heldris and Mr. Heldris Privacy Right. 9) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Glenda Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by violating Mrs. Heldris and Mr. Heldris Fourth and Fourthteen Amendment Civil Rights by ILLEGALLY Searching and Seizing certain assets of that Bank of American Joint Deposit Accout without any Authorization. PLEASE DO NOT DESTROY ANY RECORDS RELATED TO MRS HELDRIS CASE. Sincere y, L oy Heldris 3072 Valleywood Court San. Jose, CA 95148 cc: Phillip Batchelor, County Administrator Victor Westman, Contra and Clerk Contra Costa County Costa County Legal Board of Supervisors Counsel Gary Yancy, Contra Costa County District Attorney B � �1 — X1111- &7-CdC-lek February 15, 1995 Mr. Mark Finucane, Ms. Velma Berry, Deputy Ms. Anne Hause, Deputy Public Guardian Office Public Guardian Office Public Guardian Office Contra Costa County Contra Costa Co a Costa County 624 Ferry Street 624 Ferry Stree RECEIVED624, erry Steet Martinez, CA 94553 Martinez, Ca 9453 M rt nez, Ca 94553 SUBJECT: DEMAND FOR DAMAGES FGD Z U M Violation of Penal Code Violation of Federal Statue CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. Dear' Mr. Finucane and Contra Costa County Board of Supervisors. This is a DEMAND FOR DAMAGES OF TEN MILLION DOLLARS ( $10, 000,000 ) PURSUANT TO 42 USC SECTION 1983 . If you or the Attorneys at the District Attorneys Office or at the County Counsel Office, feel there is anything to talk to me about regarding this law suit, please feel free to contact by mail at my home address. This will be the only demand letter you will receive. The reasons for these demands are CORRUPT AND INEPT actions of your staff of Contra Costa County Public Guardian Office Employees. Government Code Sect. 815 . 6 requires that you or any employee"FULLY DISCHARGE YOUR MANDATORY DUTY" . A Failure to Fully Discharge yougMandatory Duty, eliminates yougimmunity under Government Code 818. 2 and 818 . 4. Plus you are never immune from charges of FRAUD, MALICE, OR OPPRESSION. Listed below are charges of violations committed by Anne Hause, Velma Berry, and others as agents of the Public Guardian Mark Finucane and the Contra Costa County Department of Health. 1) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris by ILLEGALLY invading the PRIVACY OF HER KAISER PERMANENTE MEDICAL RECORDS WITHOUT PERMISSION. 2) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris by violating Mrs. Heldris, Fourth and Fourteenth Amendment Civil Rights by ILLEGALLY -searching and seizing Mrs. Heldris Medical Records located at Kaiser Permanente Hospital, Richmond, CA. 3 ) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris by violating Mrs. Heldris Fourth and Fourteenth Amendment Civil Rights by searching and seizing Mrs. Heldris' body from the Acute Hospital known as Kaiser Permanete Hospital, Richmond. , 4) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris and Lloyd Heldris; who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by ILLEGALLY violating Mrs. Heldris and Mr. Heldris Privacy Right and the theft of Mrs. Heldris Electronically Deposited Federal Pension. 5 ) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Gladys Heldris and Lloyd Heldris, who are Joint *Depositors on an Account at Bank of America Branch Located in San 'jose by ILLEGALLY interfereing with Mrs. Heldris and Mr. Heldris Economic Business Dealings and Violating the rules of the Electronic Funds Transfer Act (EFTA) and purpetrating Wire Fraud upon Bank of America. 6) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the, Civil Rights of Mrs. Gladys He*ldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by violating Mrs. Heldris and Mr. Heldris Fourth and Fourthteen Amendment Civil Rights by ILLEGALLY Searching and Seizing the assets of that Bank of America Joint Deposit Acco4qrwithout any LEGAL Authorization. 7) .' Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Glenda Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by violating Mrs. Heldris' and Mr. Heldris, Privacy Right. 8) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Glenda Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by ILLEGALLY violating Mrs. Heldris and Mr. Heldris Privacy Right. 9) . Ms. Velma Berry and Anne Hause and other persons unknown of the Government Agency known as the Contra Costa County Public Guardians office violated the Civil Rights of Mrs. Glenda Heldris and Lloyd Heldris, who are Joint Depositors on an Account at Bank of America Branch Located in San Jose by violating Mrs. Heldris and Mr. Heldris Fourth and Fourthteen Amendment Civil Rights by ILLEGALLY Searching and Seizing certain assets of that Bank of American Joint Deposit Accout without any Authorization. PLEASE DO NOT DESTROY ANY RECORDS RELATED To MRS HELDRIS CASE. y Sincer l , c Ly Lloyd Heldris 3072 Valleywood Court San Jose, CA - 95148 cc: Phillip Batchelor, County Administrator Victor Westman, Contra and Clerk Contra Costa County Costa County Legal Board of Supervisors Counsel Gary Yancy, Contra Costa County District Attorney NO�y�;iS1NIWatl f�1Nti0� � CR 30 331330 Q3N133321 1�l.Nf 10�'��Sn��iN4 7V _ V 4 C,oERv a F.V 8 j� i i r t� Ou q CLAIM e 4V _ BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA `__%fch 12, 19961 Claim Against the County, or District governed by) BOARD ACTION the Board of SupervisoFs, 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: $807.09 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: Stan and Rosie Spinrad �;�IQII�f ',LPJ ATTORNEY: FEB 2 7 1996 Date received aouNSEL ADDRESS: 201 Conifer Terrace BY DELIVERY TO CLERK ON F br�iary �.7, ie�ne��e Danville CA 94506 BY MAIL POSTMARKED: February 26, 1996 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppHH gg DATED: February 27, 1996 BYIL DeputyLOR, Clerk II. 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: y 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 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (y ) 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. Date PHIL BATCHELOR, Clerk, B cz , 00�o., ) , 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. *For additional warnina see reverse side of this notice. 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 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 the claimant as shown above. • 1 Dated: /� _ 9'4/„ BY: PHIL BATCHELOR by JV ji Ld , Deputy Clerk CC: County Counsel `�"" County Administrator .'to: - BOARD OF SUM, VISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to person or to per- sonal property or growing crops and which accrue on or before December 31, 19879 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 1069 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 Y11Cu agat�.:sv icaCai v,aviiv .»...n..;y. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this To-rm. RE: Claim By ; Reserved for Clerk's filing stamp 1&)s ) RECEIVED H3 2 7 1996 Inst the unty of Contra Costa ) or ) SUPERVISORS District) VRKCONTRA 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 $ L27, ' _ and in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) ) er 2. Where did the damage or injury occur? (Include city and county) v-1 14 c4- X 945—e 3. How did the damage or injury occur? (Give Rill details; use extra paper if ~ required) J- P ke-e� 4. What particular actor omission on the part of county or district officers, servants or employees caused the injury or damage? (over) 5. What are the names of county or district officers, servants or employees taus: :. the damage or inbury? 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.) 8. Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT p y fir/ fiv , s y 33 7, 2", aa.a:�aE��� � * * a +: * * aeeeaessae * efeaeeea * Gov. Code Sec. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO: : (Att'bi^rue ) or by some on on h lf." Name and Address of Attorney Claimant' Signature _ (Address) -Z�v44/ Ile, �X1d)6/ Telephone No. Telephone No. efeaef * Ir • eta * * afa s � sa NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance our.for payment to any state board or officer, or to any county, city our 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 ($10,0009 or by both such imprisonment and fine. 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City: Danville, DA Zip Code: 94506 Nace: Becky Breed: Wire Hair Mix Color: 8eine Sex: Female (spayed) Weight: 0poonds Age: 1i yrs 0 mos Patient # 854 A � | Vaccination Expiration Date Rabies Information | VACCINATION | Rabies Booster Mar 01 1997 Tag No. : | | DHLP-Parvo Feb 27 1996 Serial #:12085 ! | STATUS I Bordetella Au@ 27 1995 Name :lMKAB | ! Coronavirus i ! UHLP-Corona ! I Lyme | | | --- SERVICES for Becky AMOUNT Jam 151996 OFFICE..................... Office visit/examination 29.00 Jam C51996 LABORATORY ...,.,..,.......... Standard Profile + Any/Lipase 7I80 Jan 15096 RADIOLOGY / SPECIAL STUDIES... Radiograph - 2 views Wx12 83.909N Jan 15896 MEDICAL SERVICES.......~.... Fluids - subcutaneous 23.9N Jan 15 1996 PHARMACY .............,.,... Flagyl(Netnmidamole)250mg Tab 7.75 Jan 15 1996 Hear gard Chew 0-251h Blue 11.40 --- TRANSACTION NO. 13 SUBTOTAL: 229.75 Elisa Dowd DVM Personnel 00 TOTAL DUE: 229.75' . pn,nEn/: V/MC: 229.75 BALANCE DUE: 0.00 - . (510)837-3716 p ® FAX# NOr ,' � 5 � ■,�,�� Li ,"` 510 820-6759 mmeFurnishin Cener' Ot\T ( ) S � Page AmERIcArS LARGEST CARPET RETAILER 1985 San,Ramo`n Valley Blvd., San Ramon, CA 94583 Charge . Cash i Finance Plan _1 Sold ToDate 1){n } �( Repr Purchase Order Cust Ph#H -^, n Job Cust.Ph.#W Address: Factory REQUESTED INSTALLATION DATE: `J DESCRIPTION • ----------------- ••ftf Ul_F FO t,A"�f ." t IE ' 4 ^.'� e „J'_ ,_..�.._...................... \1 4 C r f }fit __— -- -------------------------_.._ g., irk ._.<...�. ........ Guaranteed Replacement•Lifetime Installation Warranty•Guaranteed Lowest PncesTOTAL SALES AM T: $ "f TERMS: 50% DEPOSIT WITH ORDER- BALANCE DUE ON COMPLETION. PAST DUE INVOICES SUBJECT TO FINANCE CHARGES OF 11/2% PER MONTH. -- * VACUUMING & DOOR TRIMMING -,NOT INCLUDED. DEPOSIT: <$ Merchandise not returnable Accepted By X without this slip. THANK YOU FOR THIS ORDER. WE LOOK FORWARD TO SERVING YOU AGAIN. B DUE CE $ (20% RESTOCKING CHARGE FOR ORDERS CANCELLED AFTER 24 HOURS FROM ABOVE DATE) CUSTOMER COPY r � C\ �\`\ J �� �� � � c o s � � � G O \' � tS� `` `` � �v � � Z � � � -� w �� � � � � � � - � � `�` -�, �, �� � f�� ' �w�rS' %:1 �p Vii . (�.. 5 �a �r"•. ;'1 � �.1: ' -�'t - e� �-_ �t i _ CLAIM C- ' BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA MARCH 12, 1996 f 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: OVER $10,000.00 Section 913 and 915.4. Please note all "Warnings", CLAIMANT: VICKIE SPRINGS ATTORNEY: RICHARD G BATES, JR FEB 2 2 1996 1850 GATEWAY BLVD #1083 Date received � L ADDRESS: C0NC0RD. CA 94520 BY DELIVERY TO CLERK ON FEBRUAR BY MAIL POSTMARKED: HAND DELIVERED , I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. IL BATCHELOR, Clerk DATED: FEBRUARY 22, 1996 �b: Deputyd" V4 AA 0o II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( L-�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: BY: Oeputy 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 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. Dated- � / f�9� PHIL BATCHELOR, Clerk, B \)JJA 0fi Deputy Clerk T 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, *For additional warnina see reverse side of this notice. 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 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 the claimant as shown above. Dated:11,4 4 /� _ /9(? BY: PHIL BATCHELOR by1,i j eputy Clerk CC: County Counsel County Administrator 'r eq i C1aic to: BOAPM OF SUPERVISORS OF CONTRA COSTA OOUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for injury to 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, 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 nave 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 fo--= RE: Claim By ) Bes ed for Clerk's fi ing stamp VICRIE SPRINGS 3 RECEIVED' Against the County of Contra Costa ) 2 i or ) 3 .POP.m . District) CLERKBOARD'OFSUPERVISORS Fill in name ) OONTRA COST 00. 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: 1. When did the damage or injury occur? (Give exact date and hour) AUGUST 22, 1995 2. Where did the damage or injury occur? (Include city and county) PITTSBURG HEALTH CENTER 550 S,phool Strept,, pyttsh„U4 CA 94565, CONTRA COSTA 3. How did the damage or injury occur? (Give full details; use extra paper if required) SEE ATTACHMENT TO CLAIM 4. What particular act or omission on the part of county or district officers, se.^vants or. employees caused the injury or damage? Failure to act as a reasonable health care provider would under the same or similar circumstances. Failure to properly administer the injection in the proper location. Professional negligence. P wnaL are t-ne names of county or district officers, servants or employees causing the -dw-nage or Injury? Nancy Corser, PNP Pittsburg Health Center 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage- At this time claimant has had surgery on her elbow. - The full nature and extent of 'the damages at this time are unknown. 7. How was the a=mt claimed above computed? (Include the estimated amount of any prospective injury or damage.) Medi*cal Bills: $6,503.00 Special Damages: $250,000.00 8. Names and addresses of witnesses, doctors and hospitals. PITTSBURG HEALTH CENTER DR. GEE 550 School Street PITTSBURG HEALTH CENTER Pittsburg, CA 94565 9. List the expenditures you made on acwunt of this accident or injury.* DATE ITEM AMOUNT Gov. Code Sec. 91042 provides: "The claim must be signed by the claimant SM NOTICES TO: (Attorney) or by_apme person on h's behalf." Name and Address of Attorney RICHARD G. BATES, JR. d, LAW OFFICE OP RICHARD G. BATES '(Claimant I--Y'Si gnature) 1850 Gateway Blvd. , #1083 Concord, CA 94520 lasn Gateway RIUA- , Suitt- MR1 (510) 798-8055 (Address) Concord, CA 94520 (51R) 7; Telephone no. (510) 798-8055 1 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 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 im-prisonment and fine. � 9 ATTACHMENT TO CLAIM NUMBER 3 CONT Claimant was given a series of Cortisone injections in the wrong place which resulted in damages to her elbow which necessitated surgery. The employees name was Nancy Corser upon information and belief is an employee of the county of Contra Costa County and is employed as a Family Nurse Practitioner. r -t eq SPRINGS,, VIC'KIE A 77837002 PAGE: 00987 CONTRA COSTA COUNTY"HEALTH SERVICES - AGE No ... . TYPE OF DATE OF Sell 2500 ALHAMBRA AVENUE 1 BILL MARTINEZ, CALIFORNIA 9455,", . F I NAL Ili/11/95 (510) 313-8300 Q @ UT PATIENT NAME JOATIENT NUWfRjSEXf A{fE Ai>•A851ON�DATE 0MCKAROE DATE DAYS AMOUNT ENCLOSED PRINGS VICKIE' A 718310.02 F 33 0/28/95 0/28/95 1 1 $ INSURANCE COMPANY NAME GROUP NO POLICY NUMBER ouAR. VICKIE SPRINGSANTO ;' EALTH PLAN ELIC MCL AFDC 3000 NAME 14 EL CAPITAN LANE ► ANTIOCH, CA 94509 - ADDRESS PLEASE RETURN TOP PORTION WITH YOUR PAYMENT ................................:......................................................................... ----------- ----------------------------------..---------------- DATE E OT DESCRIPTION OF SERVICE TOTAL 57 CDvERAOE EST COVERAGE PATIENT SERVICE HOSPITAL SERVICES CODE CHARGES INS- co-NO. 2 INS CO, NO AMOUNT 102895 1 EMERGENCY ROOM 45300027 85.00 102895 1 ER LIMITED VISIT 45324407 50,00 ** TOTAL EMERGENCY ROOM VISITS 135.00 SLMMARY OF CHARGES BY DE EMERGENCY ROOM VISITS 135.00 SIB-TOTAL CHARGES 135.00 TOTAL LIABILITY 135.00 I T _ ") -- PATIENT NUMBER PLEAIN RIPER TO►Ai4NT 'MTA3NAl PATWWT OkLM6 IAAY IN NTCE*OARY POR Mir NLM II ON ACL 00OW-ES .HAAOCJ Not "TEo W*MP$ TMS All WAS MWPAREO,OR PLEASE PAY THIS AMOUNT Af'0 CORNEMQIO" Cr f-$kAANCf CARRIRA R 71 DO NOT PAT ANY PAT of TTE h AWOIMTS SNOW"UNOER IISTUAT[O MA4MANCE COY[RAOE O _ O 023 --JRT S'R.;T. 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Cyc Sry—Date Itm Code Description Post Dte Htch#k itv Amount C 1 1718/96 5./5200182 EXPANDED VISIT—E 1/29/96 55204 1 42. 00 C 1 1/18/96 55E60186 TX—ROOM EXPANDED 1/229/96 55204 1 9 1. 001 TOTAL. . . . . . . . . . 133. 00 -------------------------------------------------------------------------------------- AR 7. 4. 4 08/07/95 CONTRA COSTA COUNTY HEALTH SERVICES Page 1 0723 Merrithew Memorial Hospital and Clinics 2500 Alhambra Ave. ,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services PITTSBURG FINAL - OUTPATIENT SUMMARY REPORT PATIENTi •' ACCT ,# M030206049 LOC• -::'-PH U #•' M003.699311; AGE/SB 32JE:`: ROrONi Q. 08/02/95 STATt)S'. REG..>,CLZ BEDi DIS3 **-*REFERENCE::LAB.%RESUI,TSWw***�c*,t Day 2 Date AUG 3 Time 1005 Reference Units : 3 !1 a ':. MTUML. . ... NOTES: ('a) PREPUBERTAL : 1.2 - 7.8 FOLLICULAR : 1.1 - 9.6 MID-CYCLE : 2.3 - 20.9 LUTEAL : 0.8 - 7.5 POST-MENOPAUSAL : 34.4-95.8 See also (b) (b) ORIGINAL REFERENCE LAB.REPORT IN CHART. Y Patient SPRINGS,VICKIE A ' 11ge/Sex. .32/F Acct#Ma30206049 699 311'. Cq 09/28/95 CONTRA COSTA COUNTY HEALTH SERVICES Page 1 0735 Merrithew Memorial Hospital and Clinics 2500 Alhambra Ave. ,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services PITTSBURG FINAL - OUTPATIENT SUMMARY REPORT . PATIENTi •• 7777194 $3122 32/E RWMt REGt0:>;;::;:<:;:> St.: DISI: :ak:ak;Yr: :.*:9r.:9w:�4•Yr. :9G:. ::: �1Y:Ac:xi:aY:� :�l: Wr:Yr:9eak:Yr.� ale: >: :aY:�t;frylr: :........:?r.#t. ............:...Vic.#. Rp4 ...x! . ....1�..............tk....l�.......:.:..::::.?k:#:.::U .:.:::.....:............:.:.....:.....:....:...............•:::.:.:::;.::.:::.:.::::.:::....::.:......:...:.. ................ ................:.::.............................. ....::. .....:..:..�..:..;n..•,..�..:..:.,...,.:.ti::;..,:": ..:..,...•:'.•:"..., }y"ViC .:.i(vR":1::.::.:..:.�..I...QvR.1.::f:..:..::. Day 2 Date SEP 26 . Time 1005 Reference Units >COLOR .. YELLOW : s .. (:YELLOW) ......:...:................................. ) ->APPEARANCE 'l:>? `<'<< < >;< «: (CLEAR) >GLUCOSE. .> NEGATIVEEGATZVE) >.... ;MG/DL. ->BILI NEGATIVE (NEGATIVE >IETONE . TRACE ' f NEGATIVE)::: . . .. .:. ... . ... :.... ....... .... .. ... >SG .(3f}<> :' :. (1.015) "LOAD... .. ;.. . S.bf 1 : :'•>::::>?:::::>:::<':;>:C �:NEGATSUE). . ->PH 5.5 (5.0) >PROTFTN :: NEGAT:lVE .:.... (NEGATIVE) ' ....... MG/DL ->UROBILINOGEN 1.0 (0.2-1.0) EU/DL >NXTRITE NEGATIVE _ . .. GNEO A' TVE) ->LEUKOCYTE SMAI<3� ::;";;:::.'I3 NEGATIVE WBC HPF RBC OCCASIONAL (0-2) RBC/HPF >BACTERIA RARE (:NONE)<.< ->EPITHELIALS FEW SQ AM (NONE) URINECULTURE77771 Specimen: 95:B0031060R Collected: 09/26/95-1005 Status: COMP Req#: 00368843 Received: 09/26/95-1010 Source: URINE Sp Desc: CC Subm Dr: HOBERT,D.KENT,MD i rdered: URINE CULT.REG > . r Final D9/27%95 CONTAMYNANT&:;; MODERATE :.; t 8atieat. SPRINGS,VICXIE A : Age/Sext 32/F Acct#M030683`122 Un .t M00369931.1: c9 10/26/95 CONTRA COSTA COUNTY HEALTH SERVICES Page 1 1227 Merrithew Memorial Hospital and Clinics 2500 Alhambra Ave.,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services PITTSBURG FINAL - OUTPATIENT SUMMARY REPORT PATIENT::: •' ACCT:: #s. M030950547 LOC': PHC U;#: M003699311 . ;: AGE%S% 33/F Roots REG 10/24/95 STATUS: REG CT:I BED:, DIS s _ a�:..,..:.:::.:::::::: .::: .::::::::::::::::::.:.:::.:.:.:.:...............OI31I ::. A T,+ . ...::..............................:::..::::..:::.::::,:::.::::::.:...:.............:....::.:::::::::::::,:.::::::::::::. . . :.. SNA ...:.:> ::::»:::�... F <w Day 1 Date OCT 24 Time. 0935 Reference Units ->COLOR YELLOW (YELLOW) ->APPEARANCE.S: CLEAR (CLEAR) '; ->GLUCOSE NEGATIVE (NEGATIVE) MG/DL _ (NEGATIVE) ,.>KETONETRACE (NEGATIVE) (;.:015). ->BLOOD TRADE. ... ::. ...Fi:. - - (NEGATIVE) ->PROTEIN 3(1„SSG/DYv. ....,# (NEGATIVE) MG/DL ->UROBILINOGEN ` 1.0 !< (0 .2-1.0) EU/DL : ->NITRITE NEGATIVE (NEGATIVE) -->LEUKOCYTE TRADE ��H.. : (NEGATIVE} _.� a ->WBC OCCASIONAL (0-3) WBC/HPF >RBC 0 2 H:' (0-2) RBC/HPF � >BACTERIA RARE (NONE) >EPITHELIALS FEW ;SOUAM (NONE) ->OTHER a (NONE) URINE CULTURE Specimen: 95:B0034279R Collected: 10/24/95-0935 Status: COMP Req#: 00383700 Received: 10/24/95-0943 Source: URINE Sp Desc: CC Subm Dr: FISHEL,CAROL,FNP WA ordered: URINE CULT.REG > inal 10/:26/95< NO GROWTH AT 48 HRS NOTES: (a) FEW MUCUS THREADS r Patient. SPRINGS,VICKIE A Age/Sex: 33%F Acct#M030950547 Unit#M003699311 V , . Pr r-o I I I .: 1,�� -*.�t�. 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( lw,pa y (. ` :,.y, , XJy yr. ! ..-: Z _...:fir �' ti i 7'. 4 LE f ''�!w+C 4'P: 1 .� y_.• 1 f :i.f. `''1`i "` 1 `- il` Y 4 L }a S� 4iL= - - � r L�W�i 1 1 w 4 •"vyI r s L 'Rilni�C�k h A r r, y r �. + t o 1s % i 1 ,e 'Aw . Id a s k + k - IF. 4. I r, -ti r, - P �' r , '9 I.. .. 11 Fi F, * t :i 1, t : IVF X - 3 , ; h4R 1 PHC(11/86) Side 1 p r J x` ' r i f x t _F,. r- _ OUTPATIENT NO CONTRA COSTA COUNTY HEALTH SERVICES PITTSBURG HEALTH CENTER ` , r OUTPATIENT NOTES DATEtj r c it ,-V^�.I1 •.� ���6�-�-.r�. � :''��'k � � ���'e`��t�z�t'74 y7 �,.hai`A �r� � = e i _ e �,... rJ� . �e.l G�a-�-✓ t etc S �" - ., !oti•.-. gal l` o ': �, << 4- LIN `GA-S�s..c'S S _ _ �v3 S�1,�l.� '.�S�-c��-=� �'Gl• =�;'�,d(�-c:e:o� �� vr Or 5 r— ti s r�� of f afe, Lb 07 a ---------------- y of -JS` T y�S�r b f1: tl 1 •; '��`� � {/ :. S71v- iy - zty� ,.y.�,,atx g^' l .h <'FS ,:r i r A } v - f d r • CONTRA COSTA COUNTY HEALTH SERVICES -1.1-5q5 ' ." TTS "1 C PITTSBURG HEALTH CENTER SPRINGS YICK �_ .. F 20/22/I9i;2 IE OUTPATIENT NOTES 4 - 001, k GO 3bg93 'iku• f C { Y C 0 { RSERs Al. FtiP PITT OATE:: _ Y - rry '�`'��,i $�• + It �._ 5 _-. a a /� :, it :,. J. _ ,. F+^."��'���sF 1 V O ::; ] �r �'.t f Leyte S� •,/F�" Il'� �i S/YLC �'L'O'� . 'LL m 'may /�W t' �' {O(^ _ r � ; (J��✓' T ; .' E.vL .. �.e .�. tis � i•� ,! r sur i L " G d yy se .�'. •fes+ �{ ,_ �•S ! - t Qyh _ •N h ' s � ri ,�:.s- b -"Cwt t.� •: r ,�, �3vv i C . ;� ? OUTPATIENT NOTES MR-I-PHC(11/66) Side 1 000th pC9tli ; N = 0 -4 1 S� 000 1 -4 1 NNM 1 t.1 t Z t «« x. to v1�n 1 tw v 1 tw ! .o r0 M vaiui i i i z i �Ou :1400 N / -•�O t S 1 .1 &W 10 0 1 "Cook 1q 1 i %M &OR 1 t11 t i 1 1 ! 1 K X tt" 1 111 I 1 V 1 n 1 0 A „ �1"•S i t i r v-4z 1 1} i -4 I t i 1 1Z 140 I 1illl14a I I« Sal :: t iwi�a i "1 C1C101N I17 C > how 41 i< 1�1 i-4 M I `` I y IN 1 1Z•• O a O 1 30 N ONO I I •p • • •p C1 000 1-4 1411 V iOk ! 1`O 1 1�0 ! t L41 1 1 1 i Coll:t 1 1 0 1 1 I PPoi i t ! t. I 41 — i 1 i t i f # 0 » 0 -S.. t t q 1 1 « I 1 t I tit INI .. a Me SPR I NG,S, 1/I C'KI E A 30384 556 PAGE: 07466 CONTRA COSTA COUNTY HEALTH SERVICES AGE No TYPE Of DATE OF BkL 2500 ALHAMBRA AVENUE GILL MARTINEZ. CALIFORNIA 94553 IN15101 313-6500 AL 10/06/95 OU PATENT NAME PATENT NUMBER SEX AGE ADMBSION OATS OMGMwdE OATS DAYS AMOUNT ENCLOSED PRINGS VICKIE A 30384556 F 1 3218/22/95 8/22/95 1 1 $ INSURANCE COMPANY NAME GROUP NO POLICY NUMBER GUAR. VICKIE :SPRINGS 4EALTH PLAN ELIG MCL AFDC 3000 ANTOR 14 EL CAPI TAN LANE AND ANTIOCH. CA 94509 ADDRESS PLEASE RETURN TOP PORTION WITH YOUR PAYMENT ----------------------------------------------------------------------------------------------- -------------------------------------------------------------------- DATE-OF gTY.r..- - UE SCRIP TION ICES SERVICE DETOTAL EST. COYEQAOE EST COVERAGE PATEN . SERVICE L HOSPITAL SERVICES I CODE CHARGES �+c _0 MO 2 NS. CO. NO T AMOUNT 82295 1 MARCAINE .5% 2CC 41951310 7.60 082295 1 PREDNISOLONE TSA20M 41951450 12.50 ** TOTAL a*4AR14ACY - INJECTISI rS 20.10 82295 1 EXPANDED VISIT EST 51820181 42.00 082295 1 TX ROOM-EXPANDED-ES 51880185 50.00 +* .TOTAL FAMILY PRACTICE 92.00 SU8-TOTAL CHARGES 112.10 TOTAL LIA8ILITY 112.10 I 172632 9311-10-0071 1 r I .r RI PATENT NUMBER ' nfPlR TO PArw"T AOD(TA'}IAk PATOWT RiNO MAY sE NICISSY=.",;; AY PQR ANY - Nwfw aw ALL w9XAwcf c"Awws NOT"Two*m"TK4 SILL*AS PwfPA LEO.CMI PLEASE DAY THIS AMOUNT 30364556 AND coomsromeft c ♦ PASIIRAA7((' CAwweRs as NOT PAY ANT PAwT OF TNF y� AMOUNTS SMOW"tAOM'*ESTYAT(O OMAm CE COVERAO( �,_y� C 6Z COtJgT STg1EEt. g00rr 703 CONTRA COSTA COUNTY HEALTH SERVICES •1/AK2 C►ECKS PAYABf£ TO Count Avditar•Cantraner. P Y MAq TMIE I. (:Ai'YGRNIA 9A 557 LL a SPRINGS, VI CKIE A 30683722 PAGE : 02407 Y1 - ----• — --- CONTRA COSTA COUNTY HEALTH SERVICES- -. .------- 250.? ALHAMBRA AVENUE 1 enlE (DATE OF BILL MARTINEZ. CALIFORNIA 9,1553 N 1 /19/95 I510I 313-6500 T PATIENT NAME I PATIENT NVUSERISENLI AGE JADOOSS.Oft DATE t}SCNAROf DATE DAYS AMCjNT ENCLOSED PR NOS. VICKIEA 130683122F 32- 6/'25/95 b9/25/95 I 1 $ 04SVAANCE COMPANY NAME GROW NO POLICY N,IAAEICR ,UAR. VICKIE SPRINGS EALTH PLAN ELIG MCL AFDC 33000 ANTOR 14 EL CAP 1 T AN LANE NAME ANT IOCH.. CA 94509 - ADDRESS PLEASE RETURN TOP PORTION I -" "^IIP PAYMENT -------------------------------------------------- -------------------------------------------- ...--...-....-----------------....-------.-...----------- DATE OE OTY DESCRPT-ON OF SERVICE TOTAL EST COVERAGE EST COvERwGE PATIENT SERVICE HOSPITAL SERVICES COOP CHARGES v+S CO POO 1 P+S Co NO J AMOUNT 092695 1 MICRO-CULT-UA SCREE 40627424 24.00 *• TOTAL CLINICAL LA9 I 24.00 092695 1 URIN ;HFM OJAL ANY 43630466 11 . 