HomeMy WebLinkAboutMINUTES - 06181996 - C12 CLAIM
4 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
June 18, 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: $10,745.00 Section 913 and 915.4. Please note all Owe
CLAIMANT: Brad D. and Lisa Wood, parents MAY 3 a 1996
ATTORNEY:
Date received COUNTY COUNSEL
ADDRESS: 41 Virgil CtBY DELIVERY TO CLERK ON May 29, 1996 MARTINEZ CALIF.
.
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.
ppHHIL ATCHELOR, Clerk
DATED: mg47 1 qqh BY: Deputy
II. FROM: County Counsel TO: Clerk of the Board of Supervisors
0/) This claim complies substantially with Sections 910 and 910.2.
( ) This claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying
claimant. The Board cannot act for 15 days (Section 910.8).
( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send
warning of claimant's right to apply for leave to present a late claim (Section 911.3).
( ) Other:
Dated: vo, �� �g BY: �. Deputy County Counsel
_ 06
III. FROM: Clerk of the Board TO: County Counsel (1) County Adm istrator (2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
1V. BOARD 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.
Dated: o PHIL BATCHELOR., Clerk, By 1.4 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: 1994 BY: PHIL BATCHELOR by 0,41 eputy Clerk
CC: County Counsel County Administrator
Clain to: ROAM) OF S`JPERVISORS 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 na. e 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
For=.
RE: Claim By 14P a. wood 1 0 binwi., Reserved for Clerk's filing stamp
A)000 �ECENED
[ 2 9 1996
Against the County of Cbntra Cosh )
or ) "
CLERK BOARD OF SUPERVISO' :. .
District) CONTRA COSTA CO. CAS
Fill in name )
The undersigned claimant hereby makes claim against the County of Contra Costa or
the above-named District in the sum of $ LC),- 7 4�5.DD and in support of
this claim represents as follows:
1. When did the damage or injury occur? (Give exact date and hour)
uled�esd j 9 aZ �lv
2. Where did the damage or inj occur? (Include city and county)
Ll>i 11 / ss lUe%da� -8a y A, , eA , ceO16
3. How did the damage or injury occur? (Give de ails; use extra per if //
required) &v,50o urian lVead G!/os /7d/r���,
� ,bid dolly) Gu///zv �oss7�o�, //�
i K.ene and cele axe my haue & i/�,5vd ah /e o%o/ o
� a mounds � ate, 1wol-I vhe& Cva i� �Z _lame.
Dur? h�6 bide rnlleddix,/ 1010 ccJ h«b& and eom 46 a Cru �0o
OLh
u. What particular act or omission on the part of county or district officers,
se.^vants or employees caused the (injury or damage? D
/ d
/7� a/I �i/d7.� �s�s
j. wnat are the na---es of, county or district officers, Servants or employees causing
the or injury?
�L�/17✓^Q L-D S TZ� C..��GL/'l 7 -WO Q CY SGL/12 7/ZZO
y
5. What damage or injuries do you claim resulted? (Give full extent of injuries or
damages claimed.
�crQ�s a� At _two e. s. h /t�eQs rfor, auto fi�i 2e/bD �vvl-<?c
�On �� �e �ti�ek , �� ch2s �n hise`��,s
hi3 bae. on his lo� h�s
�1
0 *
7. How ums the amount claimed above computed? (Include the estimated amount of any
prospective injury or damage )
C�t-e. a �zC�le GC �D� l�J�
ire d�� aha �ctiC '5
are- 119 ���ns�v�
7"0/17 alga/ Znaf) L40
3. ?lames and addresses of witnesses, doctors and -hospitals.
&n 1/a-111 GLr. .7 -/ Cidre )9o(�y/ 5cc -
4/Od G/1J11�Z ZA7s 9 Bl 13 S�J�Cron
4V=V-: �I Gt /-sa �ECril��
9. List the expenditures you made on account of this accident or injury:
DATE. ITEM: AMOUNT
5 7 9( doG7b� Ulsi T-
Gov. Code Sec. 910:2 provides:
"The claim must be signed by the claimant
SEND NOTICES TO: (Attorney) orb some person on his behalf."