50 092695 1 URIN MICROSCP 43630607 13.00 • TOTAL LAP-(LI': C9 SPRINGS VICKIE A_. __3075.9738 PAGE : 07344 - - -- CONTRA COSTA COUNTY HEALTH SERVICES AcE No TYPEOF 2500 ALHAMBRA AVENUE 1 BILL DATE OF BILL MARTINEZ. CALIFORNIA 94553 INAL 10/25/95 15+01 313-6500 OUT PATIENT NAME PATIENT N1A6/BEQ SE%I AGE ADMISSION DATE OfSCNAROE OATS DAYS AMOUNT ENCLOSED 10 U PRINGS, VICKIE A 30759138 F 33 0/03/95 0/03/95 1 $ INSURANCE COMPANY NAME GROUP NO POLICY NUMBER GUAR- VICKIE SPRINGS HEALTH PLAN ELIC MCL AFDC 3000 ANTOR NAME 14 EL CAPITA^ LANE AND ANTIOCH, CA 94509 ADDRESS PLEASE RETURN TOP PORTION WITH YOUR PAYMENT --•----------------------------------------------------------------------------------------------------------------------=------------------------------------------------- GATE OF OTY OESCR-TION OF SERVICE TOTAL — nnVERAGE EST COvfRwGE EST COVERAGE PATIENT SERVICE NOSPIT AL SERVICES CODE CNARGCS NS CO NO 2 NS CO NO 3 AMOUNT 1 1C)391� 1 .XPANDED VISIT EST 51820181 42.00 100395 I TX P-OOM-EXPANDED-ES 51880185 50.00 TOTAL FAMILY PRACTICE 92.00 SUMMARY OF CHARGES 8Y DE FAMILY PRACTICE 92.00 SU6-TOTAL CH� IGES 92.00 TOTAL LIA8ILITY 92.00 A. 7-10-0073 PATIENT NUMBER ---IAPLEA.A REPER 70 PATIENT ADDITIONAL PATENT MLLPIO NAY AE NECESSANY PM ANY —� OOMPI ON ALL MO4+•'ES CNAROES NOT ►OSTEO Mf.EN TNI$RILL WA9 ►RErM!0,OR PLEASE PAY THIS AMOJNT ANp CORRE S►pIDENCE i N$IAIANCE CARRIERS DO NOT PAY ANY ►ART C TIt ANpo NTS SNOWN L04MR EST6AA TED PISURANCE COY.RAPE O O671 ..JUN: SIAt, -0n 203 CONTRA COSTA COUNTY HEALTH SERVICES •MAKE CMAr EC $ PAYABLE to Count A - � Y Auditor CDr111 OIIsf. NARTmfZ CAIKDRMA .rA 113 A LL 4 L .1 � ' S 1 SPRINGS, Y VI CKIE A 3097 7465 PAGE-. 0204 7 CONTRA COSTA COUNTY HEALTH SERVICES AGE NO TYPE OF � 2500 ALHAMBRA AVENUE 1 84L DATE OF B0.l - MARTINEZ, CALIFORNIA 94553 FINAL Ill/13/95 @ 1510) 313.6500 OU PATENT NAME IPATIENT NUMBER SE% AGE A04"SION DATE ONSCKAPIOE DATE DAYS AUOUNT ENCLOSED PRINGS VICKIE A 30911465 F 33 0/19/95 0/19/95 1 It1t1 INSURANCE COMPANY NAME GROUP NO POL#CY NL'ASER t aVAR- VICKIE SPRINGS EAITH PLAN ELIG ,MCL AFDC 3000 i4 ,O 14 EL CAPITAN LANENA AND ANTIOCH, GA 94509 ADORESS PLEASE RETURN TOP PORTION WITH YOUR PAYMENT _........-•--------------------------------------------------------------------------.......................................-............................................. DATE OF OTY DESCRIPTION OF SERVICE TOTAL - ... __.-_ .zSt COVERAOE EST COVERAOE PATENT SERVICE HOSPITAL SERVICES COOS CHARGES IIS CO NO 2 Et5 CO NO 7 AMOUNT ZI1995 1 BRIEF VISIT-EST 51820165 30.00 101995 1 TX ROOM-BRIEF-EST 51880169 50.00 ** TOTAL FAMILY PRACTICE 80.00 SUMMARY OF CHAR ES BY OE FAMILY PRACTICE 80.00 SUB-TOTA.: CHARGES 80.00 TOTAL LIABILITY 80.00 14871 IA99311-10-007S I PATIENT NUMBER K'A>K vo To PATIENT A001"AL PATIENT 911.3,000 MAI SE NECESSAAI POR ANY NNrKA ON ALL M{Su'"I CNAIIO(S NOT "-to WW["TIS KL WAS Pn[PANEo,DA PLEASE PAY THS) AMOUNT AID CORRESPONDENCE I NSUPANCE CAr IERS 10 NOT PAY ANY PART OP tNt - AWOM+TS SNOW'UNDER ESTMATEo-su"ANCE COYEa- p I, ROOM 203 M CONTRA COSTA COUNTY FIE AI TN SERVICES -MAKE pHEC✓r5 PA YAA(E Tp County AvdltoT-Contr ollet. 4ARf P1(I. /.AIKORINn 04533 A LL n �+R SPRINGS, l V1 CKI E A 3095054 7 PAGE: 02048 CONTRA COSTA COUNTY HEALTH SERVICES AGE NO TYPE OF DATE OF 8111 2500 ALHAI.48RA AVENUE 8111 MARTINEZ. CALIFORNIA 94553 INAL 11/13/95 15101 313-6500 OUT @ CID 0 PATIENT NAME PATENT MJMSEq SEX I AGE ADUMSOOOO DATE 04C"AROE OATS I DAYS AMOUNT ENCLOSED PRINGS VICKIE A 30950547 1 F 1 33 0/24/95 0/24/95 1 1 $ INSURANCE COMPANY NAME GROUP NO POLICY NUMBER auAA. VICKIE SPRINGS 4EALTH PLAN ELIC MCL AFDC 3000 ANTOR 14 EL CAPITAN LANE ANBD ANTIOCH, CA 94509 ADORESS PLEASE RETURN TOP PORTION WITH YOUR PAYMENT .................................................................................................. ........................................................•... DATE OF OTY DESCR PTION OF SERVICE TOTAL ST COVERAGE EST COVERAGE PATIENT SERVICE HOSPITAL SERVICES COOS CHARGES MS CO NO 2 INS CO NO 3 AMOUNT I '095 1 MICRO-CULT-UA SCREE 40627424 24.00 •+� TOTAL CLINICAL LAS 24.00 102495 1 URIN CHEM QUAL ANY 43630466 11 .50 102495 1 URIN MICROSCP 43630607 13.00 +� TOTAL LAB-CLINICS i4 PUBLIC HL 24.50 SUB—TOTAL CHARGES 48.50 TOTAL L1f.31LITY 48.50 .A 1 1`11726 U99111-10-00 6 PATIENT NUMBER f AtreR TO rATEMT AopTYSMAi rA TIt Ni IKCMO YAT K N[CESSAwY sow ANY j . +{ A jar) M:.'0!A OM ALL ..Ok^"% CMAAOtS NOT "T'>wK'N TWO eat wAS►At►Awto.CIw PLEASE PAY THIS AMOUNT 1 l 30950547 1"40 e.owwes+aa..et R MSUAAMot CAwA ITS oo NOt rAT ANY rAAT OR TW YI ANOUPOS SHOW"UMotw tsja^T[o rKVMAMCE COKwAo! O p 675 cokM' SI ktt= 00(w ;Ot � CONTRA COSTA COUNTY HEALTH SERVICES •.VAXf CHECKS PArAgtE TO County Auditor-Controller 4..RT04I CAi�i?•.M1A ,.esi a u 6 wT a SPRINGS, VICKIE* A .37 760542 PAGE: 07827 , CONTRA COSTA COUNTY HEALTH SERVICES AGE NO TYPE OF 2500 At_HAMBRA AVENUE BILL DATE OF BILL MARTINEZ- CALIFORNIA 94553 1 INAL 12/04/95 (5101 313.6500 01i I PATIENT NAME PATIENT NUL46ERISEXI AGE ADMISSION DATE DISCwwRGE OAT* DAYS AMOUNT ENCLOSED PRINGS, VICKIE A 31160542 1 F 33 1/16/95 1/1 /95 1 INSURANCE COMPANY NAME GROUP NO PDLIC, NINAEtER GUAR. VICKIE SPRINGS 4EALTH PLAN ELIC MCL AFDC 3000 -ANTNAME 14 EL CAPITAN LANE AND ANTIOCH,, CA 94509 ADDRESS PLEASE RETURS. TOP PORTION WITH. YOUR PAYMENT ..DAT ��..._1-ScRr............. 1ES iS CO R CaE EST C CITY T Y . ... ........................ DATf OF Of SCRIPTICN OF SERVICE tOTAL i COvERAGE PATTEN? SERVICE HOSPITAL SERVICES CODE Cnri. CO NO 3 AMOUNT 111695 1 HANDLING PHD 40690117 N/C +• TOTAL CLINICAL LAB 111695 1 VENIPUNTURE 43630359 N/C 111695 1 HIV—EIA TEST 43680354 14,00 ++ TOTAL I.AB—CLINICS $ PUBLIC HL 14.00 111695 1 EXPANDED VISIT EST 51820181 42.00 111695 1 TX ROOM—EXPANDED—ES 51880185 50.00 +• TOTAL FAMILY PRACTICE 92,00 SUB—TOTAL CHARGES 106.00 TOTAL LIA81LITY 106,00 I I i PATIENT NUMBER f [A9E AffEw 10 PANNI i 04TION-i PAT(NT ltlw0 MAY BE rECESSAav IDN NUu6Ew ON A,, *'KXI+KS C—OCAS NOT -09TE0 ^*-*-Tt y e[A wA5 zw wm Ow PLEA`,F PAY THy AMI,3Vty: ANO co""l SPONOf NCE W wSUw ANCE CAWhf*S DO NOT PAY ANY PA wT Of T-60 - - AVOUNTS SWON IIQEO FSYWATED wSUNANCE COvEOAOE a CONTRA COSTA COUNTY HEALTH SERVICES•MAKE CHFCAS PArtgtf ip County Aud+toT-CantroneT ea+ ccxRr ,Ititrt o,.:u x,T T m4a'.E; r;I Ktj}irgt 91151 LL n M CONTRA COSTA COUNTY HEALTH SERVICES f 30 95 `" n P D r + errittlew 4� O�G °PO4G!1d PRE-OPERATIVE ' .1 SPRINGS ` AND CLINICS HISTORY AND PHYSICAL Y Y C K I E F 1 0/ 2 2 / 1968 510 776 - 8325 c �nE bQ9no- 1 GO Date ' Patient ID P ITT ,T To be used.only for GENERAL ANESTHESIA(RISK I&II),MONL ORED ANESTHESIA,REGIONAL and SPINAL ANESTHESIA with no planned post-op admission.H&P to be done within 1 week prior to surgery;Lab to be done within.2 weeks prior to surgery. Have you had a problem with: (Circle One) DRUG ALLE IES. ( QL.n 1 rn oST a,K_t I ;o I Anemia or Bleeding Y N Medications taken on a regular balis: Arthritis Y N — Asthma or Hay Fever Y N q Back Problems Y N Previous Operations: - J � l a L. Diabetes Y N o V e C S l J L.,LcsS Fainting Spells/Convulsions Y N � e '^� I Heart Problems/Rheumatic Fever Y N Anesthetic Complications ' ` L Angina or Chest-Pain Y l ) Family History of Anesthetic Complication: 1 Palpitation or Pounding Heart F51 Family History of,A/bnormal Bleeding: Shortness of Breath � � Do you smoke?f? How many per day? �v How long? Hepatitis or Liver Disease Y N Do you drink? r L How much per day? Hives Y N Do you use street drugs? Type: Hypertension/High Blood Pressure Y N How much? How long? How often? Stroke Y Do you have: ❑ Loose teeth ❑ Bridgework ❑ Dentures ❑ Contact lens Lung Problems Y N ❑ Hearing Aid ❑ Prosthetic Device ❑ Other: Chronic Cough Y N Serious injuries or illness in the past not referred to above: ► \- Emphysema Y N Frequent Colds N Have you ever had a blood transfusion? Tuberculosis Y When? Why? OB History: Number of pregcn `ciiess2 Numb r live births Number aborti n /miscarriages Last menstrual period: Birth Control Plans: f Patient Signature: CHIEF COMPLAINT: p...) CA---- HISTORY OF PRESENT ILLNESS: -4 •l e- S s REVIEW OF SYSTEMS: CONTRA COSTA COUNTY HEALTH SERVICES �errit�w 05 r�U —n - "�j _ A o c L I M I c s PRE-OPERATIVE r HISTORY AND PHYSICAL 4� x i SP I I NGS PICK I E F 0 / 22 / 195'2 510 776 - 6325 Date 715_' onb °� �at�71�. GO 1.19 Id PHYSICAL EXAMINATION// Height el ht BP P RR �� T HEENT 4T 1.i C - - --- - - NECK HEART �Z BREASTS ^^—�- LUNGS Cl � ABDOMINAL ✓�^- �x-iC( PELVIC RECTAL ^� EXTREMITIES �,7��'• ^G � Cry- t C 1 f7 NEUROLOGICAL If LYMPHATICS OTHER • IMPRESSION: PROC DURE PLAN ANDR:CONSENT FOR -OP ORDERS:VBC LYTES [—] PT/PTT F] UA F] CHEM PANEL HCG-all tubal ligations RH(D)IMMUNOGLOBULIN IF INDICATED CHEST X-RAY EKG 1 OTHER ype of Anesthesia: ❑ General ❑ Spinal ❑ Regional ❑ Local with Standby RISK EVALUATION: I (Normally healthy)-If checked,OK to proceed for surgery. ❑ II (Systemic disease,well controlled)-If checked,OK to proceed for surgery. 0 III (Systemic disease,stability unknown)-REFER PATIENT TO PRE-ANESTHESIA EVALUATION CLINIC OR APPROPRIATE DEPARTMENT FOR STUDY AND EVALUATION. Z -' M.D. DATt SIGNATURE PRE-OPERATIVE SURGICAL NOTE: - - atwa I M.D. DATE SIGN U E _. . _ nnO 11nCIMA"IklC LIIG:T/1r!IV A\111 nLIVRI/%AI 12/19/95 CONTRA COSTA COUNTY HEALTH SERVICES Page 1 C , 1407 Merrithew Memorial Hospital and Clinics 2500 Alhambra Ave. ,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services CHART COPY OF PATHOLOGY REPORT PATIENT:' SPRINGS;<VICKI A ACCT # M0372936. 6 LOC• OPS U# N1003699311 PHONE 510 776 :8325 DOB: 10f22/62 AC:E/S?€s 33/F R(30M REG: ]2014/95 S ED• .AT. REG:: SDC $ ISIS Received: 12/15/95-1022 Status: SOUT REQ #: 00410122 Spec #: 95 : SU3882 Collected: 12/14/95- Spec Type: TISSUE MIS Subm Dr: KOFOED,JOHN,MD CLINICAL HISTORY RIGHT TENNIS ELBOW SPECIMEN COMMENTS: 1 CONTAINER SSUES A. TISSUE,MISCELLANEOUS - RIGHT EXTENSOR TENDON/SCAR . -PATHOLOGIC DIAGNOSIS FIBROUS CONNECTIVE TISSUE AND FAT SHOWING FIBROUS SCARRING AND MILD CHRONIC INFLAMMATION, REMOVED FOR RIGHT TENNIS ELBOW Dictated by: ASUNCION,GLORIA Entered: 12/19/95 - 1357 GROSS FINDINGS LABELED RIGHT EXTENSOR TENDON/SCAR. SUBMITTED IN ONE CONTAINER ARE FRAGMENTS OF BONE AND A SEGMENT OF RESILIENT TO FIRM FIBROUS TISSUE. THE SOFT TISSUE MEASURES 3.2 X 1.7 X 1 CM. THE P&AGMENTS OF BONE RANGE FROM 0.3 X 0.3 X 0.2 CM TO 1.8 X 1.3 X 0.5 CM. SECTIONS OF TAY SOFT TISSUE ARE TAKEN. Dictates by: ASUNCION,GLORIA Ent-tired: 12/18/95 - 1650 (A w MICROSCOPIC F? iDINGS MULTIPLE SECTIONS SHOW FRAGMENTS OF DENSE FIBROUS CONNECTIVE TISSUE AND FAT INCLUDING SMALL SEGMENT'§)OF SKELETAL MUSCLE. THERE IS VAGUELY NODULAR PROLIFERATION OF FIBROBLASTS AND COLLAGEN, ASSOCIATED WITH FOCAL VASCULARITY AND MILD CHRONIC INFLAMMATION. MARKERS: PTH:PHC ned ASUNCION,GLORIA 12/19/95 ** END OF REPORT ** CONTRA COSTA COUNTY HEALTH SERVICES SPRINGS, VICKIE MERRITHEW MEMORIAL HOSPITAL 36-99-31-1 OPERATIVE REPORT PAGE 1 DATE OF OPERATION: 12/14/95 SURGEON: JOHN KOFOED, M.D. ANESTHESIOLOGIST: CRAIG NIELSEN, M.D. ANESTHESIA: General, LMA. PREOPERATIVE DIAGNOSIS: Right tennis elbow, severe. POSTOPERATIVE DIAGNOSIS: Right tennis elbow, severe. FINDINGS: OPERATION PERFORMED: Right tennis elbow release. INDICATIONS FOR SURGERY: Failing conservative treatment of the right tennis elbow. DESCRIPTION OF OPERATION: The patient was prepped and draped in the usual sterile fashion. A curvilinear incision was made over the lateral aspect of the elbow. Soft tissues were reflected off of the lateral epicondyle down to the annular ligament. We then took an osteotome, knocking off the lateral epicondyle and putting some drill holes into that area. We then injected Marcaine along the incision and closed the soft tissues in routine fashion. We injected the remainder of the Marcaine deep into the wound. A long-arm splint was applied. The patient was discharged to the Recovery Room in satisfactory condition. Ancef was given at the end of the procedure. JK:cd d: 12/14/95 t: 12/15/95 aOHNOFO4ED, M.D. OPERATIVE REPORT PAGE 1 CONTRA COSTA COUNTY HEALTH SERVICES PATIENT REGISTRATION x EMERGENCY DEPARTMENT Financial Class Code G 0 GO Med.Serv. Patient# U:C'C 36'9:9311 ,0 :0'.077 Work Related? N Dr's 1 st - Patcom Type Voluntary Clerk/Con Medicare? N St.Facts? 471-83 1,002 `;E ``:,"ADM' CAMP;OS Insurance? N H Plan? Y PATIENT'S NAME Medi-Cal? "N Vet? 'S P.,R,I;N G S/D? M/Y/$ Previous Change Race Coverage#1 HEALTH PLAN: ELIG" MCL AFDC _ WHITE NON- Policy# `. Sex D.O.B. Age Information 83000 H F'G 0 1'0/2-2 x:19 6 2 °'0 3.:3 Coverage#2 Soc.Sec.# I.D: :: M.Status Policy# ;, , 550"­153'"'. 0 +88 S ` :.STN6L r :y Information Maiden Name Mother's Maiden Name Coverage#3 - Policy# Language How Arrived Information -ENGL I`S:H Other Insurance Address/Phone Note: ?P.CPP,ER PATIENT i` 595 CENTER AVE ` . Patient's Mailing Address MARTINEZ CA 14 EL`-; CAP I'TAN , ANE ANTI.00.H ;': ;: CA`, 9.450.9 Pt. Employer Day Phone Night Phone ( 51.0 )776-8325 HM 5 Occupation Local Address Employer's Address RESPONSIBLE PARTY SPRINGS . . VICKIE Resp. Party's Employer D.O.B. Relation Sex UNEMPLOYEDS.E. ;:SEL Resp. Party's Employer's Address Soc.Sec.# I.D. 558-53=0488 00000 R.P.Address Subscriber '-SPRINGS VICKIE. 14': EL '`CAPITAN" L:ANE Y Soc.Sec.# Employer. ANTIOCH . :' CR 94509 558-53-0408 Day Phone Night Phone EMERGENCY CONTACT W A N D A SPRINGS PRIMARY CARE PROVIDER&CLINIC Relationship MO - M 0 T H E GEE , L MD ';P I TT Day Phone Night Phone Admit Date Time Pre-Admit E.D.A. 754-0662 HM 10/28/95 17,=41 `! Address 5 - NO ADVANCE DIIE NEXT OF KIN Relationship Room Bed Med Sery Acc.Cd. r Day Phone Night Phone Smoke Religion Inquiry Address Last Admit Date Place NOTES atient Unable to Sign Consent to Service 1'69511/E/94 Consent to Service on file Consent to Service S gn d dated (Signature of Registration Clerk) Discharge Date: Time: 1n2895 CONTRA COSTA COUNTY HEALTH SERVICES SPR I NGS VICKIE F PITT 510 776-8325 GQ CONSENT TO SERVICES AND CONDITIONSQ q �1 _ I (�11F31002- OF SERVICES AND OF ADMISSION 10/22 / 1962 GEE. L MID 43 UCC Patient ID MEDICAL/SURGICAL TREATMENT CONSENT: The undersigned consents to any medical treatment, including but not limited to x-ray examinations, laboratory procedures, medical/surgical procedures, injections, and blood trans- fusions, considered advisable or necessary by the attending physician or by other of the hospital's medical staff, including physician residents and independent contract physicians;and further agrees to the provisions expressed on the reverse side of this form. TEACHING PROGRAM: The undersigned understands that Contra Costa County Health Services, Merrithew Memorial Hospital and Clinics, is a teaching institution and that residents, interns, and health care students, under the supervision of professional staff, may be involved in providing medical and/or health care. CONSENT TO RELEASE MEDI-CAL LABELS: The undersigned authorizes Contra Costa County Department of Social Services to release information concerning the status of the patient's Medi-Cal application, and to send the patient's Medi- Cal labels to the Contra Costa County Health Services Department. I also authorize the above Agency to send the Contra Costa County Health Services Department a Letter of Authorization, to allow the Medi-Cal program to be billed for any medical services I have received at a county facility that may be covered by the Medi-Cal program. FINANCIAL AGREEMENT: The undersigned promises to reimburse the County of Contra Costa for any hospital care and/ or medical services provided to the patient at any time within 365 days of the date indicated below, which services are not covered by Medicare, Medi-Cal, insurance or any other health care compensation carrier, at the rates established by the Contra Costa County Board of Supervisors.The undersigned further agrees to use any damages or indemnity paid to or on behalf of the patient as a result of the injury or illness which necessitated this care to reimburse the county up to the amount billed, but not to exceed the rates set by the Board of Supervisors. The undersigned waives the statute of limitations on this matter for a period of 10 years. This agreement and waiver is binding on the undersigned, his or her heirs, assigns, administrators, and executors. ASSIGNMENT OF BENEFITS:The undersigned authorizes,whether he/she signs as agent or as patient, direct payment to Contra Costa County of any insurance benefits otherwise payable to or on behalf of the patient for this hospitalization and/ or these outpatient services, including emergency services if rendered, in an amount not to exceed the County's regular charges. A photocopy of this authorization shall be considered as effective and valid as the original. The undersigned authorizes and directs the attorney, claims adjustor, insurance company and any person(s), company or corporation who may effect a settlement or payment of any claim for damages or indemnity that the patient may have arising from the injury or illness which necessitated this hospital care and/or outpatient services, to deduct the amount of the charges of these services from any sum due the patient and to pay that amount directly to Contra Costa County and the undersigned hereby assigns that amount to Contra Costa County. RELEASE OF INFORMATION FOR REIMBURSEMENT: The undersigned agrees that, to the extent necessary to deter- mine liability for payment and to obtain reimbursement, Contra Costa County may disclose portions of the patient's record, including his/her medical and psychiatric records, to any person or corporation which is or may be liable for all or any portion of the charges, including but not limited to insurance companies, health care service plans, workers'compensation carriers, Social Security Administration, and peer review organizations. The undersigned certifies that he/she has read both sides of is document, received a copy thereof, and is the patient, the patient's legal representative, or is duly authorize by the patient as jh � tieltts general agent to execute this document and acceptits terms.DATE SIGN UR PATIENT OREPRESENTATIV IF PATIENT'S REPRESENTATIVE, RELATIONSHIP TO PATIENT WITNESS TO SIGNATURE If patient unable to sign,STATE REASON: Date: By: MEDICARE PATIENT STATEMENT OF FACTS ❑Patient is years of age. ❑This visit is not the result of any kind of accident. ❑Patient is not employed. ❑No other individual is responsible for the patient's medical bills. ❑Patient's spouse is not employed. ❑INPATIENT.• I have received the Medicare Notification entitled ❑Patient is not covered by Worker's Compensation,The "AN IMPORTANT MESSAGE FROM MEDICARE." Black Lung Program or a large group health plan. I certify that all of the above statements are true. DATE SIGNATURE OF PATIENT OR PATIENT'S REPRESENTATIVE IF PATIENT'S REPRESENTATIVE, RELATIONSHIP TO PATIENT WITNESS TO SIGNATURE ' 1MERBITHEW MEMORIAL HOSPITAL & CLNVICS E � Q- ME G NCY DEPARTMENT AST TRACK It�GS YICKIE DATE: 6 -STIME: I AGE: 5j SEX: f P ITT 510 776-8325 GO ARRIVAL VIA: A IN F]W/C ❑AMBULANCE Q GURNEY C]CARRIED El OTHER F-1 OLICE TR NSFER/REFERRAL 1 � 'i `1 —. 0'1183100?. VISIT TYPE: I IAL [—]SCHEDULED RETURN UNSCHEDULED RET AM1fLESS THAN 481i�Ws 2 1.1.9 6 2. GEE • L M Q TRI STATUS: ❑ I ❑ II III ❑::IV 1028/95 03 SCC +. CHIEFrLAIPtT/HPI: Wloll NAME 5tK � T TETANUS: efsAf MpDICAL S ORY: 1 v49ATNI [I DIABETES []CVA ❑ASTHMA/COPD ❑SEIZURES CARDIAC(LIST): [_].SUBSTANCE' i. SURGERIES(LIST) ABUSE:(LIST) t 0 R CEPT{ON: OTHER: VISUAL ACUITY MEDICATIONS( 'J — — ` ALL RGI CORRECTED J I OD TIME/IN BP P R T OTHER TRIAGE INTERVENTIONS: ❑ICE, ❑DRESSING ❑COLLAR V APITIALORDERS ❑X-RAY ❑MASK ❑TYLENOL ID O �/ ❑U/A ❑UHCG ❑MONITOR ❑EKG ❑PCXR B P R T OTHEOZ ❑ABG IY R WEIGHT ❑ ❑PULSE OX ❑PEAK FLOW li i p` G R N ❑ORTHOSTATIC VS ❑CHEM bG [-]IV SOLN.: TIME SEEN: HIST® N® P L EXAMINATION RATE: ❑UA/C&S/DIP/TOX SCREEN ❑CBCD ❑ESR [-]PT ...... _ _. ------ _.. — — — --- ❑PANEL t . 2 3 ❑BCX 1 2 --- ❑ER PREG SHCG UHCG �' - -- ❑TYPE SCREEN/CROSS X_ ,, �•� ` , �n '� � ❑B.A. '❑ASA ❑ACETAMIN. ❑CARDIAC PROFILE I } ❑GC/CHLAMYDIA' ❑VDRL. 'r ff - F .�� `_ ~� --� — ~ -- - --- ❑Td BOOSTER s INITIAL/TIME _ — `-,� ,f _ -- '---- -------- �-- —r,—;--- r' ORDERS •--` „S. .l,C� '. t :�. _ ,• ;- t, _r ❑*RAY:,. - � 1 _ r "J • SWAR01710NAL RECORD DISCHARGE DIAGNOSIS: , g G25872 AK5792874 DISCHARGE CONDITION: &AMBULATORY DISPOSITION: ME ❑ADMIT Q MHCS SIGNATURE: ❑IN CUSTODY 0 OTHER: M P ' EMERGENCY DEPARTMENT RECORD% ' VVUHK/,t,;HUUL HELI--ASE a PATIENT NAME ADDRESS.. TIME OFF AUTHORIZED FROM: C 9 ❑WORK Q INSTRUCTIONS IN SPANISH ❑P.E. ❑SCHOOL O M W ❑ o 3 m \ y J. ¢ ,.r--.� - --�.: 4. -- `' DUE TO: ❑I LNESS .. s 1v.O �p �r p Sig:: ( _ ( (=a c Dis,pr � m a+ ll7IT 17"17, cJ Zai? :'O-\.:Q., d�� VOID: COPY ONLYUj FROM: ; baa RETURN D E:: =.m mac, (A: rr _¢m TRIP ONS: a �� :a W Sig: isp:. tp I► tR �mm w „1„ p qm yw 6-J VOID:COP ONLY 3 ou: J c¢mw IV w- L W SIg ... Disp: c, _ m 6 s To VOID: COPY ONLY SIGN T RE: SIGNATURE Y's' ❑cli TRANSMI AL ORDER �lfr,. TT DATE- M.D. ATE M.D.l FNP C WORKING DIAGNOSIS: =✓�--• ❑DO Nd�ORIVLCHOME FROM THIS VISIT. PRINTED INSTRUCTIONS GIVEN: INSTRUCTIONS ON REVERSE OF PAPER' ❑WOUND CARE ❑ SPRAIN/FRACTURE ❑ �OMITINQ,/DIARRHEA ❑UTI i �' ❑ASTHMA!COPD ❑ REAA INGS ❑SCREENING NURSE ❑HEAD INJURY ❑CASTS/SPLINTS. ❑COLDS/FLU. _11 ❑ EARLY PREGNAN Y ❑ EAR INFECTION LABORATORY ❑DRIVING CAUTION !' ❑ TXSTS ❑REGULAR PROVIDER ❑ EYE INJURY ❑BACK/NECK INJURY ❑ FEVER.00NTROL VAGINAL BLEEBING ❑ABDOMINAL PAIN ❑ 1 OTHER INSTRUCTIONS: ` `'" •,,o�— r , FOLLOW-UP VISITS: ❑ RETURN-TO EMERGENCY DEPARTMENT IN DAYS.BRING THIS SLIP WITH YOU WE CANNOT SET AN APPOINTMENT BUT WILL SES YOU AS.SOON AS POSSIBLE.COME AT :f KEEP YOUR CLINIC APPOINTMENT AS PREVIOUSLY PLANNED: foLLOW-UP APPOINTMENT#1 ❑ APPOINTMENT SLIP GIVEN. CLINIC/PROVIDER ❑FAMILY PRACTICE SITE TIME FRAME ❑CALL AS SOON AS POSSIBLE" ARRANGE ARRANGE APPOINTMENT REFER TO APPOINTMENT INFORMATION SHEET .a MESSAGE LEFT AT APPOINTMENT UNIT.YOU WILL BE CON- FOLLOW-UP APPOINTMENT#2 TACTED ABOUT YOUR APPOINTMENT WITHIN,TWO'WORKING DAYS.IF YOU HAVE NOT BEEN CONTACTED;CALL APPOINT- CLINIC/PROVIDER SITE TIME FRAME NT UNIT AT NUMBER LISTED ON INFORMATION SHEET , NURSE INITIAL / TIME DATE j."? I UND R ANDT E INSTRUCT IO (Patient Signature) HOW lv WALKING ❑W/C DISCHARGED: GUR'EYE]OTHER: X SIGNATURE DISPOSITION: HOME ❑A IT: — NOTIFICATION: ❑CORONER ❑dN CUSTODY❑MHCS, ❑O R:` ❑POLICE ❑CPS ❑OTHER M.D.!FNP ADDITIONAL RSING NOTES/DISCHARGE TEACHING: PATIENT VERBALIZES U STANDING OF INSTRUCTIONS. NURSING SIGNATURE MR474A•5(s/%,,. EMERGENCY DEPT. DISCHARGE.INS - ` CONTRA COSTA COUNTY HEALTH SERVICES r9 C MERRITHEW MEMORIAL HOSPITAL & CLINICS C-���' AMBULATORY CARE 76 H CONSULTATION !D/ 2---Z,/r. Z— REQUEST NOTE: This form is to be used for consultation requests (off-site and same-site). TO: ❑ PHC ❑ RH MTZ ther Consultation Appointment Date FROM: �iC ❑ RHC ❑ MTZ ❑ BHC ❑ CHC Other C?Evaluate SULT/REFERRAL TO: o(Lrw xc0r-F—h IF SURGERY INDICATED: and advise. I will follow this patient. ❑ Schedule and notify Case Manager. ❑ Please assume care for this problem. ❑ Consultation only.Discuss with Case Manager prior to scheduling. REASON FOR REFERRAL 3 3 ti (o c C, h-. rq 1-%-1 O� fJ P-Z-a,%oy'r—dlC,115 &k CcLyofit plc xtr✓ �a �o.l %` s S/(� . sk.-yrv� r`t1%e�`i o+-` . Ol ea sc. tA•, vc-►-f— , s s s 4s� RELATES MEDICAL INFORMATION TO BE SENT [❑ None] UG � � -- tivrt Should x-ray films be sent? ..�lYes ❑No Referrirovidees Name(please print and sign) Date CONSULTANT'S REPORT [❑ Dictated Of so, please write diagnosis and plan below.)] (ORTHOPEDICS) NOV 3 01995 i Cbf� W cam. D� I'L BROKEN APPOINTMENT ❑ PRN Consultant(please print and sign) Date ❑ Send Reappt. Notice ❑ Reappt. 1-2 weeks as overbook Reviewed by Case Manager/Referring Provider Date Clinic Requosting Consult Consult Site oaeRequesting' sM `caOriginal:Medical�e�MR191-8(5/95) GlnroConsult :A Phjk:CCHP AMBULATORY CARE CONSULTATION REQUEST CONTRA COSTA COUNTY HEALTH SERVICES j 2 Za 93 1$I�H �" MERRITHEW MEMORIAL HOSPITAL & CLINICS AMBULATORY CARE w tm CONSULTATIONS p R j N G S Y I CK I E ` FOLLOW-UP f 10/ 22/ 1962 510 776-6325 NOTE: This form is to be used for consultation follow-up nn i b C q'i 1— 1 GO (off-site and same-site) and for patient initiated Specialty Care. G E E • L "D _M PITT CONSULTANTS REPORT ^ ' Date of Visit [❑ Self Referral] Clinic Type Findings [❑ Dictated Of so, please write diagnosis and plan below)] 19 j Al Chart Check to Case Mgr? ❑ Yes ❑ No Consultant(please print and sign) Date Original: Consult Site MR191A-0(3/95) Yellow: Requesting Site AMBULATORY CARE CONSULTATION FOLLOW-UP CONTRA COSTA COUNTY HEALTH SERVICES I I $ 9 h MERRITHEW MEMORIAL HOSPITAL AND CLINICS 5 3a MARTINEZ HEALTH CENTER OUTPATIENT NOTES SPRINGS VICKIE F PITT 520 776-8325 GO r � � DATE I Patierpip 3 6 TR 3 a y 1 9 2 GEE: L »D t f c A -A AMk MR-I-MTZ-6 (11-89) rCONTRA COSTA COUNTY HEALTH SERVICES 1 MERRITHEW MEMORIAL HOSPITAL 8 CLINICS 01 t8 96 KKH 3p AMBULATORY CARE CONSULTATION ,. FOLLOW-UP , A GS Y YiCKIE Itl/22/ 1962 510 77.6-8325 NOTE: This form is to be used for consultation follow-up (off-site and same-site) and for patient initiated Specialty Care. 0!1 '�' t� r.1 CONSULTANTS REPORT GEE + L M p PITT Date of Visit [❑ Self Referral] iltic Type Findings [❑ Dictated Of so, please write diagnosis and plan below)] DcLS 12111 7 1 f v� 4)n�i�U-t'o'o W A '1 101, AOL I_ Chart Check to Case Mgr? ❑ Yes ❑ No Consultant(please print and sign) Date Original: Consult Site MR191A-0(3/95) Yellow: Requesting Site AMBULATORY CARE CONSULTATION FOLLOW-UP T � �Ufiq CLAIM C I BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA MARCH-12, 1996 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: $200.00 Section 913 and 915.4. Please note all "Warnings". CLAIMANT: GORDON RASMUSSEN ATTORNEY: 1996 ADDRESS: Date received FEB 2 2 ADDRESS: 6000 HIGHLAND ROAD BY DELIVERY TO CLERK ON FEBY21(��, 6 PLEASANTON CA 94588 MAR BY MAIL POSTMARKED: FEBRUARY 20, 1996 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. e ^ FEBRUARY 22 1996 PpHHIL BATCHELOR, Clerk DATED: BY: Deputy II. 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: 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 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors 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: :JOJWJ,L ,�q2, PHIL BATCHELOR, Clerk, By 0,". TP J a . 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. *For additional warning see reverse side of this notice. 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 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 the claimant as shown above. Dated: �`�}w +�� JT/9 _ BY: PHIL BATCHELOR by� putt' Clerk CC: County Counsel County Administrator C. 9 OFFICE OF COUNTY DEPUTIES: - COUNSEL PHILLIP S. ALTHOFF I' SHARON L. ANDERSON CONTRA COSTA COUNTY BRANDON D. BAUM ANDREA W. CASSIDY COUNTY ADMINISTRATION BUILDING VICKIE L. DAWES MARKE S. ESTIS P.O. BOX 69 MICHAEL D. FARR MARTINEZ, CALIFORNIA LILLIAN T. FUJII DENNIS VICTOR J. WESTMAN 94553-0116 GREGOR C. GRAVES COUNTY COUNSEL GREGORY C. HARVEY KEVIN T. KERR TELEPHONE (510) 646-2041 EDWARD LANE, R SILVANO B. MARCHESI FAX (510) 646-1078 MARYANN MMASON ARTHUR W. WALENTA, PAUL R. MUNIZ JR. VALERIE J. RANCHE ASSISTANTS February 23, 1996 DAVID F. SCHMIDT DIANA J. SILVER VICTORIA T. WILLIAMS NOTICE OF INSUFFICIENCY AND/OR NON-ACCEPTANCE OF CLAIM TO: Gordon Rasmussen 6000 Highland Road Pleasanton, CA 94588 RE: CLAIM OF: Gordon Rasmussen 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 exact 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 be more precise on the date of the occurrence. "Not sure of date this spring" is not specific enough to properly evaluate your claim. 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: February 23, 1996 at Martinez, California. CC: Clerk of the Board of Supervisors (original) Risk Management (NOTICE OF INSUFFICIENCY OF CLAIM: GOVT. CODE H 910, 910.2, 920.4, 910.8) i RECEIVED BOAPM OF SUPERVISORS OF CONTRA COSTA COUNTY FEB 2 01996 INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death or for inj----�persq� B SUPERVISORS conal property or growing crops and which accr ^ �,ece �`e`�r U T TA CO. must be presented not later than the 1" 1 or tne cause of action. Claims relating to causes of \ijury to person or to personal property or growing crop after January 1, 1988, must be presented not later than �. �jal of the cause of action. Claims relating to any othei presented not later than one year after the accrual of ''vt. Code §911.2.) B. Claims must be filed with the Clerk of tY: ��rs`at its office in Room 106, County Administration Building,�_.�atre;t Martinez, CA 911553. 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. RE: Claim By ) Reserved for Clerk's filing stamp Against the County of Contra Costa ) or ) GZ lie, District) Fill in nrme ) The undersigned claimant hereby makes claim again the Count of Contra Costa or the above-named District in the sum of $ /� �� yand in support of this claim represents as follows: ' 1. When did the damage or injury occur? (Give exact date and hour) .._121x12°i/ :�Q id2G��1 �''� �� -- 2. Where did the damage or injury occur? nclude city and c ty) 3. How did the dama a or �ehjury occur? (G!.-/e full details; use extra paper if required) �. � 9 v 4. What particular act or omission on the part of county or district officers, servants �o-r- employees caused the injury or damage? 614 �ld-�p� f� Al 1� 9 5. wnat are the names of county or district officers, servants or employees causing the dam:-ge or injury? "" l f 5. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. *Ir- www- 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) // 1 L °�- /�'i Gip/!/t� 1,G1Vb.,g1,�a 8. Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury; DATE ITEM AMOUNT 1v 417 l c17C e A4 h o7' Z3eep Gov. Code Sec. 910,2 provides; "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or by s2W person on his behalf.„ Name and Address of Attorney C aimantfs Si ture Ad s. Telephone 5 j) e e �oe No.e ��p�� '#�`� 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 suoh imprisonment and fine. v. • j fi Q _ �1 N� i J J4 CMD � ` 4 Q � t0 � r1 n"Ilk 1 1J \1VJ co U9 i i E r j acc cc I "0 LCJ C a � ° C i a. CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA March 12 1996f 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 �i� '� CLAIMANT: Raymond H Robinson FEB 7 6 1996 ATTORNEY: COUNSEL Date received MA TINEZCAI.IF• ADDRESS: PO Box 5031 BY DELIVERY TO CLERK ON February 26, 1996 Richmond CA 94805-6784 BY MAIL POSTMARKED: February 24, 1996 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. v PpHHIL BATCHELOR, Clerk s DATED: February 26, 1996 BY: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( te*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). ( ) 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: & -pl 7 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 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. Dated lh PHIL BATCHELOR, Clerk, B JL' 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. *For additional warnino see reverse side of this notice. 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 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 the claimant as shown above. Dated:_Waa42,4996 BY: PHIL BATCHELOR by puty Clerk CC: County Counsel �'� County Administrator RECEIVED [FB 2:6 W COUNTY OF CONTRA COSTA CLERK BOARD OF SUPERVISORS Clerk of the Board of Supervisors CONTRA COSTA Co. 651 Pine Street Martinez, Ca. 94553 CLAIM AGAINST COUNTY OF CONTRA COSTA, et al. CLAIMANT'S NAME: Raymond H. Robinsn PERSON(S)AGAINST WHOM CLAIM IS MADE: Contra Costa County, Contra Costa County Detention Facility, Sheriff Warren Rupf CLAIMANT'S ADDRESS: P.O. Box 5031, Richmond, Ca. 94805-0031 (510)223-6784 ADDRESS TO WHICH NOTICES TO BE SENT: P.O. Box 5031, Richmond, Ca. 94805-0031 DATE(S) OF OCCURRENCE: October 6, 1995/October 13, 1995 PLACE OF OCCURRENCE: Contra Costa County Detention Facility CLAIM ARISES FROM THE FOLLOWING CIRCUMSTANCES: On or about October 3, 1995,claimant was incarcerated in the Martinez Detention Facility. For four days,claimant was deprived of an opportunity to take a shower. Claimant continuously complained to deputies. On October 6, 1995,following another complaint to deputies, complainant was granted an opportunity to take a shower. After claimant entered the shower, a deputy directed a trustee inmate to the shower occupied by claimant. Claimant was sexually assaulted by said trustee inmate while taking a shower. After the assault,claimant was chided by deputies when he attempted to report the incident. Claimant began experiencing rectal bleeding following the incident. On October 11, 1995, claimant requested and was refused medical attention regarding the rectal bleeding. As a further, claimant requested and was refused medical attention on October 12th and October 13, 1995. Claimant was released on October 13, 1995 and received treatment thereafter. CLAIMANT'S DAMAGES: Claimant's damages are the direct and proximate result of the wrongful and negligent conduct of the deputies and include general and special damages. Claimant is entitled to punitive or exemplary damages together with attorney fees for civil rights violations. AMOUNT OF CLAIM: Minimum Federal Court jurisdiction. CLAIMANT'S COMPLAINT MAY INCLUDE THE FOLLOWING CAUSES OF ACTION: Violation of California Civil Code Sections 43, and 51.7, Title 42 U.S.C. Sections 1981 and 1983, the 4th, 5th, 8th, and 14th Amendments to the United States Constitution, negligence, negligent and intentional infliction of emotional distress and assault. Dated: 2/23/96 Raymo H. Robinson, claimant 1 ms n' rl iv 44 0 U - UUa = 1 MONIKA L. COOPER, State Bar No. 193729 Deputy County Counsel 2 GREGORY C. HARVEY, State Bar No.047974 Assistant County Counsel 3 VICTOR J. WE STMAN, State Bar No.34044 County Counsel 4 COUNTY OF.CONTRA COSTA 651 Pine Street, 9th Floor 5 Martinez, California 94553 (925),=335-1800 6 Attorneys for Defendants 7 County of Contra Costa', Deborah Knodell, Warren Rupf, Larry Thackara, 8 and Terry Wagner 9 10 SUPERIOR COURT FOR THE STATE OF CALIFORNIA 11 COUNTY OF CONTRA COSTA 12 13 RAYMOND H. ROBINSON, No. C 96 -04011 14 Plaintiff, DECLARATION OF JOAN STALEY 15 V. 16 COUNTY OF CONTRA COSTA, et al. 17 Defendants. 18 19 I, Joan Staley, declare: 20 1. I am a deputy clerk for the Clerk of the Board. I.make the following declaration of my 21 own personal knowledge: 22 2. I reviewed our Claim Log, and there are only two government tort claims filed by or on 23 behalf of Raymond Howard Robinson since January 1996. 24 3. Any claims filed by or on behalf of Raymond Howard Robinson with the County of 25 Contra Costa would be located within our files. 26 4. Attached as Exhibit A to my declaration are the pages from the Claims Log which show 27 ' The Contra Costa County Sheriff s Department is named by plaintiff as a defendant in this case. 28 The Sheriff's Department is not a separate legal entity capable of being sued. DECLARATION OF JOAN STALEY Case No.C 96-04011 1 1 the two claims filed with Contra Costa County by Mr. Robinson. The Claims Log 2 contains a record of all claims filed from January 1996 to the present, and these are the 3 only two claims filed by Mr. Robinson. 4 5. Attached as Exhibit B to my declaration is the claim filed by Mr. Robinson on February 5 -:26, 1996. This claim was denied by the Board of Supervisors. 6 6- Attached as Exhibit C to my declaration is the request to file a late claim filed by Mr. 7 Robinson on November 6, 1998. This request to.file a late claim was denied by the Board 8 of Supervisors. 9 10 I declare that the foregoing facts are true and correct. Executed under penalty of perjury, 11 in Martinez, California on December 17, 1998. 12 13 .. 14 JoanStalt Deputy Clerk for the Clerk of the Board 15 16 17 18 19 20 21 22 23 24 25 i 26 27 28 H:\GROUPS\TORT\CASES\96-2059\PLEADING\MSJDECI z DECLARATION OF JOAN STALEY 2 Case No.C 96-04011 ,�. o�� 6$Qp4 ����� S / / roi. / _` WAMW-M W, CMR��km. i BOARD ACTION RECEI 'D ATE DA's TAM NAME �_,qy� WT F ox 3 1 n 4k - -r 9 3-j,II, IIIS as q 9t� la`ylra' .00 — Ib _ 71� 90 1 ott /© <JI -� �.P.e. - A — �R9,P f 2 10-J9�Go j ..7�' 4-0 .. e CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA March 12 1996 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.opt �(jrr CLAIMANT: Raymond H Robinson IIIl>Kl FEB 2 6 1996 ATTORNEY: UNSEL Date received �"TINEZZ CAUF- ADDRESS: PO Box 5031 BY DELIVERY TO CLERK ON February 26, 1996 Richmond CA 94805-6784 BY MAIL POSTMARKED: February 24, 1996 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: February 26, 1996 Iq':L Depuiy OR, Clerk 24 l D II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( Vf 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: C7� 'p�? 9 U 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 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present (41) 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, n Dated��J /�-f 99� PHIL BATCHELOR, Clerk, B d.A L idam, 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, *For additional warning see reverse side of this notice. - AFFIDAVIT OF MAILING I declare under penalty of perjury :,:t I ar 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, aodresseo to the claimant as shown above. n ._ Dated:-,I d,4 Q - �Q ✓9 Cl 6 BY: PHIL BATCHELOR by\.21,614 puty Clerk CC: County Counsel County Administrator RECEIVED FES 26 06 6 Cf COUNTY OF CONTRA COSTACLERK soA�o of suPt:avrsaras Clerk of the Board of Supervisors CONTRA COSTA CO. 651 Pine Street Martinez, Ca. 94553 CLAIM AGAINST COUNTY OF CONTRA COSTA, et al. CLAIMANT'S NAME: Raymond H. Robinsn PERSON(S)AGAINST WHOM CLAIM IS MADE: Contra Costa County, Contra Costa County Detention Facility, Sheriff Warren Rupf CLAIMANT'S ADDRESS: P.O. Box 5031,Richmond, Ca. 94805-0431 (510)223-6784 G ADDRESS TO WHICH NOTICES TO BE SENT: P.O. Box 5031, Richmond, Ca. 94805-0031 DATE(S)OF OCCURRENCE: October 6, 1995/October 13, 1995 PLACE OF OCCURRENCE: Contra Costa_County Detention Facility CLAIM ARISES FROM THE FOLLOWING CIRCUMSTANCES: On or about October 3, 1995,claimant was incarcerated in the Martinez Detention Facility. For four days,claimant was deprived of an opportunity to take a shower. Claimant continuously complained to deputies. On October 6, 1995,following another complaint to deputies, complainant was granted an opportunity to take a shower. After claimant entered the shower, a deputy directed a trustee inmate to the shower occupied by claimant. Claimant was sexually assaulted by said trustee inmate while taking a shower. After the assault,claimant was chided by deputies when he attempted to report the incident. Claimant began experiencing rectal bleeding following the incident. On October 11, 1995, claimant requested and was refused medical attention regarding the rectal bleeding. As a further, claimant requested and was refused medical attention on October 12th and October 13, 1995. Claimant was released on October 13, 1995 and received treatment thereafter. CLAIMANT'S DAMAGES: Claimant's damages are the direct and proximate result of the wrongful and negligent conduct of the deputies and include general and special damages. Claimant is entitled to punitive or exemplary damages together with attorney fees for civil rights violations. AMOUNT OF CLAIM: Minimum Federal Court jurisdiction. CZAIMANT'S COMPLAINT MAY INCLUDE THE FOLLOWING CAUSES OF ACTION: violation of California Civil Code Sections 43, and 51.7, Title 42 U.S.C. Sections 1981 and 1983,,the 4th, 5th, 8th, and 14th Amendments to the United States Constitution, negligence, negligent and intentional infliction of emotional distress and assault. Dated: 2/23/96 i Raymo H. Robinson, claimant 'L7 E"4 4.4 M 0 ' +n U o 0 � `�_ Q ,� "" = u ;.._� ��uuU � � U ,��s1 • , APPLICATION TO FILE LATE CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA DECEMBER 8, 1998 BOARD ACTION Application to File Late Claim ) NOTICE TO APPLICANT Against the County, Routing ) The copy of this document mailed to you is your Endorsements, and.Board Action.) notice of the action taken on your application by (All Section References are to the Board of Supervisors (Paragraph III, below), California Government Code.) ) given pursuant to Government Code Sections 911.8 and _W�4,,.,U� to the "WARNING" below. v� Claimants Raymond H. Robinson I�� „ Attorney: N 0 V ' 1335 COUNTY COUNSEL Address MARTINEZ CALIF. P. 0. Box 5031 Richmond, .CA 94805-0031 November 6, 1998 Amount: Minimum Superior Court By delivery to Clerk on jurisdiction Date Received: November 6, 1998 By mail, postmarked on Hand-Delivered I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a oopy of the above noted Application to File Late Claim. DATED: November 6, 1998 PHIL BATCHELOR, Clerk, By Deputy II. FROM: County Counsel TOs Clerk of the Board of Supervisors ( )) The Board should grant this Application to File Late Claim (Section 911.6). (✓) The Board should deny this Application to File Late Claim (Section 911.6). ���tulla DATED: ll-qj? VICTOR WESTMAN, County Counsel, ByV6sWAA--Deputy II. BOARD ORDER By unanimous vote of Supervisors present (Check one only) ( ) This Application is granted (Section 911.6). (✓) This Application to File Late Claim is denied (Section 911.6). I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. DATE: BATCHELOR, Clerk, By Imo— Deputy WARNING (Gov. Code 5911.8) If you wish to file a court action on this matter, you must first petition the appropriate oourt for an order relieving you from-the provisions of Goverrnent Code Section 945.4 (claims presentation requirement). See Government Code Section 946.6. Such petition must be filed with the oousrt within six (6) months from the date your application for leave to present a late claim was denied. You may seek the advise of any attorney of your oholoe in oonneetion with this matter. If ym want to consult an attorney, u should do so immediately. V. FROM: Clerk of the Board TO: 1 County Counsel (2) County Administrator Attached are oopies of the above Application. We notifed the applicant of the Board's action on this Application by mailing a oopy of this document, and a memo thereof has ben filed and endorsed on the Board's copy of this Claim in accordance with Section 29703. y�� DATED: �Ler'u�1 �PHIL BATCHELOR, Clerk, By ��� Deputy Y. FROM: 1 County Counsel 2 County Administrator TO: Clerk of the Board of Supervisors Received copies of this Application and Board Order. DATED: County Counsel, By. County Administrator, By APPLICATION TO FILE LATE CLAIM t RECEIVED NOV 61998 APPLICATION FOR LEAVE CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. TO PRESENT CLAIM (Government Code Section 911.3) Pursuant to Government Code Section 911.3, Raymond Howard Robinson (hereinafter "Claimant") hereby makes application to the Contra Costa County Board of Supervisors for Leave to Present Claim for damages for violation of claimant's civil rights by employees of the Contra Costa County Sheriffs Office. Claimant states the reason for delay in filing this claim is due to claimant's good faith belief that the acts alleged in the proposed claim was an attempt by the Contra Costa County Sheriffs Office to cover-up prior tortuous acts, and to intimidate and discourage claimant from pursuing damages against it for acts alleged in a timely filed claim (filed February 26, 19%; rejected March 12, 1996) and that said acts were in furtherance of the acts alleged in the original claim. Claimant contends his failure to file the proposed claim was through mistake, inadvertence, surprise and/or excusable neglect and that the County of Contra Costa was not prejudiced in its defense of the claim by the failure to present the claim within the time specified in Section 911.2.. Further, claimant reported said acts to the Internal Affairs Division of the Contra Costa County Sheriff's Office which evaluated the claims and conducted its own internal investigation of the matters alleged therein. Dated: ItISLF-, - RAymoobH. ROBINSON, Claimant County of Contra Costa Clerk of the Board of Supervisors 651 Pine Street Redwood City, California 94553 CLAIM AGAINST COUNTY OF CONTRA COSTA, et al. CLAIMANT'S NAME: RAYMOND H. ROBINSON PERSON(S)AGAINST WHOM CLAIM IS MADE: Contra Costa County, Sheriffs Department, Sheriff Warren E. Rupf; Deputy Sheriff Lt. Lary Crompton, Sgt. Terry Wagner, Lary Thakara, and Deborah Knodell CLAIMANT'S ADDRESS: P.O. Box 5031 Richmond, California 94805-0031 ADDRESS TO WHICH ` NOTICES TO BE SENT: P.O. Box 5031 Richmond, Ca. 94805-0031 DATE(S) OF OCCURRENCE: April 11-18, 1996; April 19, 1996; May 16, 1996 PLACE OF OCCURRENCE: Martinez Detention Facility;Custody Alternative Bureau CLAIM ARISES FROM THE FOLLOWING CIRCUMSTANCES: On or about April 11, 1996, Deputy Sheriff Deborah Knodell caused a no-bail warrant to be issued against claimant alleging that claimant did not appear at Custody Alternative Bureau as ordered by Superior Court Judge Sepulveda. Claimant was held in San Mateo County Jail between April 11, 1996 and April 18, 1996 pending transportation on the no- bail warrant. Claimant did in fact meet with Knodell on April 11, 1996, the same day Knodell caused the warrant to issue. On April 19, 1996, Judge Sepulveda released claimant from custody of the Contra Costa County Sheriff on claimant's own recognizance. Knodell contacted the court and claimed claimant had an outstanding warrant from Santa Clara County and requested claimant be held. Sepulveda ordered claimant to be released. Claimant was not released as ordered. On May 16, 1998, claimant accompanied a process server to the Custody Alternative Bureau to serve Knodell with a subpoena. Knodell,Thakara, and Wagner, at the direction of Crompton, unlawfully detained claimant alleging that claimant was an escapee. CLAIMANT'S DAMAGES: Claimant's damages are the direct and proximate result of the malicious conduct of the Sheriffs Deputies and include general and special damages. Claimant is entitled to punitive or exemplary damages together with attorney fees for civil rights violations. AMOUNT OF CLAIM: Minimum Superior Court jurisdiction. CLAIMANT'S COMPLAINT MAY INCLUDE THE FOLLOWING CAUSES OF ACTION: Violation of California Civil Code Sections 43, and 51.7, Title 42 U.S.C. 1981 and 1983, the 4', 5' 8', and 14'h Amendments to the United States Constitution, negligence, negligent and intentional infliction of emotional distress, assault and false imprisonment. Dated: 1 l 1 5 l`i`o RAYMO H. ROBINSON, Claimant C, 1 CLAIM BOARC OF SUPERyISORS_OF_CONTRA COSTA COUNTY, CALIFORNIA MARCH 12,1996 Claim Age':nst 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: $100,000.00 + Section 913 and 915.4. Please note all ( aw CLAIMANT: RENNE OHNEMUS, INDIVIDUALLY, & AS GUARDIAN AD LITEM OF ALEXANDRIA OHNEftb 12 1996 TAYLOR OHNEMUS, AND AN UNBORN CHILD DUE IN FEBRUARY, 1996. ATTORNEY: PETER J HINTON COUNTY COUNSEL Date received MARTINEZ CALIF. ADDRESS: 1646 N CLAIFORNIA BLVD STE 600 BY DELIVERY TO CLERK ON FEBRUARY 9, 1996 WALNUT CREEK CA 94596 BY MAIL POSTMARKED: HAND DELIVERED 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a Copy of the above-noted claim. BATCHELOR,FEBRUARY 12, 1996 igil Deputy�' Clerk 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( sThis 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*Ate and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: 2 ` 1 Z BY: ( __Deputy County Couns 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. Oattd"Wa.4,01 PHIL BATCHELOR, Clerk, By , Deputy Clerk WARNING (Gov. Code section 923) Subject to certain exceptions, you have Only six (6) months from the date this notice was personally served or deposited in the aril to file a court action on this Claim. Set Goverf ment Code Section 945.6. You Pay seek the advice of an attorney of your Choice in Connection with this Patter. If you want to Consult an attorney, you should do so inaediattly. * For Additional Warning See Reverse Side Of This Notice 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 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 the claimant as shown above. Dated,14a 4.4 A 101 29� BY: PHIL BATCHELOR by -)Deputy Clerk CC: County Counsel County Administrator PETER J. HINTON, SBN 36400 RECEIVED HINTON & ALFERT A Professional Corporation FS-9= 1646 N. California Blvd., Suite 600 Walnut Creek, CA 94596 CLERK BOAR®OF SUPERVISORS Telephone: (510) 932-6006 Attorneys for Claimants Renee Ohnemus, individually, and as guardian ad litem of Alexandria Ohnemus, Taylor Ohnemus, and an unborn child due in February, 1996 CLAIM AGAINST CONTRA COSTA COUNTY To: County of Contra Costa, Board of Supervisors, 651 Pine Street, Room 106, Martinez, CA 94553 Claimants: Renee Ohnemus, individually, and as guardian ad litem of Alexandria Ohnemus, Taylor Ohnemus, and an unborn child due in February, 1996 Address of c/o Hinton & Alfert, 1646 N. California Blvd., Suite 600, Claimants: Walnut Creek, CA 94596 Claimants c/o Hinton & Alfert Telephone: (510) 932-6006 Date of incident: August 9, 1995 Location of Old River at a point 100 feet east of Suicide Beach, Incident: in an unincorporated area of Contra Costa County Amount of The amount of damages sought by the claimants as of the date of Claim: the presentation of this claim, is sufficient to establish jurisdiction in the Superior Court of the State of California. These damages consist of general and special damages, including, but not limited to loss of love, companionship, comfort, affection, solace or moral support, loss of enjoyment of sexual relations or ability to have children; loss of physical assistance in the operation and maintenance of the home; loss of financial support, funeral and burial expenses, interest, and incidental expenses. Known funeral and burial expenses totaled $7,054.96 and past and future wage losses total $940,996.00. Nature of Claimants suffered the wrongful death of their spouse and Injuries: father, respectively, and their claims include those elements of a loss of consortium claim including, but not limited to loss of love, companionship, comfort, affection, solace or moral support, loss of enjoyment of sexual relations or ability to have children; loss of physical assistance in the operation and maintenance of the home; loss'of financial support, funeral and burial expenses, interest, and incidental expenses. Name of Public Public employees, agents, and/or personnel of the County Employees of Contra Costa, presently unidentified, who had authority to Responsible: identify and post, or to take action necessary to post, advisory signals or waterway markings to restrict speed or to advise boaters of the narrow channel and the blind curve at the site of the subject accident and of which the County of Contra Costa had prior notice of the dangerous conditions which existed at the site of the subject accident. Circumstances At the time of the incident giving rise to this claim, Claimants' giving rise to decedent, Michael J. Ohnemus, was a passenger in a 1990 Ski claim: Supreme inboard ski boat, owned by Randall Ohnemus and Michael Cerino, and operated at the time of the incident by Michael Cerino. The 1990 Ski Supreme ski boat was northbound at a speed of approximately 35 miles per hour on Old River, 100 feet east of Suicide Beach, in an unincorporated area of Contra Costa County. A 1995 Majic Cigarette Scarab, owned and operated by John T. Lugar, was southbound on Old River at a speed of approximately 40-45 miles per hour. As the two boats approached the 90 degree, blind curve, the boats collided, causing fatal injuries to Michael J. Ohnemus. Claimants contend that the County of Contra Costa negligently failed to properly restrict the speed of boats in this area and failed to advise boaters of the existence of the blind curve and that the County had actual notice of these dangerous conditions prior to the date of the subject incident. These conditions contributed to the occurrence of this incident, and it is on this basis that claimants present this claim. Discovery and investigation are continuing. Dated: February 9, 1995 HINTON & F RT B PET J. KMON Attorneys for Claimant r CLAIM Q_01 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA MARCH 12, 1996' 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 ursuant to Government Code Amount: UNKNOWN Section 913 and 915.4. P10 00IR , CLAIMANT: MIDI NYHART FEB 2 3 1996 ATTORNEY: ALAN M TALBOT ESQ COUNTY COUNSEL 1990 N CALIFORNIA BLVD #740 Date received MARTINEZ CALIF. ADDRESS: WALNUT CREEK CA 94596 BY DELIVERY TO CLERK ON FEBRUARY 23, 1996 BY MAIL POSTMARKED: FEBRUARY 22, 1996 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: FEBRUARY 23, 1996 ; gyIL BATTCHELOR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( V<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: <� C( BY; o ` 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 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. Dated PHIL BATCHELOR, Clerk, By 1 'XA�, 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. *For additional warning see reverse side of this notice. 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 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 the claimant as shown above. 4- Dated-�nQ4 a4 Q 13 /!7 i_ BY: PHIL BATCHELOR b eputy Clerk CC: County Counsel County Administrator 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 per- sonal property or growing crops and which accrue on or before December 319 19872 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 1069 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. o ..i.,;. s_ aera;n. re tht rano n1b ; �r itv_ a a�at nlgMr i-s D. T� ..he claim 4r a_ ga4..s�• mc_ � __=..:� =1:.e :--t- > > ._ep < _,.e - S na.._t he filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code See. 72 at the end of this form. RE: Claim By ) Reserved for Clerk's filing stamp HEIDI NYHART ) �_""._ RECEI� z Against the County of Contra costa ) FEB 2 3 0 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: ** To be determined. 1. When did the damage or injury occur? (Give exact date and hour) 10/22/95; approx. 1: 00 - 2: 00 p.m. 2. Where did the damage or injury occur? (Include city and county) Eagle Peak Avenue, in the city of Clayton, County of Contra Costa, CA 3. How did the damage or injury occur? (Give full details; use extra paper if required). See Attachment A. 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury,or damage? Ralph Thomas Waller caused this accident by being in violation of CVC Section 22106 (unsafe backing) . (over) 5. What are the names of county or district officers, servants or employees causirg C►� the damage or injury? Ralph Thomas Waller 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. Property damage estimate attached. Claimant has incurred medical bills, the amount of which is still to be determined. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) See #6 . 8. Names and addresses of witnesses, doctors and hospitals. Douglas Herting, D.C. , 1399 Ygnacio Valley Road, Walnut Creek, CA 930-0209 Sanford H. Lazar, M.D. , 3580 California St. , Ste. 102, San Francisco, CA (#415-921-2266) 94118 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT To be determined. see #6. f • a * � � � � s * � � � � � � � � � � � � � � � * � � * a s a s s s a � • * � � � Gov. Code Sec. 910.2 vides: "The claim must beed by the claimant SEND NOTICES TO: (Attorney.) or by some persone,,,,his behalf." Name and Address. of Attorney ALAN M. TALBOT, ESQ. - BROOKMAN & TALBOT Nom$ 1990 N. California Blvd. , #740 Attorney for Claimant Walnut Creek, CA 94596 1990 N. California Blvd. , #740 Address Walnut Creek, CA 94596 510-932-4008 uc,, 510-932-4008 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 ($19000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($1090009 or by both such imprisonment and fine. ATTACHMENT A RE: HEIDI NYHART 3. Claimant was driving a certain 1995 Hyundai vehicle in a generally northerly direction on Eagle Peak Road. A certain 1981 Van Pelt fire truck, license number E778376, owned by the Contra Costa Fire Protection District, was being driven by Ralph Thomas Waller, in a generally northerly direction on Eagle Peak Road, directly in front of claimant's vehicle. At said time and place, Mr. Waller stopped the fire truck and backed the fire truck into the front of claimant's vehicle. SUN VALLEY FORD BODS : rs ; }3 SU155441.: 1-.3 0 9 3 1 R 8�27 6 260 Diamond Wa s -'•�"-�P.O.BOX 2796 • . 6AR#A8 00.5 a•_ CONCORD, CALIFORNIA:945 -09 t 12 EPA#CAD 982678742 NYHART *INVOICE* BODY.SHOP SERVICE j HEIDI (510) 686-5007 (510) 686 5005 eft 109: ,ROBLE #,.;;103 -u , �. : WALNUT CREEK CA _.94596 PAGE .1 • HOME.,; 415 951 1038 BUS 938 2857 SERVICE"ADVISOR. , 6214` STEVE` AAA COLOR.; YEAR MAKFIMODEL,..,.:.:. ..,.;:.::: w1N..:<:>:::>:> 's<': .tCEr,s..�,. ........Mitt*AG .... ........ .:.. RED 95 HYUNDAI ACCENT KMHVFT4N3SU15441 0 648 648 B823 ..:_. _.: _. ..:: EST MATE TO COMPL -.ION PROD.:: OTE::.:WARR.;;=XP... ... :.......: . .... .:..:..... ET . :::::.:.::,;;;,:..;;:.;: PQ .:.:.PAYMENT :> #[W:DATE:>`:::; 01R..Ck .. ` C0004NOV95JUN95 0TJUN95 0117: 20NOV95 N ... U . Y :: ::: OPTIONS:. DLR:SVF.:..: 08.54' 26OCT95- 17:00''20NOV95 LINE` OPCODE-TECH TYPE HOURS LIST NET TOTAL .A REPAIR AS PER CSAA ESTIMATE RB BODY REPAIRS COMPLETED. 99 CB 640.21 640.21 B REFINISH AS PER .CSAA'ESTIMATE RP'.PAINT. REPAIRS COMPLETED. 99 CP 390.00 390.00 C** GENUINE VOLKSWAGEN PARTS. RB BODY REPAIRS COMPLETED: 99 CVW .0.00 0.00 D** GENUINE PARTS RB BODY REPAIRS COMPLETED. 99 CH 0.00 0.00 1, 86510=22000 COVER ASSY 132.35 132.35 132.35 1 97606-22050 A/C CONDENSER _ 282.28 282.28 282.28 2 86535-22000 BRACKET-FR 2.55 2.55 5.10 1 86532-22000 RAIL-FR BU t x }44 39 44.39 44.39 1 86520-22050 ABSORBER-F r '`' ;`1 39 $. 139.80 139.80 1 92101-22050HEADLAMP A `' 15239 152. 39 152.39 1 92102-22050 HEADLAMP A -- 152.39 152.39 152.39 1 92305-22050 LAMP ASSIY4W*` 27.85 27.85 27.85 1 92306-22050 LAMP ASSY-85 27.85 27.85 1 66400-22020 .PANEt'ASSY '''" ; - t�2?'8.96 218.96 218.96 1 86341-2220.0-,EMBLEM'SYM i Y 7.> 8 42 8.42 8.42 1 81130-2200:1 AL LASSY 1 24 54 '"24.54 24.54 1 64100-2230.1 PANEL 166:82 166.82 1 86530-22050- RAIL- = 238,"0:6 - 238.06 238.o6 MISC PAINT.. AND MATERIALS CBM 171 .60 171 .60 MISC FREON & OIL CBM 35. 00 35.00 ADDITIONAL AMOUNT PHONE#PERSON >s:`>?:DE$CRIP: FOR DATE TIME BY / » `. ::....:...:.::.T.....,N::.>'E 1. $ LABOR AMOUNT 1030.21 2. $ PARTS AMOUNT 1621 .20 OIL/LUBRICANTS 0.00 3. $ SUBLET AMOUNT 0.00 NOTICE TO CONSUMER:' I acknowledge notice and oral approval of any additional customer or warranty work performed and/or increase in the original estimate price. I also acknowledge and approve all repairs as itemized MISC.CHARGES 206.60 and/or receipt of vehicle. I also acknowledge receipt of additional Consumer. and Warranty Information TOTAL CHARGES 2858.01 contained on the reverse side. TOTAL 0.00 ORIGINAL AMOUNT D� �b ESTIMATE $ APPROVED $ SALES TAX 150.79 PLEASE PAY Customer tome Signature r " S r 9 atu eTHIS AMOUNT .......:: ... ... CUSTOMER COPY 1 PROOF OF SERVICE BY MAIL -- CCP, 42015.5 & §1013(a) 2 I, the undersigned, declare under penalty of perjury of the laws of the State of California: 3 4 That I am a citizen of the United States and over the age of eighteen years; that I am not a party to the within action or proceeding; that my business address is 1990 N. California 5 Boulevard, Suite 740, Walnut Creek, California 94596; that on the date set forth below I served a true copy of: 6 7 CLAIM AGAINST CONTRA COSTA COUNTY 8 9 10 by depositing said copy in the United States Mail, at Walnut Creek, California, in a sealed 11 envelope, postage thereon prepaid, addressed as follows: 12 Clerk, Board of Supervisors County Administration Building, Room 106 13 651 Pine Street Martinez, CA 94553 14 CERTIFIED MAIL - RETURN RECEIPT REQUESTED 15 16 17 18 19 20 21 At said time, there was regular delivery of the United States Mail between said places of deposit 22 and address(es). 23 Executed at Walnut Creek, Contra Costa County, California, on February 16, 1996. 24 25 26 SHARON HANNEY 27 28 4 LAW OFFICES OF RECEIVED BROOKMAN & TALBOT FEB SUITE 740 FEB 2 3 19% 1990 NORTH CALIFORNIA BOULEVARD WALNUT CREEK, CALIFORNIA 94596-3711 CLERK BOARD OF SUPERYlSORS TELEPHONE (510) 932-4008 CONTRA COSTA CO. FAX: (510) 937-1828 February 16, 1996 Clerk, Board of Supervisors County Administration Building, Room 106 651 Pine Street Martinez, CA 94553 CERTIFIED MAIL - RETURN RECEIPT REQUESTED RE: CLAIM OF HEIDI NYHART Dear Clerk: Enclosed please find the above-mentioned claimant(s) Claim against the County of Contra Costa. Please return an endorsed copy to this office in the self-addressed, stamped envelope provided. Thank you for your cooperation and assistance. Very truly yours, BROOKMAN & TALBOT Sharon Hanney, Secretary to Alan M. Talbot /sh Encl. .. .. N 'I r Q- CD � u} d +� _ - d . o N cr x v Q V Vast 1 O �a cam— t Vy' a div Q CLAIM Q_1 r BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA MARCH 12, 1996 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 "W�"^ ,�II � CLAIMANT: CYNTHIA AND RICHARD BROWN FEB 1 6 1996 ATTORNEY: ALAN M TALBOT NsEL 1990 N CALIFORNIA BLVD.#740 Date received COpUT NEZCALIF- ADDRESS: WALNUT CREEK CA 94596 BY DELIVERY TO CLERK ON FEBRUARY 15, 1 ,R BY MAIL POSTMARKED: FEBRUARY-14, 1996 I. FROM: Clerk of the Board of Supervisors TO: County Counsel. Attached is a copy of the above-noted claim. DATED: FEBRUARY 16, 1996 ppHHIL ATCHELOR, Clerk BY: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( his 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: 2 ��Imo'"I Le 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 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. Dated:`W&,,J, f9 9(o PHIL BATCHELOR, Clerk, B , 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. *For additional warning see reverse side of this notice. 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 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 the claimant as shown above. Dated: , /,3 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel T� County Administrator �9 , LAW OFFICES OF BROOKMAN & TALBOT SUITE 740 1990 NORTH CALIFORNIA BOULEVARD WALNUT CREEK, CALIFORNIA 94596-3711 TELEPHONE(510) 932-4008 FAX: (510) 937-1828 February 13, 1996 Clerk of the Board of Supervisors Room 106, County Administration 651 Pine Street Martinez, CA 94553 RE: CLAIM OF CYNTHIA BROWN, RICHARD BROWN Dear Clerk: Enclosed please find original and one copy of the above-mentioned claimants' Claim against Contra Costa County. Please endorse receipt on the copy and return it to this office in the self-addressed, stamped envelope provided. Thank you for your cooperation and assistance. Very truly yours, BROOKMAN & TALBOT r Sharon Secreta M. Talbot /sh Encls. Cla?m 3.o: BOARD OF SUPERVISORS OF OONTRA COSTA COUNTY 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 first 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 T orm. � • � +� � � � a � � � � f a s �t f �t � � f � f • � � � � � a � f f • a �t �t • �t � * f RE: Claim By ) Reserved for Clerk's filing stamp CYNTHIA BROWN, RICHARD .BROWN ) RECEIVE® Against the County of Contra Costa FEB 15 x h CLERK B D OF RYISORS Fill in name ) CONTRA CO 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: ** _ Amount of medical bills and general damages are 1. Flben did the damage or injury occur? (Give exact dote and hour} to 13 tned. 10/16/95; approx. 8 : 40 a.m. 2. Where did the damage or injury occur? (Include city and county) N Sunrise House, Inc. , Unit M, 135 Mason Circle, in the City of Concord, County of Contra Costa, California 3. How did the damage or injury occur? (Give full details; use extra paper if required) Claimant, CYNTHIA BROWN, was in a restroom and slipped and fell on a liquid substance or water left on the floor. ----------- --_--_N-_�N_NN_N_NN 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? The liquid substance or water was allowed to remain on the floor, causing a hazard for its patients. (over) 5. 'What are the names of county or district officers, servants or employees causing* C►' 1 the damage or injury? Unknown. 6. What damage or injuries do you claim resulted? (Give full extent of injuries or dawges clamed. Attach two estimates for auto dAma e. Claimant, CY THIA BROWN: low-bac .,&_.tai.lbone_injuries— Medical: through 1"1/13/95 : $1 ;634 .,06 -& continuing. !' Claimant, RICHARD BROWN: Loss of Consortium, the.�.extent of which is to be determined. --QenQLa1 damages: To Be peter,,Mined. aurjo djctjon: -uperior Court 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) See attached medical bills for claimant, CYNTHIA BROWN, through 11/13/95. 6. Names and addresses of witnesses, doctors-and hospitals. John S. Riddel, D.C. , Riddel Chiropractic, 3147 Putnam Blvd. , Ste. E', Pleasant Hill, CA 94523; #945-7890 Brian F. Topkis, M.D. , 2021 Mt. Diablo Blvd. , Walnut Creek, CA; #930-9978 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT See attached medical bills for claimant, CYNTHIA BROWN, through 11/13/95. Gov. Code Sec. 910.2 provides: "The claim must e by the claimant SEND NOTICES TO: (Attorne ) or some ers hip by Name and Address of^ `tei�. 1? ALAN M. TALBOT-i-5-4§' BROOKMAN & TALBOT VWSE 1990 N. California Blvd. , #740 ALAN M. FALBOT, At orney for Claimants Walnut Creek, CA 94596 1990 N. California Blvd. , Ste. 740 Address a nu ree , CA 94596 Telephone No. 510-932-4008 Telephone No. 510-932-4008 • e �te � e �t �tf � ff • f � a � � NOTICE Section 72 of the Penal Code provides: "Every person who, with intent to defraud, presents for allowance our 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. .APPROVED OMB-0938-0008 PLEASE � BROOKMAN & TALBOT' DO NOT t 1990 NORTH CALIFORNIA BLVD. STAPLE i WALNUT CREEK CA 94596-3711 w IN THIScc AREA (510) 932-4008 a U PICA -` -- HEALTH INSURANCE CLAIM FORM PICA 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER Ia.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) HEALTH PLAN BLK LUNG (Medicare#) ❑(Medicaid#)❑(Sponsor's SSN) F-� (VA File #) (SSN or ID) [] (SSN) El (ID) 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) BROWN, CYNTHIA MM 1 DD YY 01 ! 28 ! 59 M F THE SUNRISE HOUSE 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 129 PIONEER AVE. self[] Spouse Chim[ Other CITY STATE 8.PATIENT STATUS CITY STATE Z O WALNUT CREEK CA Single Married Other F.• ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) Q 94.596 (510) 938-9127 Employed Full-Time❑ Part-Time cc Student StudO Student 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z Z_ f] W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX Cc MM DD YY YES ©NO M F ® Z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME MM DD YY M F YES KI CA Q c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME Z ves 0No LIABILITY (PI ) W C.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? Q CL YES � NO If yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED AT-U_gE_0 N FTI F DATE 1 1 /1 h/9 S SIGNED S I_GN-A-LU(3E-ON F T L-F 14.DATE OF CURRENT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM . DD � YY INJURY(Accident)OR GIVE FIRST DATE MM DD YY MM qD : YY MM pD YY 10120 ;95 PREGNANCY(LMP) FROM N/A TO N/A 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY N'A N/A FROM TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES ❑YES ENO 21.DIA.GF40SIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION CODE ORIGINAL REF.NO. 1 E885 FALL FROM SLIP/TRIPS I +84.6_0 LUMBOSAC AL 23.PRIOR AUTHORIZATION NUMBER 2. 1t847- 0 CERVICAL SPRAIN/ST4. ) +724. 71 COCCYX HY. 24. A B C D E F G H 1 J K Z Fro ATE(S)OF SERVICE To Place Type PROCEDURES.SERVICES,OR SUPPLIES DIAGNOSIS DAYS EPSD RESERVED FOR O of of (Explain Unusual Circumstances) CODE, $CHARGES OR Family EMG COB LOCAL USE 1- MM DD YY MM DD YY Service service CPT/HCPCS I MODIFIER UNITS Plan 4 1 11 10� 95 1 11 1 99212 1-4 40 !00 - fl U. ; z 2 111 1095 1 1 97012 1-4 18 ,45 a 3 11 13; 95 11 1 99213 1-4 65 , 00 CL Cn 4 11 13; 95 ! 1 1 97012 1-4 1.8 '45 z a 5 !n } IL 6 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE 68-0148119 0 PS] 2335 6I1A j O ❑r govi. Ims,YES claNOeeback ) $ 141 i90 $ i s 141 90 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AN �j {tp10ES WERE 33.PHYSICIAN'S, BI ESS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDER r`�(1rlf h t n� e r doff i ' fi 0 f VbVL CHIROPRACTIC CENTER (I certify that the statements on the reverse - +! ,. •? 4t f_l apply to this bill and are made a part thereof.) if i 3147 P U T N A M BLVD. SUITE E JOHN S. RIDDEL, D. C. j NOV .2 1 1995 PLEASANT HILL, CA 94523 SIGNED �','/16/95DATE )t If PIN#168290 GRPp CIAPPggVED Y J E4 OlJNCIL OAI TETICA�SfglfE 8/88) �) PC ~-PMJVT�f1 E FORM HCFA-1500 (12-90) �J 1 1 1 VJ 1 J. `� .L FORM OWCP-1500 FORM RR8-1500 PLEASE \. BROOKMAN & TALBOT APPROVED OMB-0938-0008 DO NOT 1990 NORTH CALIFORNIA BLVD. STAPLE WALNUT CREEK CA 94.596-3711 `� w IN THIS (510) 932-4008 AREA j cc i U _-;PICA - HEALTH INSURANCE CLAIM FORM PICA -X 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA - OTHER ta.INSURED'S I.D.NUMBER - (FOR PROGRAM IN ITEM 1) HEALTH PLAN BLK LUNG - (Medicare#) E](Medicaid#)❑(Sponsor's SSN) 0 (VA File #) (SSN or ID) 0 (SSN) g(0) - 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) MM DO ; YY BROWN, CYNTHIA 01128 ; 59 M F THE SUNRISE HOUSE 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 129 PIONEER AVE. Sen[:] Spouse[] Child❑ Other© CITY STATE 8.PATIENT STATUS CITY STATE Z WALNUT CREEK CA O Single Married® Other P ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) Q M' 94.596 (510 938-9127 Employed® FulStudent PartStudenTimt � � ¢o Student Student <L 9.OTHER INSURED'S NAME(Last Name,First Name.Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z 0 W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX Cr MM DD YY n YES ©NO 1 M F © _z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME 0 MM DD YYZ i. M F YES 1XI CA. Q c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME - Z YES �NO LIABILITY (PI ) d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? C a YES ® NO if yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON FILE DATE 11/16/95 SIGNED SIGNATURE ON FILE 14.DATE OF CURRENT: 4 ILLNESS(First symptom)OR 5.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 1'0 2-e .-5 INJURY(Accident)OR I GIVE FIRST DATE MM DD YY FROM MM pn YY TO MM N ftp YY i PREGNANCY(LMP) / H A 7.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18,HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY N/A N/A FROM TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES YES D NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION CODE ORIGINAL REF.NO. 1 E885_ FALL FROM SLIP/TRIP3 i +846_0 LUMBOSAC AL .. 23.PRIOR AUTHORIZATION NUMBER 2. +i 847_0 CERVICAL SPRAIN/STa. ( -x724.. 71 COCCYX HY 24. A B C D E F G H I J K FromDATE(S)OF SERVICETo Place Type PROCEDURES,SERVICES,OR SUPPLIES DAYS EPSD O_ DIAGNOSIS RESERVED FOR of of (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE f" MM DD YY MM DD YY Service Service CPT/HCPCS I MODIFIER UNITS Plan d S 1 11' 15! 95 11 1 i 99212 1-4 40 j 00 LL 2 11 15; 95 11, 1 : 97012 1-4 18 �45 w ; J 3 11' 15 95 11 1 '` 97010 1-4 18 !45 O a Z sl J, S 6 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE 68-0148119 . 2335 61 A (Forgovt.claims,see bacic) 76 '90 YES NO $ $ i $ 76 90 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 132.NA F I VICES WERE 33.PHYSICIAN'S. BI ESS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RE D�R o 1 n o( ;_r,ni )r ,,q.p�,�gy ' (IceRifythatthestatementsonthereverse _ fC1V4JGL CHIROPRACTIC CENTER apply to this bill and are made a part thereof.) j tit 3147 PUTNAM BLVD,, SUITE E JOHN S. RIDDELD. C. (��{j Nov 2, 1 1995 ,�I PLEASANT HILL, CA 94523 SIGNED 11/16/<;; DATE I I , PIN#1 68290 GRP# C( IX11VED j�YJ pQ�OUJJCILIO�MEPIJ $� VJCE B/6 -�^--�I�pL� _E PRINT OR TYPE FORM HCFA-1500 (12-90) L A 1 M L 5 1 1 1 1 1 �. - -_ FORM OWCP-1500 FORM RRB-1500 ( APPROVED OMB-0938-0008 PLEASE � BROOKMAN & TALBOT DO NOT 1990 NORTH CALIFORNIA BLVD. G; INTHIS E i WALNUT CREEK CA 94.5.96-3711 w IN TH AREA { (510) 932-4008 Q U - -PICA -- HEALTH INSURANCE CLAIM FORM PICA Fr'71Y 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER 1a.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) HEALTH PLAN BLK LUNG (Medicare#1 ❑(Medicaid#)❑(Sponsor's SSN) E1 (VA File #) (SSN or!D) [] (SSN) 0, (ID) 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.3.PATIENT'S BIRTH DATE SEX4.INSURED'S NAME(Last Name,First Name,Middle Initial) MM DD , YY BROWN. CYNTHIA 01 ! 28 ! 59 M F , . THE SUNRISE HOUSE 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 129 PIONEER AVE. sen spouse? Child Other CITY STATE 8.PATIENT STATUS CITY STATE Z WALNUT CREEK CA Single Married In Ocher O ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) G 94.596 151@ ) 938-9127 Employed® Student Pat-Timed Student Student ` O LL 9.OTHER INSURED'S NAME(Last Name,First Name.Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z Z_ p W i a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX cc MM DD YY :3 (�YES NO M F © Z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME i MM DD YY 10 M F 7 YES �NO CA Z �V EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME Z �vEs 1No LIABILITY (P1 ) d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? d YES FI NO M yes.return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED DATE1 /165 . _ _ SIGNED al-!�NA R QN_ Y i4.DATE OF CURRENT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION I Mtn D YY INJURY(Accident)OR GIVE FIRST DATE MM DD YY MM D YY MM PD YY 1 6 2D 9 5 PREGNANCY(LMP) FROM N 9A TO N/A : 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES NIA N/A FROM MM DD YY TO MM DD YY --9.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES El YES ❑NO '21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION CODE ORIGINAL REF.NO. E885_ FALL FROM SLIP/TRIPS X6_0 LUMBOSAC AL 23.PRIOR AUTHORIZATION NUMBER z. +t 84.7_@ CERVICAL SPRAIN/ST4. I +724.. 71 COCCYX HY 24. A B C D E F - G H I I J K Z DATE(S)OF SERVIC Place Type PROCEDURES,SERVICES,OR SUPPLIES DAYS EPSD O From Elo DIAGNOSIS RESERVED FOR of of (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE F- MM DD YY MM DD YY Servic Service CPT.!HCPCS MODIFIER UNITS Plan Q 1I 11; 02 95 j 1 1 99212 1-4 40 j00 0 ILL z 2 11. 02. 95 1 1 97010 1-4 18 !45 w J 3 11 02 95 1 1 97012 1-4 1845 a. c� 4 11. 061 95 11 1 99212 1-4 40 100 0 Z 5 11, 06 95 11 1 97010 1-4 18 45 N 61 If 06i 95 1 1 97012 1-4 18 45 a 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE (For govt.claims,see back) 68-@148119 1:112335 6I1A El YES NO $ 15.3 ;80 $ $ 153 180 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME ANOL BR�SS AG)411fY HFpRE 6 I ES WERE 33.PHYSICIAN'S, BI ESS,ZIP CODE x INCLUDING DEGREES OR CREDENTIALS REND �p I o er hin rre qr Offiti0)!� If certify that the statements on the reverse ! �� i,- ._ �ffbtL CHIROPRACTIC CENTER apply to this bill and are made a part thereof.) I �- f ��! t 3147 PUTNAM BLVD. SUITE E JOHN S. RIDDEL. D. C. I inNOV 2 1g95 SIJ PLEASANT HILL. CA 94523 SIGNED 11/16/95 DATE 1 t J PINu168290 GAP# y 11•;r---- CrAPPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8.66) ���•�-�� 79L i PRlNT OR TYPE FORM HCFA-1500 (12-90) AIM 2335 11021106951 "' FORMOWCP-1500 FORMRRB-1500 PLEASE s �, BROGKMAN & TALBOT APPROVEDOMB-0938-0008 f DO NOTi :1.990 NORTH CALIFORNIA BLVD. StAPLE WALNUT CREEK CA 94596-3711IN W AREAS (5,10) 932-4008 Cr a I U - i PICA _ - - J HEALTH INSURANCE CLAIM FORM PICA ,. 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER 1a.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) (Medicare#) (Medicaid#) (Sponsor's SSN HEALTH PLAN BLK LUNG ) F-1 (VIFile #) F-1 (SSN or ID) 0 (SSN) C(ID) 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4,INSURED'S NAME(last Name,First Name,Middle Initial) BROWN, CYNTHIA dl i ig 9Y9 M F Xj THE SUNRISE HOUSE 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No..Street) 129 PIONEER AVE. Self[:] Spouse[] Child[[ Other'E CITY STATE 8.PATIENT STATUS CITY STATE Z WALNUT CREEK CA Single Married E] Oiher E] F ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) a 94.596 (510\ 938-••9127 Employed[n Full-Time 1:1 Student / \ cc J Student Student ` / O 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER LL Z_ ❑ LSl a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX Z MM DD YY :3YES NO M F to LLLJJJ Z_ b.IOMHER IDNDSUR YD' S DATE OF BIRTH SEX b.AUTO ACCIDENT? X PLACF'(S le) b.EMPLOYER'S NAME OR SCHOOL NAME CC AA ❑ i Mr-A F 1-1F1F1 NO I Q c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACC DENT? c. N c RAM NAME ~ YES NO � ' �`-3''4"�"' P��°� w d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANO�ER HEALTH BENEFIT PLAN? d O YES NO ff yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED__SIGNATURE ON FILE DATE 11/16/95 SIGNED SIGNATURE ON FILE 14.DATE OF CURRENT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT pUNABLE TO WORK IN CURRENT OCCUPATION 1R1 2E0 95 INJURY(Accident)OR GIVE FIRST DATE MM DD YY MM N! £-1 . YY MM NPA YY PREGNANCY(LMP) FROM TO i 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DO YY N/A N/A FROM TO 19,RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES YES C NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION 1 E885_ FALL .FROM SLIP/TRIPS 846=0 LUMBOSAC AL CODE I ORIGINAL REF.NO. 23.PRIOR AUTHORIZATION NUMBER 2. +�7_0 CERVICAL SPRAIN/ST4. ) +724.. 71 COCCYX HY 24. A B C D E F G H I J K Z DATE(S)OF SERVICE Place Type PROCEDURES,SERVICES,OR SUPPLIES DAYS EPSD F O of of DIAGNOSIS RESERVED FOR From To (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE MM DD YY MM DD YY Service Service CPT,HCPCS MODIFIER UNITS Plan a 11: 01 95 1 1 99212 1-4 40 ; 00 0 LL Z 2 11, 01' 95 1 1 f 97010 1-4 18 'a51 w J a 3 11 01 951 11 1 97012 1-4 18 ; 45 to 4 11 01' 95 11 3 7614.0 1-4 35 !00 0 Z i � a 5 En i x 6 i i a 25.FEDERAL TAX LD.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 2B.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE (For govt. back) 68-0148119 2335 6I 1 A DN $ 111 ;90 s i $ 111 :90 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.N .dDRESS OF FACILITY WHEFIE VICES WERE 33.PHYSICIAN'S, P BI ESS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RE W ED(If other than home or offide) �� L CHIROPRACTIC CENTER (I certify that the statements on the reverse ) ; �;�. .-- - - apply to this bill and are made a part thereof.) M 31a7 P U T N A M BLVD. SUITE E JOHN S. RIDDEL, D. C. Nov PLEASANT HILL, CA 94523, SIGNED 11/16/95 DATE I i`('j .,..� PIN#168290 GRP# CNAPPR VED Y pM OUNCI ON ME I AL ERVICE 8/6�LS l__-� MPLEA FORM HCFA-1500 (12-90) I M x 3 11L011��1 ?51 �___.____- ��PFu -e��rPE FORM OWCP-1500 FORM RRB-1500 PLEASE BROOKMAN & TALBOT APPROVED OMB-0938-0008 DO NOT 1990 NORTH CALIFORNIA BLVD, STAPLE ' WALNUT CREEK CA 94596-3711 C� W IN THIS (510) 932-4008 AREA a U ;PICA ' HEALTH INSURANCE CLAIM FORM PICA .� 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER 1a.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) HEALTH PLAN BLK LUNG (Medicare N) (Medicaid#)❑(Sponsor's SSN) (VA File #) (SSN or ID) [:] ___y(SSN) I �{`(ID) 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) BROWN, CYNTHIA 81 A 1 6Y9 MFj F 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 129 PIONEER AVE. self Spouse Child Othern CITY STATE 8.PATIENT STATUS CITYSTATE Z WALNUT CREEK CA o Single[:]SinglMarried [n Other El ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(IN( CODE) Q 94596 (510) 938-9127 Employed Full-Time Part-Tim / cc 1:1Student Student e 1 O 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER LL Z_ Cl.. W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX cc YES NO MM DD YY M❑ F ® Z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME MM DO YY Z I M F YES �NO LCA; Q c.EMPLOYER'S NAME OR SCHOOL NAME C.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME Z �vEs 0No LIABILITY (PI) u' d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THEREANOTHER HEALTH BENEFIT PLAN? Q a YES Z NO If yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. / SIGNED SIGNATURE ON FILE DATE 10 L_31-L95 SIGNED SIGNATURE ONIFIL._E Y 14.DATE OF CURRENT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16,DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 1 Y INJURY(Accident)OR GIVE FIRST DATE MM DD YY MM D , YY MM D YY L 3 PREGNANCY(LMP) - FROM jy g A - TO N 9,q 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATIONDATESRELATED TO CURRENT SERVICES MM DO YY MM DD YY N/A N/A FROM TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES Ej YES ❑NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION CODE ORIGINAL REF.NO. 1 E�f�5_ FALL FROM SLIP/TRIP 3 I +846. 0 Ll1MBOSAC AL 23.PRIOR AUTHORIZATION NUMBER 2. L+847_0 CERVICAL SPRAIN/ST,, L±724. 71 COCCYX' HY 24. A B C D E F G H I J K Z DATE(S)OF SERVICE Place Type PROCEDURES,SERVICES,OR SUPPLIES DAYS EPSD _O From ToDIAGNOSIS RESERVED FOR of of (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE MM DD vY MM DO YY Se"iCE Service CPT/HCPCS MODIFIER UNITS Plan Q 1 10 20; 95 3 99205 1-4 85100 p LL Z 2 10 20; 95 3 72052 1-4 190 ; 00 w J 3 10 20 95 3 721@@ 1-4 95 00 Cn 4 10 20095 1 3 99070 1-4 25x00 0 Z U 5 � } i = i I I t 1 I a 6 1 1 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE 68-0148119 2335 6I1A �oYES� cl ] NOeback) $ 395 00 $ $ 395 ;00 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S, BILI SS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED(If other than home or office) L CHIROPRACTIC CENTER (I certify that the statements on the reverse appty to this bill and are made a part thereof.) 3147 PUTNAM BLVD, SUITE E JOHN S. RIDDEL, D. C. PLEASANT HILL, CA 94523 SIGNED 1@/31/95 DATE PIN#168290 GRP# (AP 9,OV D Y q GOUT L ON E81 A S€RVICE 8/88) PLEASE PRINT OR TYPE FORM HCFA-1500 (12.90) C L L 19 1 2@ VJ �f7 5 1 i FORM OWCP-1500 FORM RRB-1500 PLEASE l BROOKMAN TALBOT APPROVED OMB-0938-0008 b DO NOT 1990 NORTH CALIFORNIA BLVD. STAPLE I cc IN THIS WALNUT CREEK CA 94.596-3711. w AREA (510)' 932-4008 - a 1 U >q--iPICA HEALTH INSURANCE CLAIM FORM PICA r � 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER 1a.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) (Medicare#) (Medicaid#) (Sponsor's SSN HEALTH PLAN BLK LUNG (VA File #) � (SSN or ID) � (SSN) �DCl1D) 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) MM i DD i YY BROWN, CYNTHIA 01 : 28! 59 M F X 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7,INSURED'S ADDRESS(No.,Street) 129 PIONEER AVE. Self 0 Spouse[:] Child Other[g] CITY STATE 8.PATIENT STATUS CITY STATE Z WALNUT CREEK CASingle Married❑X Other O ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) Q 94596 (510) 938-9127 Emplcyed® Full-Time0 ❑ Part-Tim > Student Student e O LL 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z Z_ 0 LU a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX rr MM DO YY n YES NO ! 1 M F (n LLLJJJ Z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME MM DD YY ! M F YES NO C A Z Q c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME YES �NO LIABILITY (PI) W d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? Q ,�c, a YES L__J NO 11 yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. - 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON FILEDATE 10/31/95 SIGNED SIGNATURE ON FILE. 14.DATE OF CURRENT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION A T'6 PREGNANCY(LMINJURY pOR GIVE FIRST DATE MM + DD YY FROM MmN/DA YY TO MM YY 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY N/A N/A, FROM TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES D YES 1:1 NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22,MEDICAID RESUBMISSION CODE _ ORIGINAL REF.N0. 1 E� 885_ FALL FROM SLIP/TRIP3. X6. 0 LUMBOSAC AL 23.PRIOR AUTHORIZATION NUMBER - 2. (+847_0 CERVICAL SPRAIN/ST,. X724.. 71 COCCYX HY 24, A B C D 7 1 E F G H I J K Z FromDATE(S)OF SERVICE To Place Type PROCEDURES,SERVICES,OR SUPPLIES DAYS EPSD Q DIAGNOSIS RESERVED FOR of of (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE f"' MM DO YY MM DO YY ServiceService CPT/HCPCS MODIFIER UNITS Plan Q 1 c 1 10 21� 95 1J 1 99212 1-4 40'! 00 0 i LL 1 Z - 2 10 21; 95 11 1 97014 1 1-4 18145 w 3 10 2195 1 1 11 1 970101-4 18 ; 45 fr 4 10 23; 95 11 1 99212 1-4 40; 00 0 Z l 1 Q 5 10 23195 1 1 97012 1-4 18 45 N } 6 10 23! 95 1 1 97010 1--4 18: 45I L a 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE 68-0148119 E] [n 2335 6I1A ( or go cla❑ims,Neeeback) $ 153 80 $ $ 153 i80 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S,At 191 BILI SS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED(If other than home or office) ( L CHIROPRACTIC CENTER (I certify that the statements on the reverse apply to this bill and are made a part thereof.) 3147 P U T N A M BLVD. SUITE E JOHN S. RIDDEL, D. C. PLEASANT HILL, CA 94523 SIGNED 10/31/95 DATE PIN#168290 GRP# AP v D Y OU L ON E I A S vlcE a/ea) PLEASE PRINT OR TYPE FORM HCFA-1500 (12-90) C L IK 2 S 0 2' � �1 FORM OWCP-1500 FORM RRB-1500 PLEASE BROOKMAN & TALBOT APPROVEDOMB-0938-0008 DONOT ) 1990 NORTH CALIFORNIA BLVD. /�� STAPLE ; WALNUT CREEK CA 94596-3711 (/" w IN THIS 1 AREA 1 (510) 932-4.008 � � ---- Q U IXnPICA - - - HEALTH INSURANCE CLAIM FORM PICA 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER ta.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) (Medicare#) (Medicaid#) (Sponsor's SSN) (VA File # HEALTH PLAN BLK LUNG ) [:] (SSN or 1D) [] (SSN) [:]((ID) 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX _ 4.INSURED'S NAME(Last Name,First Name,Middle Initial) MM , DD , YY BROWN, CYNTHIA 01128! 59 M F 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 129 PIONEER AVE. Self[:] Spouse Child Othe,M CITY STATE 8.PATIENT STATUS CITY STATE Z WALNUT CREEK CA Single Married® Other O ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) Q 94 596 510 938-9127 Employed® Full-Time❑ Part-Time a Student Student O 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX IM MM DD YY YES ®NO M F i b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME 0 MM DD YY Z i I M F DYES 1XI l CA; - Q c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME Z �YES 1No LIABILITY (PI ) W d.INSURANCE PLAN NAME OR PROGRAM NAME tOd.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? Q a ❑YES ® NO If yes.return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON FILE DATE 10/31/95 SIGNED SIGNATURE ON FILE y 14.DATE OF CURRENT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION TIO : 2® lf�,l j INJURY(Accident)OR GIVE FIRST DATE MM !, DD YY MM N DDA YY TO MM N pQ YY PREGNANCY(LMP) FROM / /H 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES N/A MM DD YY MM DD YY N/A FROM TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES YES [:]NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION CODE ORIGINAL REF.NO. 1 (E885_ FALL FROM SLIP/TRIPS i +84.6. 0 LUMBOSAC .AL 23.PRIOR AUTHORIZATION NUMBER 27. 0 CERVICAL SPRAIN/ST4 +724.. 71 COCCYX HY 24. A B -C - D E _F G H I J K Z F DATE(S)OF SERVICET0 Place Type PROCEDURES,SERVICES,OR SUPPLIES DIAGNOSIS DAYS EPSD RESERVED FOR j O of of (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE MM DD YY MM DD YY Servic Service CPT/HCPCS I MODIFIER UNITS Plan Q 1 10 24' 95 1 IJ 1 99212 1-4 40100 Cr U_ Z 2 10 24! 95 14 1 97012 1-4 18 45 w � J 3 10 24 95 1 1 97010 1-4 18 45 rr 4 i Z Q i i i U 5 N i } i i i i i i S 6 � � 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE 2335 6I1A (For claims,see back) 68-0148119 ❑ � � YESES [:] NO $ 76 i90 $ i $ 76 190 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S, 4411 BIL ESS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS I RENDERED(if other than home or office) � (_ CHIROPRACTIC CENTER (I certify that the statements on the reverse apply to this bill and are made a pail thereof.) 3147 PUTNAM BLVD. SUITE E JOHN S. RIDDEL, D. C. PLEASANT HILL, CA 94523 SIGNED 10/31/95 DATE PIN#"68290 GRP# C"7$1frD aY ACOUN�LL4 LE 8/88) PLEASE PRINT OR TYPE FORM HCFA-1500 (12-90) LJ5 FORM OWCP-1 500 FORMRRB-1500 APPROVED OMB-0938-0008 1 PLEASE BROOKMAN & TALBOT DO-NOT 1990 NORTH CALIFORNIA BLVD. C'� w STAPLE WALNUT CREEK CA 94596-3711 IN THIS' f AREA I (510) 932-4008 a -;XnPICA -- HEALTH INSURANCE CLAIM FORM PICA ; 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER 1a.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) HEALTH PLAN BLK LUNG (Medicare#) ❑(Medicaid N)❑(Sponsor's SSN) Fj (VA F!e N) (SSN or ID) Ej (SSN) f 7410) - 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) MM DD YY BROWN, CYNTHIA 01 ;, 28! 59 M F S.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 129 PIONEER AVE. Sen 1:1 Spouse o Child Other CITY STATE 8.PATIENT STATUS CITY STATE Z WALNUT CREEK CA Single Married® other f-� O ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) a 94596 510) 938-9127 Employed y Full-Time❑ Part Time cc P9 °` Student Student O 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z Z_ 0 W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX cc YES ®NO MM i DD YY M❑ F ® Z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME 0 MM DD YY M F DYES 1XI CA a c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME Z rYES �NO LIABILITY (PI) LU 1-- d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? d YES ® NO 11 yes.return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON FILE DATE 10/31/95 SIGNED SIGNATURE ON FILE 14,DATE OF CURRENT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION Tt@ . 212) : 915 1 INJURY(Accident)OR GIVE FIRST DATE MM DD YY FROM NIM N�DA YY TO MM N pn YY PREGNANCY(LMP) /H 17,NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES N/A N/A FROM TO MM DD YY MM DD YY 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES 11 YES []NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2.3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION CODE ORIGINAL REF.NO. 1 �E885_ FALL FROM SLIP/TRIPS +846_0 LUMBOSAC AL 23.PRIOR AUTHORIZATION NUMBER 27_0 CERVICAL SPRAIN/ST 4 � _±7.24. 71 COCCYX HY 24. A B C D E FG H I J K Z From DATE(S)OF SERVICE Place Type PROCEDURES.SERVICES.OR SUPPLIES DIAGNOSIS DAYS EPSD RESERVED FOR O of of (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE F MM DD YY MM DD YY Servic Service CPT/HCPCS I MODIFIER UNITS Plan a 1 10 25! 95 1 1 99212 1-4 40 00 0 z 2 10 25' 95 11 1 97012 1�4 1$ 45a. w � J 3 10 25i 95 11 1 97010 1-4 18 45 Cn 4 10 251, 95 1 1 99070 1-4 20, 00 0 Z a s N s 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE 68-0148119 FIN 2335 6I1A ❑(Fvesorgovt.cla❑ims,seebacl) No $ 96 ; 90 $ $ 96 ;90 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S, I BILI SS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED(If other than home or office) 1 tJ LJG L CHIROPRACTIC CENTER (I certify that the statements on the reverse apply to this bill and are made a part thereof.) 314.7 P U T N A M BLVD. SUITE E JOHN S. RIDDEL, D. C. PLEASANT HILL, CA 94523 SIGNED 10/31/95 DATE PIN#168290 GRP# FORM HCFA-1500 (12-90) 1 gy I��o ppy E aias> PLEASE PRINT OR TYPE C�qP4lf G�J� VJLJ � FORMOWCP-1500 FORMRRB-1500 PLEASE ) BROOKMAN & TALBOT APPROVED OMB-0938-0008 DO NOT j % 1990 NORTH CALIFORNIA BLVD. STAPLE WALNUT CREEK CA 94.596-3711 �� w IN THIS (510) 932-4.008 AREA a � U -1 �17 PICA --- -----.--� HEALTH INSURANCE CLAIM FORM PICA 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER ta.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) (Medicaid# HEALTH PLAN BLK LUNG (Medicare#) ❑ )❑(Sponsor's SSN) ❑ (VA File#) ❑ (SSN or ID) ❑ (SSN) I 1 yID) 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) BROWN, CYNTHIA d11 fb tyg M F 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No..Street) 129 PIONEER AVE. Self❑ Spouse❑ Child❑ other] CITY STATE 8.PATIENT STATUS CITY STATE Z WALNUT CREEK CAo Single❑ Married[�(j Other ❑ � ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) d 94596 510 938-9127 Employed Full Time Part-Time ) Cr L-J Student 1:1 Student ElO 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER u' Z w a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX MM DO YY ❑'YES (�NO M❑ F n Z u Z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME 0 MM DD YY IM F ❑YES NO C A, Q c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME Z ©YES ❑NO LIABILITY (PI ) w F- d. d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? d CIL ❑YES U NO If yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON FILE DATE 10/31/95 SIGNED SIGNATURE ON FILE 141VE(1W YT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ,\ . <D( `Pp 4 INJURY(Accident)OR GIVE FIRST DATE MM DD : YY FROM MM N AA YY TO MM NPA: YY PREGNANCY(LMP) 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES N/A N/A MM DD I YY MM DD YY FROM TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES ❑YES ❑NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2.3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION E885 FALL FROM SLIP/TRIP +846. 0 LUMBOSA AL CODE ORIGINAL REF.NO. 23.PRIOR AUTHORIZATION NUMBER +84.7, 0 CERVICAL SPRAIN/ST +724. 71 COCCYX HY 2. I_.- 4. L ._ 24. A 8 I C D -...E -F G H I J K Z DATE(S)OF SERVICE Place Type PROCEDURES,SERVICES,OR SUPPLIES DIAGNOSES DAYS EPSD RESERVED FOR O From To of of (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE E- MM DD YY MM DD YY Servic Service CPT/HCPCS I MODIFIER UNITS Plan s 10 26; 95 1 1 1 99212 1-4 40; 00 IM 1 z 10 26', 95 1 1 97012 1-4 18 45 cc •2 � w �. i J 10 26; 95 1 1 : 97010 1-4 18. 45 a 3 iCIO cc O 4 Z d_ 5 (n I i I i i d 6 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. j27 ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE I (For govt.claims,see back) 68-0148119 ❑ 2335 6I1A ❑ YES ❑ NO $ 76 ; 90 $ $ 76 ;90 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S. 1A'l 1'lBILI PkbtWESS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED(If other than home or office) L CHIROPRACTIC CENTER (I certify that the statements on the reverse apply to this bill and are made a part thereof.) 3147 P U T N A M BLVD. SUITE -E JOHN S. RIDDEL, D. C. PLEASANT HILL, CA 94523 SIGNED 10/31/95 DATE PIN#168290 GRP# FORM HCFA-1500 (12-90) CC413pRD B.Y,.QMf160UNC11.AN AdEAICAL S gg E 8168) PLEASE PRINT OR TYPE FORM OWCP-1500 FORM RRB-1500 PLEASE ` BROOKMAN & TALBOT APPROVED OMB-0938-0008 DO-NOT11 1990 NORTH CALIFORNIA BLVD. STAPLE WALNUT CREEK CA 94596-3711 �` w IN THIS' '' AREA (5-10) 932-4008 cc a U I j -71PICA HEALTH INSURANCE CLAIM FORM PICA i_]X 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER 1a.INSURED'S I.D.NUMBER - (FOR PROGRAM IN ITEM 1) #) (Medicaid# HEALTH PLAN BILK LUNG (Medicare ❑ )❑ (Sponsor's SSN) ❑ (VA File #) ❑ (SSN or ID) ❑ (SSN) r 0) 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) BROWN, CYNTHIA 01 ,281 59 M F 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 129 PIONEER AVE. Self❑ Spouse[] Child❑ OtherF] CITY STATE 8.PATIENT STATUS CITY STATE Z WALNUT CREEK CAO Single❑ Married® Other ❑ � ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) a 94596 (510 938-9127 Employed Full-Time Part-Time cc Student ❑ Student ❑ 1 O 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z _Z W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX Ix �c MM DD YY ❑YES I `I NO M❑ F Cf) u _Z b.OTHER INSURED's DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME MM DD i YY M F ❑YES NO CA Z c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME Z [ YES NO LIABILITY SPI ) d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? a a ❑YES [ NO if yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON FILE DATE 10/31/95 SIGNED SIGNATURE ON FILE Y 14. E URS( T: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION t11Pa7 j� 1�J INJURY(Accident)OR GIVE FIRST DATE MM DD YY FROM MM N YY TO MM N (4, YY PREGNANCY(LMP) 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES N/A N/A MM DD YY MM DD YY FROM TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES ❑YES ❑NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1.2.3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION E885FALL FROM SLIP/TRIP +846. 0 LUMBOSA AL CODE ORIGINALREF.NO. 3. 1 23.PRIOR AUTHORIZATION NUMBER ZI+847. 0 CERVICAL SPRAIN/ST4 +724. 71 COCCYX HY 24. A B C D E F G H I ' J K Z From DATE(S)OF SERVICE To Place Type PROCEDURES,SERVICES,OR SUPPLIES DAYS EPSD _O DIAGNOSIS RESERVED FOR of of (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE MM DD YY MM DD YY ServiceService .CPT/HCPCS MODIFIER UNITS Plan Q 10 27; 95 11. 1 99212 1-4 4000Cr 2 10 27� 95 1 1 97010 1-4 18 45 ac w i J 3 10 27 95 1 1 11. 1 97012 1-4 18 45 CL N 4 10 27' 95 1 11. 1 99070 1-4 40 00 0 i a 5 W � Y I i i i I i d 6 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE 68-014.8119 F-] [X] ❑claims,2335 6I1A (For YES NOsee eback) $ 116 ; 90 $ s 116 190 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S, P1,10 4 BIL SS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED(if other than home or office) R1 iF1AFE�F L CHIROPRACTIC CENTER (I certify that the statements on the reverse 1 L7 U G apply to this bill and are made.a part thereof.) 3147 PUTNAM BLVD. SUITE E JOHN S. RIDDEL, D. C. , PLEASANT HILL, CA 94523 10/31/95 168290 SIGNED DATE PIN# 1 GRP# ��qA Rp���r���.{�_D gy..p, ,{,O�}NG�,gp�,M�,g��q{, {�E 6188) PLEASE PRINT OR TYPE FORM HCFA-1500 (12-90) C L f 1 1 1 1 L J J:� 1&J tE( tL IV FORM OWCP-1500 FORM RRB-1500 BROOKMAN & TALBOT APPROVED OMB-0938-0008 PLEASE i 1990 NORTH CALIFORNIA BLVD. qt DO NOT ; �• � STAPLE WALNUT CREEK CA 94596-3711 LU IN THIS AREA (510) 932-4008 cc . i � a U ;�-1PICA L - - -- HEALTH INSURANCE CLAIM FORM PICA 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER ta.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) HEALTH PLAN BLK LUNG,�,y (Medicare#) ❑(Medicaid A')❑ (Sponsor's SSN) F-] (VA File k) ❑ (SSN or ID) ❑ (SSN) I y0D) 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) BROWN, CYNTHIA 8"1 ; A 1 619 M F 5.PATIENT'S ADDRESS(No.:Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 129 PIONEER AVE. Self❑ Spouse❑ Child❑ othe,E] CITY STATE 8.PATIENT STATUS CITY STATE Z WALNUT CREEK CAO Single❑ Married� Other ❑ � ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) Q 94596 510 938-9127 Employed FullTime Part Time ( \ cc Student ❑ Student ❑ ` / O 9.OTHER INSURED'S NAME(Last Name,First Name,Middle initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER LL _Z W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX cc MM DD YY :D ❑YES NO i M❑ F Z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME J Q MM DD YY M F ❑YES �` NO I CA! ZQ c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME ~ YES NO LIABILITY (PI) w d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? Q a ❑YES [�] NO ff yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON FILE DATE 10/31/95 SIGNED SIGNATURE ON FILE 14.D((ATE OF CURRENT: A ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT pUNABLE TO WORK IN CURRENT OCCUPATION PREGNANCY(LMP) M INJURYOR GIVE FIRST DATE M DD YY FROM MM N/ �y YY TO MM N DfA YY 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY PAM DD YY N/A N/A FROM TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES ❑YES ❑NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION CODE ORIGINAL REF.NO. 1 Ei 885_ FALL FROM SLIP/TRIP L+846_0 LUMBO,SAC AL J 23.PRIOR AUTHORIZATION NUMBER z L=.-0 CERVICAL SPRAIN/ST4 L±724. 71 COCCYX HY 24. A B C D .. E F G H I J K Z FromDATE(S)OF SERVICE To Place Type PROCEDURES,SERVICES,OR SUPPLIES DIAGNOSIS DAYS EPSD RESERVSD FOR O of of (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE F MM DD YY MPA DO YY Service Service CPT/HCPCS I MODIFIER UNITS Plan Q 10 28' 95 11 1 99212 1-4 40 00 o z 10 2895 1 1 97012 1-4 18 ; 45 z w I J 10 28 95 1 1 97010 1-4 18145 a 3 1n 10 301 95 1 I 11 1 99212 1-4 40 00 cc 0 4 Z 10 30 95 11 1 97010 1-4 18; 45 5 (n } 10 30 9 1 1; 97012 1-4 18145 a s 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE b8-0148119 2335 bI1A I (For govt.claims,see back) ❑ ❑ YES ❑ NO $ 153 i 80 $ $ 153 ;80 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 132.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S, BIL SS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS I RENDERED(If other than home or office) L CHIROPRACTIC CENTER (I certify that the statements on the reverse - apply to this bill and are made a part thereof.) 3147 P U T N A M BLVD. SUITE E JOHN S. RIDDEL9 D. C. PLEASANT .HILL, CA 94523 SIGNED 10/31/9;DATE I PIN#1682GRP# ,qP RfffD o pp1�q 5�V{�E s/aa) PLEASE PRINT OR TYPE FORM HCFA-1500 (12-90) CLHI'I LJ 7Jt1Lt51� J L FORMOWCP-1500 FORMRRB-1500 PLEASE i ) BROOKMAN SC TALBOT APPROVED OMB-0938-0008 DCStvOT 1990 NORTH CALIFORNIA BLVD, STAPLEWALNUT CREEK CA 94.596-3711 e� w IN THIS { (510) 9,32-4008 � AREA a I � v ;PICA HEALTH-- --�`��--- -- HEALTH INSURANCE CLAIM FORM PICA r-r � 1, MEDICARE MEDICAID CHAMPUSCHAMPVA GROUP FECA OTHER fa.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) (Medicaid# HEALTH PLAN BLK LUNG (Medicare#) Y" E] )❑(Sponsor's SSN) ❑ (VA File #) E] (SSN or ID) ❑ (SSN) I {YID) 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) BROWN, CYNTHIA 6"1,; A 69 M F S.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 129 PIONEER AVE. Self❑ Spouse[:] Child[] other CITY STATE 8.PATIENT STATUS CITY STATE Z WALNUT CREEK CAO Single❑ Married � Other ❑ "'49' 9 IP C TE PHQNE(In Ike Area God e1 ZIP CODE TELEPHONE(INCLUDE AREA CODE) 99'996 1YJ �J8-91�77 Employedr�( Full-Time Part-Time l c LJ Student ❑ Student ❑ / O ILL 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z Z_ W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX MM DD YY ❑YES NO M❑ F z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME MM DD YY CA I Nj F ❑YES No Z -� Q c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAMER PROGRAM NAME I- �YES ❑NO LIABILITY ?PI ) W d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? Q a ❑YES NO If yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON FILE DATE 10/31/95 SIGNED SIGNATURE ON FILE 14.DATE OF CURRENT: A ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT�I UNABLE TO WORK IN CURRENT OCCUPATION 1x11"0 `90 d�lsj INJURY(Accident)OR GIVE FIRST DATE MM DD YY MM N TA YY MM N PA i YY PREGNANCY(LMP) FROM TO I I 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES I MM DD YY MM DD YY N/A N/A FROM TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES ❑YES ❑NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION E885 FALL FROM SLIP/TRIP +84.6. 0 LUMBOSA AL CODE ORIGINAL REF.NO. 1. 1 3. L-.- 23.PRIOR AUTHORIZATION NUMBER 284-7_0 CERVICAL SPRAIN/ST4724. 71 COCCYX HY 24. A B C D E F G H - I J - K Z F DATE(S)OF SERVICE To Place Type PROCEDURES,SERVICES,OR SUPPLIES DIAGNOSIS DAYS EPSD RESERVED FOR O of of (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE ~ MM DD YY MM DD YY Service Service CPTrHCPCS I MODIFIER UNITS Plan Q 1 10 31; 95 11. 1 99212 1-4 4.0 !1 00 0 z 10 '311 95 11 1 97128 1-4 20 , 91. 2 cc w 10 31; 95 1 1 " 97012 { 1-4- 18 45 a 3 � O 4 O Z i L) 5 W 6 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE 68-0148119 2335 6Ili (For govt.claims,see back) YES ❑ NO $ 79 ; 36 $ $ 79 ;36 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S, I ' BILY1 SS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED(If other than home or office) (r CHIROPRACTIC CENTER (I certify that the statements on the reverse apply to this bill and are made a pan thereof.) 314.7 P U T N A M BLVD. SUITE E JOHN S. RIDDEL, D. C. PLEASANT HILL, CA 9.4.523 10/31/95 168290 SIGNED DATE PIN# GRP# 6APJ TKD otlt�pi� Fa P�1 S fl+/fE a/88) PLEASE PRINT OR TYPE FORM HCFA-1500 (12-90) CLH 7 I F Y,I J .L6S!!IE 2 i 5:v, FORMOWCP-1500 FORMRRB-1500 1 PROOF OF SERVICE BY MAIL -- CCP. 42015.5 & 41013(a) 2 I, the undersigned, declare under penalty of perjury of the laws of the State of California: 3 That I.am a citizen of the United States and over the age of eighteen years; that I am not 4 a party -to the .within action or proceeding; that my business address is 1990 N. California 5 Boulevard, Suite 740, Walnut Creek, California 94596; that on the date set forth below I served a true copy of: 6 CLAIM TO THE COUNTY OF CONTRA COSTA 7 8 9 by .depositing said copy in the United States Mail, at Walnut Creek, California, in a sealed envelope, postagethereon prepaid, addressed as follows: 10 VIA CERTIFIED MAIL - RETURN RECEIPT REOUESTED 11 Clerk of the Board of Supervisors 12 Room 106, County Administration Building 651 Pine Street 13 Martinez, CA 94553 14 15, 16 17 18 19 At said time, there was regular delivery of the United States Mail between said places of deposit and address(es). 20 13 P.- Executed at Walnut Creek, Contra Costa County, California, on Februa , 1996. 21 22 23 SHARON HANNEY 24 25 26 27 28 'd p t+� w w W 9 R 4 4 GA j `4 lz :x ulco � HI /yam O 1A. to O CLAIM C q BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA '-Marchi 12, 1996 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 9 "Warnings". CLAIMANT: California Dental Ceramics, Inc. �o Martin J. McHugh FEB 2 6 1996 ATTORNEY: DCOUNTY COUNSEL Date receivedMARTINEZ CALIF.CALIIF ADDRESS: 1825 Contra Costa Blvd. BY DELIVERY TO CLERK ON February 26, 1996 Pleasant Hill CA 94523 BY MAIL POSTMARKED: February 23, 1996 via: Risk Mgmt I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. ppH gg , DATED: February 26, 1996 EY DeputyLOR, Clerk II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( v-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: .2—2_7— 1(Q 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 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. Dated: f�(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. *For additional warning see reverse side of this notice. 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 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 the claimant as shown above. Dated:� � /c/'9/„ BY: PHIL BATCHELOR b eputy Clerk l CC: County-Counsel County Administrator .-a:r, moo: BOAH) OF SRERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. Clam relating to causes of action for death or for injury to 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, 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 Sec. 72 at the end of this f/1r--. uu YY YY YY YY YY YY YY YY R£: Claim By ) Reserved for Clerk's filing stamp -RECEIVED Against the County of Contra Costa fM 2S 19% or ) Vc� ; ( CLERK BOARD Of S ERVI ORS District) K CONTRA 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 $ end in support of this claim represents as follaws: 1. When did the damage or injury occur? '(Give exact date and hour) 0-30 2. Where did the damage or injury occur? (Include city and county) IX 3. How did the damage or injury occur? (Give full details; use extra paper if required) 0—Fk, e-r A901,1- c(.,_d ecQ -ems-�- 5cc Locv.. Q lLp,,A-k It 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? �Vp i n 04 k,& (5m Lc cA%J j�� (o - 3q-1 5. WriaL ar-e me n:---)es of county or district officers, servants or employees causing the damage or injury? Eric Wata, Ckc- it -7 6. What damage or injuries do you claim resulted? (Give ftll extent of injuries or damages claimed. Attach two estimates for auto damage. 100 Ck o\,2 7. HOW 'Was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) 6. Names and addresses of witnesses, doctors and hospitals. je�stc.-a' U CL I 35T3 1`�A-C- ut-f�-r+(e- � 9. List the expenditures you made on account of this accident or injury-. DAT£—E ITEM. AMMTNT Gov, Code Sec. 910:2 provides: "The claim must be signed by the claimant SEND NOTICES TO: (Attorney) or b)r some persan on his behalf." Name and Address of Attorney ( Ca- G-�,r�. ig �CafaS C-) ex c-A- Telephone No. Telephone No. 510 - (A7 - N 0 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 z*uch im-prisonment and fine. - Page 1 �f PROFESSIONAL AUTOMOTIVE 3331 MT. DIABLO BLVD. LAFAYETTE, CA 94549 (510) 283-2160 , CD LOG NO 0002054 DATE 11/26/95 SHOP CONTACT: '.SCOTT ' -. INSP DATE 11/30/95 OWNER CALIFORNIA DENTAL CERAMICS ADDRESS 1825 CONTRA COSTA BLVD. CITY STATE PLEASANT HILL CA HOME PHONE ZIP 94523 WORK PHONE LIC# 3DFP584 VIN 2HGEH235OPH521504 BODY COLOR WHITE - NH538 MILEAGE 82261 CONDITION GOOD ACCT'NG CTL# ELNEW PART EC=ECONOMY PART EU=SALVAGE PART EP=SEE PX REPORT P=CHECK I=REPAIR/ALIGN/SUBLET L=REFINISH N=ADDITIONAL LABOR OPERATION TE=PART/PARTIAL REPLACE , ET=LABOR/PARTIAL REPLACE IT=LABOR/PARTIAL REPAIR AA=APPEARANCE ALLOWANCE RP=RELATED PRIOR DAMAGE UP=UNRELATED PRIOR DAMAGE NOTE: REPAIR TIME - 3 BUSINESS DAYS NOTE: POSSIBLE EXHAUST DAMAGE —OPEN 1993 HONDA CIVIC CX' 2 DOOR HATCHBACK H0242A/B OPTNS G/ OGDE MC DESCRIPTION MFG. PART NO. PRICE AJ% HOURS R N� U566 REAR BUMPER R&I ADDTL LABOR . 8 1 I� 566 COVER,REAR BUMPER REPAIR/ALIGN 2 . 0*1 LI 566 COVER,REAR BUMPER REFINISH 2 . 1 4 El 567 ' ABSORBER,REAR BUMPER 71570SR3A00 49 . 83 . 6 1 E M03 FLEX ADDITIVE ECONOMY PART 10 . 00* 4 L M15 COLOR TINT REFINISH . 5*4 6 ITEMS FiINAL CALCULATIONS & ENTRIES GROSS PARTS 49 . 83 OTHER PARTS 10 . 00 PAINT MATERIAL 57 .20 PI RTS TOTAL 117 . 03 TAX ON PARTS & MATERIAL @ 8 .250% 9 . 65 LABOR RATE REPLACE HRS REPAIR HRS 1-SHEET METAL 54 . 00 . 6 2 . 8 183 . 60 2-MECH/ELEC 62 . 00 3-FRAME 54 . 00 4-REFINISH 54 . 00 2 .6 140 .40 5-PAINT MATERIAL 22 . 00 LABOR TOTAL 324 . 00 TAX ON LABOR @ . 000% SUBLET REPAIRS TOWING I I i /TOTAL VIC CX 2 DOOR HATCHBACK Page 2 0 0002054 Date 11/26/95 450.68 450 . 68 ADP SHOPLINK U ES LOG 0002054 DATE 11/26/95 15 :5.5:22 R3. 1 CD 11/95 PXN:NN/00/00/00/00 COPYRIGHT 1995, AUTOMATIC DATA PROCESSING, INC. *THIS ESTIMATE, BASED ON OUR INSPECTION, DOES NOT INCLUDE ANY ADDITIONAL PARTS OR LABOR THAT MAY BE REQUIRED AFTER THE WORK HAS BEEN STARTED. OCCASIONALLY, AFTER WORK HAS BEEN STARTED, DAMAGED OR BROKEN PARTS ARE FOUND WHICH WERE NOT EVIDENT ON THE FIRST INSPECTION. BECAUSE OF THIS, THE PRICES WITHIN THIS ESTIMATE ARE NOT GUARANTEED** _ --------------------------------------- ------------------------------------- I 1 k I t AS LISTED FOR LABOR AND MATERIALS VERBAL AGREEMENTS NOT BINDING-Es IMA(ES FREE 9 �j 7 8 2555 Nuith?YID O NE AbIDPESS PHO [:Sl.Ni ,IURA CO. _. ". .. UId A P III(-) . A DRESS PHONE LICENS[NUA-13"eR YE -MAKE IMODEL �f l� MILEAGE MOTOR NO. SERIAL NO. _ QUAN. DESCRIPTION OF LABOR OR MATERIAL PART NO. MATERIAL LABOR 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 i.)IAL LA13C R-MAY BE REQUIRED AFTER THE WORK HAS BEEN OPENED UP.OCCASIONALLY AFTER WORK HAS STARTED WORN PARTS ARE DISCOVERED WHICH ARE NOT EVIDENT ON FIRST INSPECTION.BECAUSE OF THIS THE ABOVE PRICES ARE NOT GUARANTEED. AI"fslAl L1;1:1'; ESTIMATE ----------- ]AX !Ot ESTIMATED APPROVED BY AUTHORIZED AN CEPTED PAIL,_?ul r�>w Sl I:A�t 013U_l I&PAIRS BY OWNER TOTAL 7(G� OR AGENT DATE REDIFORM. 4L429 -- -- • C-q k ' I ? m tQ d v U [ x �' CLAIM BOARD of SUPERVISORS OF_CONTRA COSTA COUNTY, CALIFORNIA MARCH 12, 1996 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: STACEY CIHA T36IBIId��1ATiORNEY: WILLIAMC JOHNSON ESQ F E B 16 1996 1901 HARRISON ST STE 1650 . Date received ADDRESS: OAKLAND CA 94612 BY DELIVERY TO CLERK ON FEBRUARYCbb�7N6EL 10-- BY MAIL POSTMARKED: FEBRUARY 14, 1996 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a Copy of the above-noted claim. FEBRUARY 16 1996 QQNNII ATCHELOR, Clerk 1 �pATED: 91: Deputy 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 tate and send warning of claimant's right to apply for leave to present a late Claim (Section 911.3). pp a (✓) Other: Ivan. , N/�Q. fZ( '/RPM 01 aL t WIQMf 91 a4t4t-t, IAXA, dtkl CZ tr4-,*. Ulf 0. A"P.L Af_ `gyp AA C1ak to Aad Dated: Z-00 — 9 BY: 6Deputy County Coun: II1. 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. i Dated: -MPHIL BATCHELOR, Clerk, By Q,�1. • 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 Goverwhent Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this flatter. If you went to consult an attorney, you should do so immediately. * For Additional Warning See Reverse Side Of ThiS Notice AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all titles herein rontioned, 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 the claimant as shown above. Dated:_`71:3 99 BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator RECEIVE® 9 FEB ! 51996 1 cF RMISORS COSTACOMM CO. 2 CERTIFIED MAIL - RETURN RECEIPT REQUESTED 31 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: STACEY CIHA 9 CLAIMANT'S TELEPHONE 10 NUMBER: (510) 837-8054 11 CLAIMANT'S ADDRESS: 278 Via Cima Court Danville, 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: August 18, 1995 19 PLACE CLAIM ACCRUED: Merrithew Memorial Hospital 2500 Alhambra Avenue 20 Martinez, California 94553 21 CIRCUMSTANCES OF CLAIM: On April 3 , 1994 , Claimant, STACEY 22 CIHA, sustained a left distal radial fracture . She presented to 23 MERRITHEW MEMORIAL HOSPITAL and was examined and treated by medical 24 practitioners at MERRITHEW MEMORIAL HOSPITAL, who she is informed and 25 believes are agents and employees of the County of Contra Costa, 26 hereinafter referred to as Respondents . 1 1 On April 13 , 1994 , Claimant 2 underwent closed reduction of the fracture at MERRITHEW performed by 3 Respondents . 4 On September 28, 1994, Claimant underwent another operative 5 procedure at MERRITHEW performed by Respondents for malunion of the 6 left distal radial fracture . 7 On July 19, 1995, Claimant underwent a third procedure at 8 MERRITHEW performed by Respondents for non union of the fracture . 9 Thereafter, on or about August 18, 10 1995, Claimant discovered for the first time that Respondents had 11 fractured her left arm during the operative procedure of July 19, 12 1995, and that Respondents were negligent and careless in the 13 medical and surgical care, treatment, diagnosis, technique and 14 management of her condition and that Respondents provided 15 substandard medical treatment at MERRITHEW MEMORIAL HOSPITAL for the 16 diagnosis, care and treatment and management of her left distal 17 radial fracture. 18 ITEMIZATION OF 19 INJURIES: Claimant, STACEY CIHA, sustained a fractured left arm, limitation of 20 motion and use of the left arm and hand, loss of strength and other 21 injuries and damages, the full extent of which is presently 22 unknown. 23 DATED: February 14, 1996 BE 1 / T, JO NSON & GALLER 24 By,/ 25 WILLIAM OHNSON 26 Attorney2• or Claimant 2 7 t i 5 t M ON F pul 0 G t 00 _ 0 v-+ o acv r o oGa 0- VA VA o ch N S � ? C-2 m � to CD ,d Ids t to O O t f t CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA •MARCH 12,-19960 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. PleaseVDC�%HD CLAIMANT: LIZA ALLEN FEB 2 6 1996 ATTORNEY: DIANE M JOSEPHS COUNTY COUNSEL Date received MARTINEZCAUF. ADDRESS: 685 MARKET ST STE 320 BY DELIVERY TO CLERK ON FEBRUARY 26, 1996 SAN FRANCISCO.CA 94105 BY MAIL POSTMARKED: FEBRUARY 23, 1996 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. FEBRUARY 26 1996 PPHHIL ATCHELOR, Clerk ' DATED: BY: Deputy 1I. 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). ( ✓Y Other:— Olt'A- .moo �t r►�ec. r.o � ,Ly�C oQl�n,fiJ ��'[�.u,�.-�, �.l/'� �..-. Dated: 2 - 2 '1 — 9 Le 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 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. Dated: la HIL BATCHELOR, Clerk, By 411 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, *For additional warnina see reverse side of this notice. 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 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 the claimant as shown above. Dated: `��,�1 /q9� BY: PHIL BATCHELOR by eputy Clerk CC: County Counsel County Administrator 4 CLAIM AGAINST THE COUNTY OF CONTRA COSTA The undersigned hereby presents the following Claim against the County of Contra Costa in accordance with the Provisions of Government Code §910 et sec . NAME AND ADDRESS OF CLAIMANT: Liza Allen 4 Bradford Island - U. S . Mail River Route, Stockton, CA 95219 ADDRESS TO WHICH NOTICES ARE TO BE SENT: JOSEPHS & BLUM 685 Market Street, Suite 320 San Francisco, CA 94105 DATE OF INCIDENT: The last incident occurred on August 29, 1995 when claimant was terminated. LOCATION OF INCIDENT: Bradford Jersey Island ferry and areas that it serves . DESCRIPTION OF THE INCIDENT INCLUDING THE REASON FOR THE BELIEF THAT THE COUNTY OF CONTRA COSTA IS LIABLE FOR DAMAGES : The County of Contra Costa provides funds and in some manner controlled and/or participated in the acts alleged herein. Please see Exhibit "A" which is attached and incorporated herein. The facts surrounding this incident also give rise to breach of covenant of good faith and fair dealing and wrongful discharge claims as well as intentional and negligent infliction of emotional distress . DESCRIPTION OF ALL THE DAMAGE WHICH YOU BELIEVE YOU HAVE INCURRED AS A RESULT OF THE INCIDENT. Wage loss, past and future (exceeding $200, 000) ; Medical and related expenses, past and future (approximately $10 , 000) ; Attorneys ' fees as provided by law; Emotional Distress, pain and suffering ($250, 000) . NAME OR NAMES OF ANY EMPLOYEES CAUSING THE DAMAGE THAT YOU ARE CLAIMING. Ralph Heringer, Brent Gilbert, and others in management, whose identity and/or exact role is unknown to Claimant . Dated: February 22, 1996 JOS PHS & BLUM iane M. Jo ephs Attorney f r Claimant FRECEIVE® _ LIZA ALLEN 2 k:= CLERK BOARD OF SUPERVISORS CONTRA COSTA CO. EMPLOYMENT COMPLAINT OF DISCRIMINATION UNDER DFEH # THE PROVISIONS OF THE CALIFORNIA. FAIR EMPLOYMENT AND HOUSING ACT EEOC ff If dual-filed with EEOC, this form may be affected by the Privacy Act of 1974, see reverse. CALIFORNIA DEPARTMENT OF FAIR EMPLOYMENT AND IJOUSIK, and EEOC COMPLAINANT'.S NAME(indicate Mr. or Ms.) TELEPHONE NUMBER(INCLUDE AREA CODE) Allen, Liza J. (Ms.) (510) 684-9328 ADDRESS 4 Bradford Island - U.S. Mail River Route CITY/STATE/ZIP COUNTY COUNTY CODE Stockton, CA 95219 San Joaquin 077 NAMED IS THE EMPLOYER, LABOR ORGANIZATION, EMPLOYMENT AGENCY, APPRENTICESHIP COMMITTEE,-STATE OR LOCAL GOVERNMENT AGENCY WHO DISCRIMINATED AGAINST ME NAME TELEPHONE NUMBER (INCLUDE AREA CODE) Heringer, Ralph, As an Individual (916) 777-6091 ADDRESS 20101 State Road #12 CITYISTATEIZIP COUNTY COUNTY CODE Iselton, CA 95641 Isleton 067 CAUSE OF DISCRIMINATION BASED ON (CHECK APPROPRIATE BOX[ES]) EIRACE 0 SEX III DISABILITY D RELIGION 0 NATIONAL ORIGIN/ANCESTRY 0 COLOR 0 AGE 0 MARITAL STATUS 0 OTHER (SPECIFY) NO.OF EMPLOYEES/MEMBERS DATE MOST RECENT OR CONTINUING DISCRIMINATION RESPONDENT CODE-; 100 TOOK PLACE (month, day, and year) August 29, 1995 44 THE PARTICULARS ARE: 1. 1 began my employment in July, 1994 as a Deck Hand earning $7.50 per hour. From July, 1994 through August, 1995 1 was subjected to sexual harassment, differential treatment, and a hostile work environment triggered by and perpetuated by Brent Gilbert, Chairman of the Reclamation District, #2059. The unlawful conduct and work environment was perpetuated and ratified by others at the immediate supervisory level and board level through their functions and actual tolerance and tactic allowance of such conduct. On August 29, 1995 1 was terminated. 11. 1 was told by Ralph Heringer, Operations Manager, that Brent Gilbert made a claim against me and though Ralph believed the claim was exaggerated due to Brent's attitude towards me, the others at the board went along with Brent due to his influence. When I asked if there was anything I could do to get my job back, he told me there, was nothing I could do. 111. 1 believe that I was sexually harassed, subjected to a hostile work environment, given differential treatment, and terminated because of my sex (Female). The following is a brief delineation of reasons for my belief: A. From July, 1994 though August, 1995 1 was subjected to sexual harassment by Brent. Gilbert, Chairman of the Reclamation District, The comments included but were not limited to: "move your skinny ass." "if she were a man I'd cold cock her," "she's a dumb broad and a cunt." Mr. Gilbert continually harassed me in my employment. Due to his sexist animus towards me, by explicit sexual cornments such as those above and other abusive comments and actions to make the job more difficult and hostile so that I would be forced to quit. He even attempted to hire someone to rewrite the rules and procedures, ultimately admitting his sexual animus towards me Page 1 of 2 Gh) b t,'+" W EMPLOYMENT �' r COMPLAINT OF DISCRIMINATION UNDER DFEH 4_ THE PROVISIONS OF THE CALIFORNIA FAIR EMPLOYMENT AND HOUSING ACT EEOC''/# COMPLAINANT'S NAME(S) (indicate Mr. or Ms.) Allen, Liza J. RESPONDENT'S NAME(S) Heringer, Ralph, As an Individual THE PARTICULARS ARE: and his desire to get me fired. Eventually the rules were rewritten making my job more difficult and in certain aspects more dangerous. B. I was not provided any toilet facilities until November, 1994, when I ordered a portable toilet. However, the portable toilet company decided it was not cost effective to maintain one toilet in the area and took the portable toilet. C. I presented ideas to Ralph Heringer, Operations Manager, of alternated plans for toilet use. However, nothing was done and I was toid that Brent did not want the toilet on the levee. D. On or about March, 1995 1 was forced to wear'a life jacket although previous male. deck hands did not have to wear the jacket. The wearing of the life jacket made the job more difficult and dangerous as to the aspects of this line of work. E. I reported as least 3 to 4 times in November, 1994, April, 1995, July, 1995 and August, 1995 to Ralph Heringer as well as to others that Brent Gilbert, Chairman was continually abusive and made sexually harassing remarks. No action was ever taken against him. F. I was never provided with Gilbert's actual claim, but even if there had been any truth to it, it was simply a pretext for Brent Gilbert to get rid of me. G. To my knowledge, no DFEH notices were posted at the Delta Ferry Authority. Page 2 of 2 Re-typed and mailed for signature February 02, 1996. O I also want this charge filed with the Federal Equal Employment Opportunity Commission (EEOC). I declare under penalty of perjury that the foregoing is true and correct of mown kno ledge ex ept as to matters stated on my information a d b lief and as to those matters I believe it to be true. q Dated a CI /l 1L`Iz (Q, 7R9 MPLAIN NT'S SIGNATURE At o� S ,l�j City DFEH-300-01 (Rev. 12/92) S:FG:ea DATE FILED: DEPARTMENT OF FAIR EMPLOYMENT AND HOUSING gTATF nF ('Al 1CnDNHA fU o 13 Ln mLn c� - - N MMOMMMINK (3 mmimmmw 1 m sommonowl , � 00 i ru i ` ! :u - C3 C3 �,. o -�nj LU - - {n sac a I a t u LL ,i r+ - 1 9 CLAIM BOAKC OF SUPERVISORS OF CONTRA COSTA COUNTY,CALIFORNIA LMARCH 12, _1996' Claim Against the County, or District governed by) BOAR, 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. 4 eeall_"WarningS% 19091CLAIMANT: HUGO LA TORRE AND SYLVIA LA TORRE ATTORNEY: ALLAN M TALBOT ESQ FEB 14 1996 Date received COUNTY COUNSEL ADDRESS: 1990 N CALIFORNIA BLVD #740 BY DELIVERY TO CLERK ON WNRYAk 1996 WALNUT CREEK CA 94596 BY MAIL POSTKARKE0: FEBRUARY 12, 1996 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. pp gg DATED:_ FEBRUARY 14, 1996 Bdlt Depuiy�' Clerk I1. FROM: County Counsel. TO: Clerk of the Board of Supervisors ( LThis claim complits 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: Dated: —� S BY: Deputy County Couns 1I1. 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. Dated�f,L,,,�e., 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 Clatter. if you want to consult an attorney, you should do so iWadiately. 4 For Additional Warning See Reverse Side Of This Notice AFFIDAVIT OF MAILING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citiien 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:�411AAL 13�99�_ BY: PHIL BATCHELOR by Deputy Clerk CC: County Counsel County Administrator ell LAW OFFICES OF BROOKMAN & TALBOT SUITE 740 REGE'v� 1990 NORTH CALIFORNIA BOULEVARD WALNUT CREEK, CALIFORNIA 94596-3711 4 TELEPHONE (510) 932-4008 FAX: (510) 937-1828 B�Ap $UPEFt1/tSQRS CONTfRA COSTA CO. February 12, 1996 Clerk of the Board of Supervisors Room 106, County Administration Building 651 Pine Street Martinez, CA 94553 RE: Claim of Hugo LaTorre and Sylvia LaTorre Dear Clerk: Enclosed please find original and one copy of the above-mentioned claimants' Claim against the County of Contra Costa. Please endorse receipt on the copy and return it to this office in the self-addressed, stamped envelope provided. Thank you for your cooperation and assistance. Very truly yours, BROOKMAN & TALBOT Sharon Hanney, Secretary to Alan M. Talbot /sh Encls. Cla in '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 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, 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 1069 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. RE: Claim By ) Reserved for Clerk's filing stamp HUGO LA TORRE, SYLVIA LA TORRE ) RECEIVED Against the County of Contra Costa ) FEB 14 N% &Cx ) i � CLERK BOARD OF SUPE ORS CONTRA COSTA CO. Fill in name ) The undersigned claimant hereby makes claim a§ainst the County of Contra Costa or the above-named District in the sum of $ * and in support of this claim represents as follows: ** - Amount or me ica bills and general damages N_----M----------------- �-Y--f-Q 1. When did the damage or injury occur? (Give exact date and hour) 10/30/95, approx. 4 : 50 p.m. 2. Where did the damage or injury occur? (Include city and county) Mt. Diablo Boulevard and S. Thompson Road, in the City of Lafayette, County of Contra Costa, California 3. How did the damage or injury occur? (Give full details; use extra paper if required) See Attachment A. 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury.or damage? Mr. Womack was inattentive in his driving, resulting in his vehicle colliding with claimant' s vehicle. (over) 5. 'what are the names of county or district officers, servants or employees causing-, the damage or injury? Eric Wolfgang Womack 6. what damage or injuries do you claim resulted? (Give full extent of injuries or. damages claimed. Attach two estimates for auto damage. ` Claimant, HUGO LA TORRE: neck and back injuries, the extent of which is still being determined. Medical bills to date: $1, 609 . 54 & continuing. Claimant, y-u71n LA TORRE: Loss of Consortium. 7. How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) See attached medical bills for . claimant, HUGO LA TORRE. .. 8. Names and addresses of witnesses, doctors and hospitals. John S. Riddel, D.C. , 3147 Putnam B1vd. , ' Ste. #E, Pleasant Hill, CA 94523 #945-7890 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT Medical bills for claimant, HUGO LA TORRE, to date total $1, 609 . 54 and are continuing. Gov. Code Sec. 910.2 provides: " claim must be signed by the claimant SEND NOTICES TO:-w-(-Attorne, )-�-v... ;, o some person on his behalf." Name and Addres"s':'of':Attorney, ALAN M. TALBOT, ESQ. BROOKMAN & TALBOT Attorney for Claimants 1990 N. California Blvd. , #740 Walnut Creek, CA 94596 1990 N. California Blvd. , Ste. 740 Address Walnut Creek, CA 94596 ^-- *T^�J• 510-932-4008 Tele- e No 510-932-4008 l�ii V!/13VLJ�YYr l.. ' rr+h.�.cn R Ir .s 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. RE: HUGO LA TORRE v. CONTRA COSTA COUNTY ATTACHMENT A TO CLAIM PRESENTED TO THE COUNTY OF CONTRA COSTA 3. Claimant was driving his 1993 Honda Civic vehicle in a generally westerly direction in the#1 lane of Mt. Diablo Boulevard. Officer Eric Wolfgang Womack, an employee of the City of Lafayette, was on duty and driving a certain 1995 Ford patrol car, and was travelling in a generally westerly direction in the #1 lane of Mt. Diablo Boulevard, directly behind claimant's vehicle. When claimant stopped his vehicle for a pedestrian crossing Mt. Diablo Boulevard at its intersection with S. Thompson Road, claimant was rear-ended by Officer Womack's vehicle. The City of Lafayette is responsible because it's employee, Officer Womack, was driving inattentively. n. BROOKMAN & TALBOT APPRovEDOM6-ossa-ooyaq PLEASE, i �� DOtNOT a 1990 NO. CALIFORNIA BLVD, STE. 740 STAPLE IN THIS 1 WALNUT CREEK CA 94596 w AREA ' (510) 932-4008 0 1 U ,PICA -- - -- - - HEALTH INSURANCE CLAIM FORM PICA 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER Ia.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) HEALTH PLAN BLK LUNG (Medicare#) (Medicaid# y' )❑ (Sponsor's SSN) F-] (VA File #) (SSN or ID) � (SSN) I 4%(1D) 155-58-1771 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) LATORRE, HUGO 6"3 c 6`1! Y9 M F LATORRE, HUGO 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 4492 BUCKTHORNE CT. Self A SpouseE] Child other 4492 BUCKTHORNE CT. CITY STATE 8.PATIENT STATUS CITY - STATE Z CONCORD CA �X Ei CONCORD CA Single Married Other � ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) Q 94521 (510) 674-9063 Employed Full-Time -n Part Time 94521 (510) 674-9063 cc Student l Student O 9.OTHER INSURED'S NAME(Last Name.First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z LL CA. DENTAL CERAMICS - 0 W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE OF BIRTH SEX YES NO W`�i ®017i Jyy9 MF I'-1 fn n LJ Z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME Q MM i DD vv M F YES ONO CALIFORNIA DENTAL CERAMICS Z c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME Z CA. DENTAL CERAMICSYES El WORKERS ' COMP. w F- d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? Q a WORKERS ' COMP. A YES [:] NO 1/yes.return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED_SIGNATURE ON FILE _ DATE 01/31/96 SIGNED SIGNATURE ON FILE 14.DATE OF CURRENT: 4 ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION NIM DD i YY INJURY(Accident)OR GIVE FIRST DATE MM i DD YY MM p i YY MM pg i YY PREGNANCY(LMP) FROM N9`� TO N/L1 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM ; DD 1 YY MM DO YY N/A N/A FROM TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES YES [:]NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1.2,3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION 723. 3 CERVICOBRACHIAL SYN CODE ORIGINAL REF.NO. _ 23.PRIOR AUTHORIZATION NUMBER 2. L_._ 4. L-.- 24. A B C D E F G H I J K Z From To OF SERVICE Place Type PROCEDURES.SERVICES,OR SUPPLIES DAYS EP SD O DIAGNOSIS RESERVED FOR of of (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE MM DD YY MM DD YY Servic Service CPT/HCPCS MODIFIER UNITS Plan Q 01 16; 96 3 97260 1 32 ; 60 0 IL 2 01 1696 1 1 97012 I 1 18 ! 45 rc w - i J 3 01 16' 96 13. 1 97010 1 18 ; 45 U) 4 01 18 96 3 97260 1 32 60 0 Z 5 01 18 96 1 1. 97012 I 1 18 45Li I } 01 18' 96 I 1 1.: 97010 6 1 18 ' 45 a 25.FEDERAL TAX I.D.NUMBER SSN EIN i 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE 68-0148119 2341 9 I 2 A ❑ ai (For govt.claims,see back) 139 1.0 0 1 139 ;00 YES NO $ $ $ 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S, BILI A ESS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED(it other than home or office) Rl~HI9EL CHIROPRACTIC CENTER . (I certify that the statements on the reverse apply to this bill and are made a part thereof.)- 3147 PUTNAM BLVD. SUITE E JOHN S . RIDDEL, D.C. PLEASANT HILL, CA 94523 01/31/96 168290 SIGNED DATE - - PIN# GRP# C(1p1qD 3P41fOLogLP3P�11A8�3� FORM HCFA-1500 (12-90)2E 8/88) PLEASE PRINT OR TYPE FORM OWCP-1500 FORM RRB-1500 PLEASE, f BROOKMAN & TALBOT APPROVEDOMB-0938-Oog� ¢ -DO.NOT 1990 NO. CALIFORNIA BLVD, STE. 740 (/may STAPLE WALNUT CREEK CA 94596 w AREA i (510) 932-4008 cc Q X-IPICA - - --- - - HEALTH INSURANCE CLAIM FORM PICA 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER 1a.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) (Medicare#) (Medicaid#) (Sponsor's SSN) (VA File #) (SSN or ID) 8(SSN NG ID ❑ ❑ ❑ ❑ ❑ ) LID) 155-58-1771 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) LATORRE, HUGO h 6°I� S,9 M F ...LATORRE HUGO 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 4492. BUCKTHORNE CT. . Self[?� Spouse[] Child❑ Other❑ 4492 BUCKTHORNE CT. CITY STATE 8.PATIENT STATUS CITY STATE Z CONCORD CACONCORD CA O Single❑ Married J Other ❑ � ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) Q 94521 (510) 674-9063 Employed Full-Time❑ Part-Time❑ 94521 �510� 674-9063cc Student Time 1 O 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER LL CA. DENTAL- CERAMICS Z W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSUREyDy',S},DATE [}O,F BIRTH SEX cc YES ❑NO 1!1�7 61 i 119 M F ❑ N � � Z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME MM j DD YY M F ❑YES �NO CALIFORNIA DENTAL CERAMICS Z c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME Z CA. ..DENTAL CERAMICS ❑YES ❑NO WORKERS ' . COMP. ...;_:. W F- d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? d WORKERS ' COMP. A YES ❑ NO If yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED: SIGNATURE ON :FILE. DATE 01/.15/96 SIGNED SIGNATURE .ON FILE 14.DATE OF CURRENT: ILLNESS(First symptom)OR 15,IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM � DD YY INJURY(Accident)OR GIVE FIRST DATE MM DD YY MM D YY MM py YY PREGNANCY(LMP) FROMMM /�'i TO NPA! 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES N/A N/A MM , DD YY MM DD YY FROM TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES ❑YES ❑NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2.3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION 723. 3 CERVICOBRACHIAL SYN CODE ORIGINAL REF.NO. 3. L .- 23,PRIOR AUTHORIZATION NUMBER 2. .- 4. L .- 24. A B C D E F G H 1 J K Z FromATE(S)OF SERVICE To Place Type PROCEDURES,SERVICES.OR SUPPLIES DAYS EPSD _O of of DIAGNOSIS RESERVED FOR (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE PAM DD YY MM DD YY Servic Service CPT/HCPCS I MODIFIER UNITS Plan Q 1 01 04; 96 .11 1_ : 97128 1 20 91 o Z 2 01 0496 1 11' 97010 1 ;:; 18 ; 4 0r W 01 04; 9 1 11 1.::° 99213 1 1 39; 3 98 a .- - fn 4 01 05 96 I 1 I: : 99080 ' �Yf nd,,: . . 1._ �:: 125; 00.- o - t z 5 01 091 96 3 97260 I 1 . 32 60 cn 01 09 961 1 .97012 18 _ 6 i 1 ; 45 a 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE 68-01,48119 r� 2 3 41 9 I 2A (For govt.claims,See back) 2 5 5I 3 9 ❑ u [:] YES ❑ NO $ $ $. 255 ;,39 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S, BILI A ESS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED(if other than home oroffice) ::R19DEL 'CHIROPRACTIC. CENTER. (I certify that the statements on the reverse _ - apply to this bill and are made a part thereof.) I 3147 ..PUTNAM BLVD. SUITE E JOHN S-RIDDEL, D.C . PLEASANT HILL,. .CA 94523 SIGNED 01/15/96 DATE PIN#168290 GRP# C(ffARfffD Gy P f OLO(1LOyIO J 716E 8/88) PLEASE PRINT OR TYPE FORM HCFA-1500 (12-90) FORM OWCP-1500 FORM RRB-1500 Yi 1J 1\1\: 1\iJ ( �; BROOKMAN & TALBOT APPROVED PLEASE. k /� APLE �'17o•NOT ' ' � 1990 NO. CALIFORNIA BLVD, STE. 740 (J��(/(� NTTH S j WALNUT CREEK CA 94596 w AREA ; (510) 932-4008 a U PICA `- -- --"--------j HEALTH INSURANCE CLAIM FORMPICA iX i� 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER 1a.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) (Medicaid# HEALTH PLAN BLK LUNG (Medicare#) y� {�� ❑ ) ❑ (Sponsor's SSN) ❑ (VA File #) [:] (SSN or/D) ❑ (SSN) L_l l�) 155-58-1771 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) LATORRE, HUGO P 3. Ell Y9 M FF LATORRE, HUGO 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 4492 BUCKTHORNE CT. Self[N Spouse[] Child❑ Other[] 4492 BUCKTHORNE CT. CITY STATE 8.PATIENT STATUS CITY STATE Z CONCORD CA F CONCORD CA 0 Single Married Other � ZIP CODE TELEPHONE(Include Area Cade) ZIP CODE TELEPHONE(INCLUDE AREA CODE) Q 94521 (510) 674-9063 Employed Full-Time Part-Time 94521 (510) 674-9063 Student Student O 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z Z CA. DENTAL CERAMICS o w a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSUREDS DATE OF BIRTH SEX cc ❑YES ❑NO {!13 i VJ /i 3Y9 M F ❑ Z El b.OTHER INSURED'S DATE OF BIRTH SEX b:AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME 0 MM DD vv _ M F ❑YES17NO CALIFORNIA DENTAL CERAMICS Z c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME Z CA. DENTAL CERAMICS ElYES ElNO WORKERS ' .COMP. LU d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? Q a WORKERS ' COMP. A YES [:] NO If yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED, SIGNATURE ON FILE DATE 01/15/96 SIGNED SIGNATURE ON FILE _ 14.DATE OF CURRENT: ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION ,l MDA DID YY � INJURY(Accident)OR GIVE FIRST DATE MM � DD � YY MM p� YY MM Dy YY i PREGNANCY(LMP) FROM N/h TO N/t1 17.NAME OF REFERRING PHYSICIAN OR,OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES N/A N/A MM DD YY MM DD : YY FROM TO i 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES ❑YES ❑NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,23 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION 723 . 3 CERVICOBRACHIAL SYN CODE ORIGINAL REF.NO. 23.PRIOR AUTHORIZATION NUMBER 2. �_._ 4. - 24. A B C D E F G H I J K Z From TE(S)OF SERVICE To Place Type PROCEDURES.SERVICES.OR SUPPLIES DIAGNOSIS DAYS EP RESERVED FOR 0 of of (Explain Unusual Circumstances) CODE $CHARGES OR Family MM DD YY MM DD YY ServiCE Service CPT/HCPCS I MODIFIER UNITS Plan EMG COB LOCAL USE Q 01 10' 96 3 97260 1 1 a 32 60 0 w 2 01 10 96 j 11 1 97012 1 18 45 w 3 01 10 96 1 1 - 97010 1 18 45 4 o Z i i i i i I U 6 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? . 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE 68-0148119 fX'� 2 3 41 9 I 2A I (For govt.claims,see back) 69 , 5 0 ❑ LJ I El YES E] NO $ 1 i $ - i $ 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S,S BILI AM ESS,ZIP CODE INCLUDING DEGREES OR CREDENTIALS RENDERED(If other than home or office) RIFEIDEL CHIROPRACTIC CENTER , (I certify that the statements on the reverse - 9 apply to this bill and are made a part thereof.) - 3 147 PUTNAM BLVD. SUITE E JOHN S. RIDDEL, D.C. PLEASANT HILL, CA 94523 01/15/96 168290 SIGNED DATE PIN# GRP# pPXlrffD 1k 141jO' L:f01 11(r nE 8/88) PLEASE PRINT OR TYPE FORM HCFA-1500 (12-90) C<Lt11 L'1 G `�1 11 Y/ l 1G - FORM OWCP-1500 FORM RRB-1500 PLEASE- BROOKMAN & TALBOT APPROVEDOMB-0938-00 ,, DO NOT ; 1990 NO. CALIFORNIA BLVD, STE. 740 STAPLE NTHS 1 WALNUT CREEK CA 94596 LU AREA (510) 932-4008 EE Q X ,,PICA --- -- ------ HEALTH INSURANCE CLAIM FORM PICA -,FTX-'. ]. t. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER Ia.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) (Medicaid#) (Sponsor's SSN) (VA File # HEALTH PLAN BLK LUNG (Medicare#) y' E] E] � ) � (SSN or/D) � (SSN) I {>{ID) ) 55-58-1771 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S pB,IRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) W0 ID LATORRE, HUGO / S9 M F LATORRE, HUGO 5.PATIENT'S ADDRESS(No.,Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 4492 BUCKTHORNE CT. Self[N SpouseF] ChildE] Othero 4492 BUCKTHORNE CT. CITY STATE 8.PATIENT STATUS CITY STATE Z CONCORD CA �X CONCORD CA Single Married Other � ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) Q 94521 (510) 674-9063 94521 (510) 674-9063 Employed Full-Time Part-Time � Student El Student O 9.OTHER INSURED'S NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z CA. DENTAL CERAMICS z 0 W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S}�DATE pO�F BIRTH SEX Ix YES �NO �J i 01 i S9 M F ❑ Z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME MM DO YY M i FL] YES DNo CALIFORNIA DENTAL CERAMICS Z c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME Z CA. DENTAL CERAMICSYES El WORKERS ' COMP. W I- d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? d WORKERS ' COMP. A YES ❑ NO /f yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED SIGNATURE ON FILE DATE 01/31/96 SIGNED SIGNATURE ON FILE__ t4.DATE OF CURRENT: 4 ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM 00 YY INJURY(Accident)OR GIVE FIRST DATE MM i DD YY MM YY MM N�g YY To L_ PREGNANCY(LMP) FROM N9A L'1 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD YY MM DD YY N/A N/A FROM TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES DYES ONO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION 723. 3 CERVICOBRACHIAL SYN CODE ORIGINAL REF.NO. 23.PRIOR AUTHORIZATION NUMBER 2 L .- 4. I _ - 24. A B C D E F G H I J K Z DATEDIAGNOSIS S)OF SERVICETo Place Type PROCEDURES.SERVICES,OR SUPPLIES DAYS EPSD RESERVED FOR O_ of of From (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE MNI DD YY MM DD YY Servic Service CPT/HCPCS MODIFIER UNITS Plan Q 1 01 30; 96 3 97260 1 32 ; 60 a LL 2 01 30 96 1 1 97012 j 1 18 45 s W J - a 3 i � O 4 Q 5 i � 6 CL 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. 27.ACCEPT ASSIGNMENT? 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE 68-0148119 XC� 2 3 41 9 I 2 A or govt.claims,see back) 51 05 51 ;05 YES NO $ $ $ 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S, BILI ANZEAPY ESS,ZIP CODE NCLUDING DEGREES OR CREDENTIALS RENDERED(If other than home or office)' I�3�H�3EL CHIROPRACTIC CENTER (I certify that the statements on the reverse apply to this bill and are made a part thereof.) 3147 - PUTNAM BLVD. SUITE E - JOHN S-RIDDEL, D.C . PLEASANT HILL, CA 94523 01/31/96 168290 - SIGNED DATE PIN# GRP# CILPAy.1 D 8188) PLEASE PRINT OR TYPE FORM HCFA-1500 (12-90) G J l 1l1 l 3 Yl 1l1 l J�lJ 7 D G FORM OWCP-1500 FORM RRB-1500 '--------"{ '.i Vi\1'x_:1\.: eL.EASJE- I BROOKMAN SC TALBOT APPROVED OMB-0938-000 DO NOT 1990 NO. CALIFORNIA BLVD, STE. 740 INHIS , i WALNUT CREEK CA 94596 w AREA (510) 932-4008cc a U ;PICA --� HEALTH INSURANCE CLAIM FORM PICA 1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER ta.INSURED'S I.D.NUMBER (FOR PROGRAM IN ITEM 1) HEALTH PLAN BLK LUNG V 5 5-5 8-17 71 (Medicare#) E](Medicaid#)❑ (Sponsor's SSN) � (VA File #) [j (SSN or ID) 0 (SSN) I OD) 2.PATIENT'S NAME(Last Name,First Name,Middle Initial) 3.PATIENT'S BIRTH DATE SEX 4.INSURED'S NAME(Last Name,First Name,Middle Initial) LATORRE, HUGO �" ��/ 3Y9 M F LATORRE, HUGO 5.PATIENT'S ADDRESS(No..Street) 6.PATIENT RELATIONSHIP TO INSURED 7.INSURED'S ADDRESS(No.,Street) 4492 BUCKTHORNE CT. Sell Spouse0 Child[] Other❑ 4492 BUCKTHORNE CT. CITY STATE 8.PATIENT STATUS CITY STATE Z CONCORD CA [ � CONCORD CA 2 Single Married .Other ZIP CODE TELEPHONE(Include Area Code) ZIP CODE TELEPHONE(INCLUDE AREA CODE) Q 94521 (510) 674-9063 Employed Full-Time Part Time 94521 (510 ) 674-9063 uu Student Student O 9.OTHER INSUREDS NAME(Last Name,First Name,Middle Initial) 10.IS PATIENT'S CONDITION RELATED TO: 11.INSURED'S POLICY GROUP OR FECA NUMBER Z CA. DENTAL CERAMICS o W a.OTHER INSURED'S POLICY OR GROUP NUMBER a.EMPLOYMENT?(CURRENT OR PREVIOUS) a.INSURED'S DATE O�F BBIRTH SEX cc YES NO V1 J i 6/p .3Y9 M j F E] N i i u �-_1 Z b.OTHER INSURED'S DATE OF BIRTH SEX b.AUTO ACCIDENT? PLACE(State) b.EMPLOYER'S NAME OR SCHOOL NAME MM oo vv M Lj F [YES NO CALIFORNIA DENTAL CERAMICS Z c.EMPLOYER'S NAME OR SCHOOL NAME c.OTHER ACCIDENT? c.INSURANCE PLAN NAME OR PROGRAM NAME Z CA. DENTAL CERAMICS YES �NO WORKERS ' COMP. w d.INSURANCE PLAN NAME OR PROGRAM NAME 10d.RESERVED FOR LOCAL USE d.IS THERE ANOTHER HEALTH BENEFIT PLAN? a Q WORKERS ' COMP. u YES ❑ NO 1/yes,return to and complete item 9 a-d. READ BACK OF FORM BEFORE COMPLETING&SIGNING THIS FORM. 13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize 12.PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary payment of medical benefits to the undersigned physician or supplier for to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment services described below. below. SIGNED_SIGNATURE ON FILE DATE 01/3_1_/96 SIGNED SIGNATURE ON FILE 14.DATE OF CURRENT: I ILLNESS(First symptom)OR 15.IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 16.DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION MM DD YY INJURY;Accident)OR GIVE FIRST DATE MM i DD YY FROM MM NYW YY TO MM NPA YY PREGNANCY(LMP) 17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a.I.D.NUMBER OF REFERRING PHYSICIAN 18.HOSPITALIZATION DATES RELATED TO CURRENT SERVICES N/A N/A MM DO YY MM DD YY FROM TO 19.RESERVED FOR LOCAL USE 20.OUTSIDE LAB? $CHARGES YES ❑NO 21.DIAGNOSIS OR NATURE OF ILLNESS OR INJURY.(RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22.MEDICAID RESUBMISSION 723 . 3 CERVICOBRACHIAL SYN CODE ORIGINAL REF.NO. 23.PRIOR AUTHORIZATION NUMBER 2. L .- 4. 24. A B C D E F G H I J K Z FromDATES)OF SERVICETo Place Type PROCEDURES.SERVICES.OR SUPPLIES DIAGNOSIS DAYS EPSD RESERVED FOR O of of (Explain Unusual Circumstances) CODE $CHARGES OR Family EMG COB LOCAL USE H MM DD YY MM DD YY ServiceService CPT.'HCPCS MODIFIER UNITS Plan Q 01 23' 96 3 97260 I 1 32160 0 LL 01 231 96 1 1 1 97128 1 1 20191 0c 2 w 3 01 2311 96 1 1 1 1 97014 1 18145 CIL En 4 01 25196 3 97260 1 32 ; 60 o Z 01 25" 96 1 1 97012 1 r 18 45 5 � � � N a 6 25.FEDERAL TAX I.D.NUMBER SSN EIN 26.PATIENT'S ACCOUNT NO. j 27.ACCEPT ASSIGNMENT?r 28.TOTAL CHARGE 29.AMOUNT PAID 30.BALANCE DUE 68-0148119 T2341 9 12A (For govt.claims,see back) 12 3 01 12 3 01 YES NO $ $ $ 31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32.NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33.PHYSICIAN'S,SUIPtItfit BILI A ESS,ZIP CODE Z. INCLUDING DEGREES OR CREDENTIALS RENDERED(If other than home or office) RI$DOEL CHIROPRACTIC CENTER (I certify that the statements on the reverse apply to this bill and are made a part thereof.) .. 3147 .'PUTNAM BLVD. -SUITE E JOHN S. : RIDDEL, D.C . PLEASANT HILL, CA 94523 01/31/96 i 168290 SIGNED DATE PIN# I GRP# ly o r o L IP�p E e/as) PLEASE PRINT OR TYPE FORM HCFA-1500 (12-90) CPPB, �, 4 F �4 2"3 '1 G"5�&2 FORM OWCP•1500 FORM RRB-1500 Riddel Chiropractic Center 3147 Putnam Blvd. Suite E Pleasant Hill, CA 94523 (510) 945-7890 January 04, 1996 Brookman & Talbot 1990 No. California Blvd, Ste. 740 Walnut Creek, CA 94596 RE: Hugo LaTorre DIAGNOSIS 1 723 . 3 CERVICOBRACHIAL SYNDROME DATE SERVICE DESCRIPTIONS CHARGE BALANCE --------------------------------------------------------------- 11/15/95 72052 DAVIS SERIES 190- 00 190. 00 11/15/95 99070 Ice Pack 25. 00 215 .00 11/15/95 99070 Cervical Pillow 40.00 255. 00 11/15/95 99205 Comprehensive Initial Exam W 92 . 24 347 . 24 11/16/95 97128 Ultrasound 20.91 368 .15 11/16/95 97012 Motorized Flexion Traction 18 . 45 386.60 11/16/95 97260 Manipulation 32. 60 419 .20 11/17/95 9-7260 Manipulation 32. 60 451 . 80 11/17/95 97012 Motorized Flexion Traction . 18 . 45 470 . 25 11/18/95 97260 Manipulation 32. 89 503 . 14 11/18/95 97128 Ultrasound 20. 91 524 .05 11/18/95 97012 Motorized Flexion Traction 18 .45 542. 50 11/21/95 97260 Manipulation 32 .60 575.10 11/21/95 97010 Hot Pack 18 .45 593 . 55 11/21/95 97012 Motorized Flexion Traction 18 . 45 612.00 11/22/95 97260 Manipulation 32 . 60 644 .60 11/22/95 97012 Motorized Flexion Traction 18 . 45 663 . 05 11/22/95 97128 Ultrasound 20.91 683 . 96 11/27/95 97260 Manipulation 32 .60 716. 56 11/27/95 97010 Hot Pack 18.45 735.01 11/27/95 97012 Motorized Flexion Traction 18 .45 753 .46 12/01/95 97260 Manipulation 32.60 786. 06 12/01/95 97128 Ultrasound 20- 91 806 . 97 12/01/95 97012 Motorized Flexion Traction 18 . 45 825. 42 12/01/95 76140 Radiology Report 35 .00 860 . 42 12/04/95 99213 Intermediate Re-Exam Work Co 39 .98 900 .40 12/04/95 97010 Hot Pack 18 . 45 918 . 85 12/04/95 97014 Elec/Stim Unattended 18 . 45 937 .30 12/05/95 97260 Manipulation 32.60 969- 90 12/05/95 97014 Elec/Stim Unattended 18 . 45 988 .3 r-" 12/05/95 97010 Hot Pack 18 . 45 1006 . 8 32.60 10 39 . 41 iji 12/07/95 97260 Manipulation 60. i ,'All n; I? ' 12/07/95 97128 Ultrasound 20-91 10 K 12/07/95 97012 Motorized Flexion Traction 18 .45 1079.-70 Manipulation 32.60 1111. 3d( ;(.{ ::-;-L 12/12/95 97260 ManLj 12/12/95 97010 Hot Pack 18.45 1129.81 L -------------- 12!=12/95 97128 Ultrasound 20 . 91 1150 .72 C � 12/14/95 97260 Manipulation 32 .60 1183 .32 12/14/95 97128 Ultrasound 20 . 91 1204 . 23 12/14/95 97012 Motorized Flexion Traction 18 . 45 1222 .68 12/16/95 97260 Manipulation 32 . 60 1255.28 12/16/95 97010 Hot Pack 18 . 45 1273.73 12/16/95 97012 Motorized Flexion Traction 18 .45 1292.18 12/19/95 97260 Manipulation 32. 60 1324.78 12/19/95 97010 Hot Pack 18 . 45 1343.23 12/19/95 97012 Motorized Flexion Traction 18 . 45 1361.68 12/23/95 97260 Manipulation 32 . 60 1394 .28 12/23/95 97012 Motorized Flexion Traction 18 . 45 1412 .73 12/23/95 97010 Hot Pack 18 . 45 1431 .18 12/28/95 97260 Manipulation 32 .60 1463 .78 12%28/95 97012 Motorized Flexion Traction 18 . 45 1482.23 12/28/95 97010 Hot Pack 18 . 45 1500 . 68 12/30/95 97260 Manipulation 32.60 1533 . 28 12/30/95 97010 Hot Pack 18 . 45 1551 .73 12/30/95 97012 Motorized Flexion Traction 18 . 45 1570 .18 01/04/96 97128 Ultrasound 20. 91 1591 .09 01%04/96 97010 Hot Pack 18 . 45 1609 . 54 $1609 . 54 $1609. 54 JAN 9 ;nq . Cq 1 PROOF OF SERVICE BY MAIL -- CCP, §2015.5 & &1013(a) 2 I, the undersigned, declare under penalty of perjury of the laws of the State of California: 3 4 That I am a citizen of the United States and over the age of eighteen years; that I am not a parry to the within action or proceeding; that my business address is 1990 N. California 5 Boulevard, Suite 740, Walnut Creek, California 94596; that on the date set forth below I served a true copy of: 6 CLAIM TO THE COUNTY OF CONTRA COSTA 7 8 9 by depositing said copy in the United States Mail, at Walnut Creek, California, in a sealed envelope, postage thereon prepaid, addressed as follows: 10 VIA CERTIFIED MAIL - RETURN.RECEIPT REQUESTED 11 Clerk of the Board of Supervisors 12 Room 106, County Administration Building 651 Pine Street 13 Martinez, CA 94553 14 15 16 17 18 19 At said time, there was regular delivery of the United States Mail between said places of deposit and address(es). 20 Executed at Walnut Creek, Contra Costa County, California, on February 12, 1996. 21 22 AZI 23 SHARON HANNEY 24 25 26 27 28 ljrq � o � Q N o � r J � N co ro � r, u.► N JS M. w v• c� ✓ � Q �N ' W �7CA�„y.17• o� G`accP.n"�pN Q CLAIM C. BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA MARCH 12, 1996, 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: UNMOWN Section 913 and 915.4. Please note all "Warnings". CLAIMANT: AVERIE COHEN M ATTORNEY: JEFFREY A BERCHENKO FEB 16 1996 115 SANSOME ST FOURTH FLOOR Date received CpQUN COUNSEL ADDRESS: SAN.:FRANCISCO CA 94104 BY DELIVERY TO CLERK ON FEBRUARY IQAR MCALIF. BY MAIL POSTMARKED: FEBRUARY 14, 1996 1. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted 'claim. �qIL gATCHELOR, Clerk - �p DATED: FEBRUARY 16, 1996 : Deputyl 41, II. FROM: County Counsel TO: Clerk of the Board of Supervisors ( his 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: - 2-0 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 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. DatedHIL 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. *For additional warning see reverse side of this notice. 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 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 the claimant as shown above. Dated: 3 (® BY: PHIL BATCHELOR by Agp�puty Clerk CC: County Counsel County Administrator RECEIVED C. BOGATIN, BERCHENKO & CORMAN FEB 15 IN ATTORNEYS AT LAW CLERK M.J.BOGATIN 115 SANSOME STREET,FOURTH FLOOR JEFFREY A.BERCHENKO' SAN FRANCISCO,CALIFORNIA 94104 FACSIMILE (415)362-4119 WILLIAM CORMAN ANDREW M.GOLD CERTIFIED TAXATION SPECIALIST THE STATE BAR OF CALIFORNIA BOARD OF LEGAL SPECIALIZATION February 14, 1996 Andrea Cassidy Office of County Counsel 651 Pine Street Martinez, CA 94553 Clerk of the Board Contra Costa County 651 Pine Street, 1 st Floor Martinez, CA 94553 Arthur C. Miner Contra Costa County Private Industry Council 2425 Bisso Lane, Suite 100 Concord, CA 94520-4891 Marianne Combs , .4.�� , ,. _ .... � , . . . . '.. .,,. • - Statewi&Printing 8i Graphics ;a 663 "l Street -_ Los Banos,;CA 93635 - Barbara Martin Eller Media Company. 1601 Maritime Street Oakland, CA 94607 Re: Averie Cohen v. Statewide Printing& Graphics, Contra Costa County Private Industry Council and Eller Media Company Dear Ms. Cassidy, Mr. Miner, Ms. Combs, and Ms. Martin: The undersigned is counsel for Averie Cohen, a professional photographer who owns the copyright in and to the photograph which was prominently used by the Contra Costa County Private Industry Council on numerous billboards located at BART stations since approximately November 1995. The photograph at issue depicts two men, one of whom is leaning over.to fix an office machine while the other observes. This letter is to inform you that the underlying copyright to my client's photograph was infringed as a result of the unauthorized commercial publication of this photograph as part of the Contra Costa County Private Industry Council's billboards. However, in the hope that the above infringing acts were not made with the knowledge and approval of-Statewide Printing & Graphics, the Contra Costa County Private Industry Council or Eller Media Company, this letter is to notify each of you of the problem, and to seek a settlement of my client's claims prior to the filing of a Federal copyright infringement action. Ms. Andrea Cassidy Mr. Arthur Miner Ms. Marianne Combs Ms. Barbara Martin February 14, 1996 Page 2 In late Summer or early Fall of 1995,my client provided a negative for the above- described photograph to Marianne Combs of Statewide Printing& Graphics. Statewide Printing & Graphics was authorized to use this photograph in the Contra Costa County Private Industry Council's Pictrends newsletter only. The limitation of"Photography for Pictrends"was stated on her invoices. Additionally, please refer to Civil Code §988(c) resolving ambiguities in the extent of a license agreement in favor of the author or artist. Notwithstanding the limited nature of this license,my client's copyrighted photograph was later posted on billboards in at least five BART stations, including El Cerrito, Walnut Creek, Pleasant Hill, Concord and North Concord/Martinez during at least November 1995. It is the unauthorized use of Ms. Cohen's photograph in the above-cited billboards which constitutes a direct and willful infringement of my client's rights in and to her copyrighted photograph. Contrary to Ms. Combs' assertion in her December 23, 1995 correspondence to Arthur Miner of the Contra Costa County Private Industry Council, Ms. Rita Hays never contacted my client concerning the use of her negatives for making photo enlargements for use on billboards. In addition, my client never entered into any written or oral agreement with Ms. Combs,the Statewide Printing & Graphics or the Contra Costa County Private Industry Council concerning the use of her photograph in billboards, or anywhere other than the Pictrends newsletter. As you may be aware,the Federal Copyright Act(17 U.S.C. §201(b)) states that the copyright belongs to the author or artist, absent any express written instrument, signed by both parties, transferring title to the work. No such copyright transfer or license has been effectuated by my client for the above unauthorized uses, and my client therefore retains all rights not expressly granted in and to the copyright in the photograph published and displayed as part of the above-described BART billboard advertisements. I do understand Mr. Miner's claim that his agreement with Statewide gives him such rights. However,that agreement is only effective between Statewide and the P.I.C. My client is not a party to that agreement,nor did she ever discuss any arrangement other than specific licensed uses of her photography. Accordingly, the extensive commercial use of my client's photograph as part of these billboard advertisements constitutes an unauthorized"reproduction," "publication" and "display" of my client's work as defined at§106 of the Federal Copyright Act(17 U.S.C. §106(5)). It was therefore incumbent upon Statewide Printing& Graphics, the Contra Costa County Private Industry Council and Eller Media Company to obtain a license from my client before prominently reproducing,publishing and displaying this photograph as part of these billboard advertisements throughout the East Bay BART transit district. In addition, these billboard advertisements constitute a"derivative work" as defined at §101 of the Copyright Act. Here, Statewide Printing& Graphics, the Contra Costa County Private Industry Council and Eller Media Company have taken my client's copyrighted photograph and incorporated it as part of a"collage" of text and other illustrations displayed as part of this billboard advertisement. Inasmuch as §106(2) of the Copyright Act grants a C Ms. Andrea Cassidy Mr. Arthur Miner Ms. Marianne Combs Ms. Barbara Martin February 14, 1996 Page 3 copyright owner the exclusive right to authorize and prepare derivative works based upon the copyrighted work, Statewide Printing & Graphics,the Contra Costa County Private Industry Council and Eller Media Company have infringed upon this right by failing to obtain my client's permission with respect to such derivative use. Any entity that has profited from this infringement is liable to my client,the claims of Marianne Combs' December 23, 1995 letter notwithstanding. In the event of litigation on this copyright issue, my client would be able to choose between statutory damages of up to $100,000 per infringing act, or alternatively, damages to herself(lost income from the licensing of this image to Statewide Printing & Graphics, the Contra Costa County Private Industry Council and Eller Media Company), or the remedy of profits of the infringer. However,prior to filing an action for copyright infringement, in which my client will seek statutory damages of up to $100,000 per infringement, as well as attorneys' fees,we seek to offer Statewide Printing & Graphics,the Contra Costa County Private Industry Council and Eller Media Company an opportunity to settle this dispute and avoid litigation. As a settlement offer protected by California Evidence Code §§1152 and 1154, my client tentatively offers to settle her claim without filing suit if all companies immediately disclose all additional displays made of Ms. Cohen's copyrighted photograph, and pay Ms. Cohen an agreed upon sum, dependent upon such additional use by Statewide Printing& Graphics,the Contra Costa County Private Industry Council and/or Eller Media Company. Should additional undisclosed use of my client's copyrighted photograph be discovered, my client reserves the right to withdraw this proposed settlement offer. This letter is also to demand that Statewide Printing & Graphics,the Contra Costa County Private Industry Council and Eller Media Company immediately cease and desist from any current commercial publication, reproduction and display client's photograph, including but not limited to the immediate removal of said billboards. My office must receive your notice of cessation no later than February 21 sc Also,please note that the additional requirements of Government Code §911.2, requiring timely notice to Contra Costa County, are met by this letter. My office spoke with Andrea Cassidy, who in her capacity as a staff attorney for the County Counsel, advised the undersigned that the Private Industry Council was a unit of Contra Costa County government. She further stated that the County had no special claim form. This claim is filed under the "relating to any other cause of action,"portion of§911.2. Despite Ms. Cassidy's assurances, I do note that the P.I.C.'s letterhead lists a Board of Directors. An explanation of how an entity can have its own governing board, and still be a unit of government is sought. Absent a timely, explanation,the undersigned will assume the P.I.C. is a private non-profit corporation that is merely funded by Contra Costa County. Thus Government Code requirements would be irrelevant. Please also be aware that my client has non-payment claims against Statewide. Any potential settlement will have to include this sum. Ms. Andrea Cassidy Mr. Arthur Miner Ms. Marianne Combs Ms. Barbara Martin February 14, 1996 Page 4 Thank you in advance for your prompt reply to this letter. To avoid litigation, a good faith reply must be received no later than February 21, 1996. Should you have any questions in the interim,please do not hesitate to contact the undersigned. Very truly yours, A .X304" *omeya A. BERCHENKO t Law Enclosures cc: Averie Cohen JAB:nah F :.v a ..~ONE��` } 3 ski.-. • •. ,.. - v •WALNUT CREEK � t ' 7 �` ~x �RY COUNCIL 1 � RIVATENDU , 1 PIC �R k G ASKILLED- TO YOU ORC % E T NO COSTm PROVIDIN SKILLED WORD p,�'tti.� ..'its-:u..•a�3'•� ..._.. } .k r i . i .. V T N O 't, i �I+ ky k N G 0 E 4 y� 4 t W U at �o CLAIM . BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA MARCH 12, 1996 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: MICHAEL RAY HANNEMAN pamli'V7.3) ATTORNEY: FEB 16 1996 Date received �g�I .ry OOUNGL ADDRESS: 514 E. EVERGREEN AVE BY DELIVERY TO CLERK ON FEBRUARY 15, W91NEZCAUP, SANTA MARIA CA 93454 BY MAIL POSTMARKED: FEBRUARY 13, 1996 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. DATED: FEBRUARY 16, 1996 PpHHIL BATCHELOR, Clerk BY: Deputy II. FROM: County Counsel TO: Clerk of the Board of Supervisors (v1( Or 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: p2 —1\1 _1-1 \J0 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 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. Dated: W, 1A . �99�PHIL BATCHELOR, Clerk, B T . 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. *For additional warnina see reverse side of this notice. 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 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 the claimant as shown above. Dated:JnQAJA&, �� �9/ 42 BY: PHIL BATCHELOR by , Deputy Clerk CC: County Counsel County Administrator Claim *to: BOARD OF SUPERVISORS OF CONTRA COSTA OOUNTY INSTRUCTIONS TO CLAIMANT A. Claims relating to causes of action for death/ or for injury to person or to per- sonal property orgrowingcrops 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 11 1988, must be presented not later than six months after the aecrual .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 1069 County Administration Building, 651 Pine Street, Hartinez, 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. L. 11 1.iaG Z + ir .t1011tbn.LuV aMw•.a oxe..—t.�— te c1 n ims mnbe filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this Tom—. * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * RE: Claim By _ ) Reserved for Clerk's filing stamp RECEIVE Inst the County of Contra Costa ) FEB 1 519% or ) x 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: 1. When did the damage or injury occur? (Give exact date and hour) 7/-677,4,n- 111-919& 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details; use extra paper if required) f'C�.yir���a/7d 'i?.. i1iT" T.F- .V ��� �'��" f7'©�� 1�f/��" G✓�� /t/m�/'v0!1C .81�� �lr�,�i l.,Cai.D�?�L-�'� 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? - /�/T�'!�� �/' /`�"�/r�Y`-.../ � ✓ /Ct�.. Lam./�f'I 1 IY //� � �� 7-0 (over) 5. What are the names of county or district officers, servants or employees causing CA the damage or injury? 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. 25//99A i✓ '�J��.�'` :F;4An&--A/ Ot/?-., 7. - How was the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) ;P-6vVq,q.� � IVf t 77 8. Names and addresses of witnesses, doctors and hospitals. 9. List the expenditures you made on account of this accident or injury: DATE ITEM AMOUNT ///TCS / -//)??Gr �s'GCyN,�s l�i� ,ala- • o d G/ y��� -t' � .tea • �'/f Gov. Code See. 910.2 provides: "The claim must be signed by the claimant SEND NOTICES TO=`_ ;(Attorrie ry) or by some person on his behalf." Name and Address of Attorney (ClaimaoM Signature fr (Address) Telephone No. Telephone No.• rS'os 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 ($19000), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($1090009 or .by both such imprisonment and .fine. ® 6 t l 3 n r i ��..- R • is `� c�• r' ' kr a ; nt p• l 4. t SM iF f ,. ?t _ ' t a most Pks k t 0 r:. .�'.c,yk.�,"r!R' `�+�_1 ,p' a ��y� � ,"VSs• ". Z` �. v 2pp11 i 1 t � v X nrt€5 y n � 'S .tib �• �'� �'"-F;�'> T r x bQ Z Y a d us a 4- Q. U d o 0 5i-o d �o � N @� � � U H C m t6 �I N d � a w N i2 tH Q, d i4 c�0 dcLQ, � Z NEa � 2WJ► dt0 -5 cN �� t� WV q •cotes cr. U • `t W`y U) w a o d cru^y a Cd Q v O N o a U-0cb�( Z O d G N w U uJLn ai t31 � � td w•t7 � N �.d CD .. � r s N c 4 m r O a..coN v Z N o- r � 0 4 ' VVL)hr% ull"lUrairl C•7 REF z NO. 2 7 2326' P. Auto Supply ease keep this receipt for your information and protection.Claims for refund,exchange, -Tirei Swer"vi 0 or adjustment will be considered only upon its presentation. STORE VALIDATION CASHIER INITIALS CUSTOMER NAME HOME PHONE NO. STORE M07— AR NO DATE TIME ADDRESS CONTACT PHONE NO. TIRE BATTERY MFG. SIZE aty bELIVERED/ADJUSTED,TI I RES I E.F NO 0 I — _jjAL N 'S CITY Zil� DE STATE MAX.TIRE WARRANTY WARRANTY VSPECIFIED IN MILE! SPECIFIED IN MONTHS YEAR, MAKE MODEL PO NO. MI MO it C. 1XV,:j-P� i"- TIRE REGISTRATION D CUSTOMER MILEAG� LICENSE NO. STATE EPA NO. POST CARD TO BE E GRAND/AL'S IL4 L/I / MAILED BY: _J---I__1__J--- ADJUSTED BY AUTHORIZED BY PROMISED DATE&TIME WRITTEN By SAVE PARTS? ALL PARTS NEW r� (,/ UNLESS OTHERWISE (---. YES NO SPECIFIED REASON FOR TIRE ADJUSTMENT-SELECT ONE METHOD OF 0124 0215 0432 0153 0226 I—]CASH CHECK [:]CREDIT CARD GRAND/AL'S CARD 0199 0497 0453 0486 0997 1 PAYMENT 0113 0420 0418 0475 1000 MATED:: :ADDITIONAL WORK REQUESTED l3Y:CUSTOMER :: DESCRIPTION: AMOUNT. :...:ESTIMATE.. MINIM _7 I CHARGUM 1,VIA To- (Z 0-) 7- C AUTHORIZATION OF ADD'L ADDITIONAL ESTIMATE AND TOTAL ESTIMATE BY DATE PRE-INSPECTION ESTIMATE TOTAL TOTAL. TO I TIME TOTAL ESTIMATE TECH ,., .SKU.NO I :.R�i:!:LABOFV�;:: UNIT PRICE:TOTAL PRIG ..No/, � MFG.PART'NO :JOEI:OR:PART:DESCRIPTION:.-- .......... ............. . . .. ......... r 7 Coir .. ..... ...... .......... ........... ............. ........... . ......... X., ....... .... Notice to Consumer: Please read DIAGNOSTIC MEASUREMENTS SUBTOTAL 'Z BRAKE DRUMS/ROTORS BALL JOINTS BEFORE REPLACING MERCHANDISE important information on back AFTER TURNING LEFT RICH.I LEFT RIGHT !t hereby authorize you or your employees(a perform the repair or installation work -1 FRONT FIGHT FRONT Cr itemized hereon,including the costs of labor and materials.I hereby grant you and/or LET AL ACTUAL ACTUAL ACTUAL your empleovees permission to operate the vehicle herein described at my risk on LU LLI CREDIT streets,highways or elsewhere for the purpose of testing and/or inspection.Air express a- --- —_--- mechanic's lie is acknowledged on this vehicle to secure the amount of costs indicated LEFT REAR RIGHT FEAR a- SAFE SAFE 0 SAT`F SAFE :D _J hereon.In the event I fail to pick-up and pay lot my vehicle as agreed upon.1 NET TOTAL understand a daily storage fee of$20.00 per day may be charged to r-commencing 11 MERCHANDISE 48 hours alter I have been notified repairs have been completed.I will not field Your I have(received)(seen)the replaced parts. — business 1-1—o,damage to the vehicle described herein.or its contents X RAND RA FG SIZE 'T MAX.M1,1X BATTERY RAN111 SPECIFIED IN MONTHS NT.�' MAKE" M' M, .0 LlpiiISE NO S NO. 11 S, LEFT ACTUAL C:L A, �AIE in the case of lite,theft,accident,natural disaster,or any other cause TORQUE SPECS._J_control �� STATE SALES beyond you I understand the initial estimate of repair is subject to change due to discovery The benefits of the Tire Road Hazard Warranty were TAX % o additional worn of damaged parts after the approved repair has started.Should uddilional needed repairs be discovered,1,the customer,will be so advised and will explained to me and I have decided to accept. have the right to authorize or decline the additional needed repairs before the additional 1-1 YES F NO INITIAL :TO T.AUlLAB09.�._-:: repair,are started.I understand This estimate expires 15 days after the date hereon The warranty information is described on th—eve,se side of this document. -------- MROAD� EST D AND WORKMANSHIP CERTIFIED- TOTAL SALE X X -'cusTomrp—AiiTiioRi7ATinN.qir.'NATIIRF CAT.N 9423 IR8-94) PART NO PCP-F9423 SKU NO 120189 1 1 , � .►rte . .3 1 ° n gt t G s� s• r ��� 11 '. YR Awl- 3Y � r� _...,..... AUTO 1617 k BROADWAY SANTA MARIA CA 922-7861 2/04/96 15:0409 ��;:;.,r;<:?:>:i::;x;sr•{-r-ki:�;;�V�:�.is is�-a;::t�k is�:rr 4:?`#:r: Cashier: 0000002377 Refster$02 PA 1 ;r.,-----_ (I- - -ac .i yf ,��i O ._. ... 4r PA 1 079812 210 2 10 STEM 41SR50 RUPE (TR 16) L 9400 5 i. i19(Basic Fixed Labor) � !i PALANCU 17 GENERAL LABOR � SUBTOTAL 62,74 _ .kx, .�lgy;'% .1 "CHECK PAYMENT" -66,21 CHANGE DUE 0 A Tmnsaction 40011410 THANK youi COME AGAINI Receipt RequiTed For Returns I �.q N L � 1 � 1 t�i • VVV VVV E Win y �� f a i s CLAIM BOARC OF SUPEGyISORS OF CONTFA COSTA COUNTY, CALIFORNIA -IMARCH_12,._ 1996' 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 1V below), given pursuant to Government Code Amount: $1,000,000.00 Section 913 and 915.4. Pleas e4, (ti'M CLAIMANT: SOCORRO MORALES AND JOSE A MORALES FEBF14 1996 ATi ORNE Y: JUSTIN A ROBERTS COUNTY COUNSEL Date received MARTINEZCAUF, ADDRESS: PO BOX 876 BY DELIVERY TO CLERK ON FEBRUARY 12 1996 LAFAYETTE CA 94549-4722 BY MAIL POSTMARKED: F ,RRTTARY 1(1 1 AA6 I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. QQ g DATED: FEBRUARY 14, 1996 9diL Deputy�' Clerk Il. FROM: County Counsel TO: Clerk of the Board of Supervisors (L,4-'This claim complies substantially with Sections 910 and 9.10.2. ( j 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: l� 7 BY: Deputy County Coun! III. 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. Oated:J�AA..,_L 1A_ 199 HIL BATCHELOR, Clerk, Sy . Deputy Clerk MARNING (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 wail to fits a Court action on this claim. See GOVC" ent 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. * For Additional Warning See Reverse Side Of This Notice 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 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 the Claimant as shown above. Dated: ` 4,1.4 9 2(a BY: PHIL BATCHELOR by Duty Clerk. CC: County Counsel County Administrator RECEIVED LAW OFFICES OF 11Z W JUSTIN A. ROBERTS {FEB[ 1078 CAROL LANE, SUITE 203 POST OFFICE BOX 876 CLERK ORS LAFAYETTE, CALIFORNIA 94549-4722 CONTRA COSTA CO. TELEPHONE (510) 283-4880 February 10, 1996 CERTIFIED MAIL NO. 037 001300 RETURN RECEIPT REQUESTED Clerk of the Board of Supervisors Contra Costa County 651 Pine Street Rm 106 Martinez CA 94553 Re: Socorro Morales and Jose A. Morales Dear Sir/Madam: Socorro Morales and Jose A. Morales hereby make claim against the County of Contra Costa, Pittsburg Health Center, Contra Costa County Health Services, for the sum of One Million Dollars ($1,000,000.00) and make the following statements in support of their claim: a. Claimants' address is 253 W. 12``' St, Pittsburg, CA 94565. b. Notices concerning the claim should be sent to the Law Office of Justin A. Roberts, c/o Justin A. Roberts, Esq., 1078 Carol Lane, Suite 203, Lafayette, California 94549; telephone: (510) 283-4880. c. The date and place of the occurrence giving rise to this claim.are that on or about August 11, 1995, and continuing thereafter, Claimant Socorro Morales received medical care and treatment at the Pittsburg Health Center. At said time and place, and at all times prior thereto, agents and/or employees of Pittsburg Health Center failed to properly examine, diagnose, test, treat, or otherwise tend to the condition of Claimant. As a proximate result of said failure of examination, diagnosis, testing and treatment, Claimant Socorro Morales sustained chronic and/or permanent impairment and pain. Jose A. Morales makes a claim for loss of consortium. February 10, 1996 Page 2 d. A general description of the injury or damage includes the chronic and/or permanent pain, swelling, disfigurement and impairment to the left hand,wrist, arm and shoulder sustained by Socorro Morales. e. The true and complete name or names of the public employee or employees causing the injury, damage or loss are not known at present. f. The amount of this claim is One Million Dollars ($1,000,000.00). The basis of the above amount includes medical expenses to date, future medial expenses, loss of wages, future loss of wages, and all special and general damages as allowed by law. ustin A. Roberts On Behalf of Claimants Socorro Morales and Jose A. Morales JAR:clr N Q W� o NN 0 CQ �O O ^ry y Y 6 N N Q o N x AIX 0 a 4 v '+� V C H 4 k CLAIM BOARD of SU;EpVISORS OF CONTRA COSTA COUNTY, CALIFORNIA MARCH 12, 199'6 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: $70,000.00 OR $20,000.00 Section 913 and 915.4. Please CI'AaWiM3 NOT LEDGIBLE jj����'"�' CLAIMANT: JAMES V M6CALLSON F E B 16 1986 ATTORNEY: COUNTY COUNSEL Date received MARTINEZ CALIF. ADDRESS: 164 MANOR DRIVE BY DELIVERY TO CLERK ON FEBRUARY 15, 1996 BAY POINT CA 94565 BY MAIL POSTMARKED: HAND DELIVERED I. FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. IV1XI CHELOR, Clerk DATED: FEBRUARY 16, 1996 : Deputy II. 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: CP —��- _a BY: ���' Deputy County Couns 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. BOAR/D ORDER: By unanimous vote of the Supervisors present (d ) 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. Oated:'M,aA_,* i. Aq . l996, PHIL IATCMELOR, Clerk, ByNAIIOlg , Deputy Clerk WARNING (Gov. code section 923) MJect to certain exceptions, you have only six (6) months from the date this notice was personally served or deposited in the sail to file a court action on this claim. See Goverment Code Section 945.6. you may seek the advice of an attorney of your choice in Connection with this tauter. If you want to Consult an attorney, you should do so immediately. * For Additional Warning See Reverse Side Of This' Notice 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 18; and that today I deposited in the United States Postal Service in Martinez, plifornia, postage fully Prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated:/Yn�� ,r_ f3 . /`T9b BY: PHIL BATCHELOR b Deputy Clerk CC: County Counsel County Administrator . _k-aim '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 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, 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 Sec. 72 at the end of this �� e • eea * ea • eesaeeseeaesa * • aeeee * eeeeeeeaeeae * RE: Claim By ) Reserved for Clerk's filing stamp -:5-Av,A s t1AACCA ( sQ,v ) RECEIVE® Against the County of Contra Costa ) 15W6 or ) o2;io.�.( SOFTS istrict) Fill in ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named District in the sum of $ ,W,00 o .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) � / v� h'78 3. How did the damage or injury occur? (Give full details; use extra paper i required) Dv� /�Ae -&/2� - � t �4 Gr C moi° o, s w� 12j 'Id 4. What particular act or omission on the part of county or district officers, servants or employees caused the injury or damage? 7-1q i Jvkle fo t0lft'fVI.4 illi 6f-a244t`, o,v 5 7�v�i� C�9 -Se-, (over) 5 •What are the names of county or district officers, servants or employees causing the damage or injury? v• 9 • n 6. What damage or injuries do you claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage. LleoL 7. How :as the amount claimed above computed? (Include the estimated amount of any prospective injury or damage.) t1 8. Names and addres es of witnesses, doctors and hosp#tals. ^�( 13�Oek'^^'4pi J%C')efz ©N 'Duty /0I5- w,C,'D FF i31c1- '1 3 0Z c � LA - A�LR')s9' Vk-�Z 9. List the expenditures you made on account of this accident or injury: DATE ITEAMOUNT M Fyoo 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 41 Claimant's Signature !A.vQ rz 0"p, Address Telephone No. Telephone No. S/o- yS�� �/`7 S s * * • • e * ir a *' a • e # ee fey NOTICE Section T2 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 waiting, 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.