Name and Address of Attorney
1iUo�
Claimant's Signature)
(Address.
&a D//?
Telephone No. Telephone No�`J!,U `� ;� 83
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 ($10,000, or by
both sz-:ch i rico use^t and ri e /
3 70. &0 /I(.�S
15 J$' CM'80 and in su �rrn� Ck-t 't-I0,0MOD, wa,5/�+ a-ble- 1v jo 4) 5 1
0' Md Ue- 0 r-O(knd abDu-J- I D dQ 5. PMl ed GloAs ccs`' � 2,5.6-0
�( 7
•" i�g
l •1 1
•
ALLERGIES
• _
K • 0 YES
•
}�;• yl.. !, .i.1: ,, ' -'r=, t r. f�•1 �I s�1. -. I, c 1::_
A.
r` •!r r''�I .r� It �••• tr"�`!,y 7 ''ri'j1 N, �1:T'�I j'%
!'fir r '�+� '► `/�1- .Zy
�..-�i�.C•.I•.�-• L�•..-ai ♦:•.-,._J..f.._- 1_C'r�-_�'-(�r._ �•�:fJ.-11.�':i�.. r!�-'yc�a.!'��
-t1t;`lam\�,�, al�`1�_rl•`'`�•,�.:- �1r,/.':._,��-'`;'�;..a�ij•�-��:-�``T''��;t�l_`h�•�:,:�tL•��••1 t�
�
- :... —.. _J'• ... .alt - �.�-�,:. �T: r.. �''.`•:,`_cam. _._.•,{:,a �....! .i�;.. �..�•}t...
r�. r' rr'•�'r.'�r<_�>r`C rJ�-.1.'�r�J� � ( =, 'io
=f;r.:�1r .i' '•_'il• ��'r� J"^;�.f{:.:,I•:;J�-�. ._%�. t�r•••' •, .'•� ,v.�(h:�''.}•.a� '�:'...t
��� � � ;) �fl-.a,.'1.L r:t1.,1::��-•�J_'1. �.�~,i�' f 1_.:G.i. J t"��� a� �
iI �.�• c
,�.' `v._�,^;�� `, .�1,.�f 'a ,tel .`,`/1 ','•�,_`�t_�I�.1.`Z��':�;� :r \'l-.'.'�1 re•t��;�1'^��4'.
'� .� .�� '::y_' = ,�I:.�i ,�,t �',}+:. 'I r.-I•`.r'' �'+��-._.i t. .�14-.•.� .:JIB-,
�. �. `,. ,�. ,: rl�. ,._)�• _ �:'). ). ?-:)ter " .>f.: ;('. "S
- (,� riz .•i.-tri -, i,,1^:� ._ C-' 1 %.— �I:• 1 rl::`►il:• II
n �I .�f-=;�1_.•�•f' il'�, .•�•;r,..IJ.J� ;r'.,�� ORDERS
'J�'•�'��� ,_r j�-1, •►-.' .�_ u :,:' .� .r :];�,`,.f�: j.I�.JJnat,l��r:JJ^��n�;�Yr':1:I.�i,
' v:'r. ••��.• t. tri. .,I" DC7^!._ -, '�Y` f-,t•^�� .0 t-'�1 •�-�`,._ Y. ..( ':..- `, •c f•,Z;.1,.�� ;i
r._IIS `.'(r.-1',t\:o ' :l: i;' '��. •i 1 ... ,a r ,:
C>��• �, ..I�.� .l f.-1�.,.►�x�f��.a .1 -ai. `�;l r 'aY
�i..���1`��'n-r:--J�':r, r.".y��lR•,. �.✓�:-T' •Kt-►;µ-r�r�l::i,lir-���•��f'-,1.rJ•��.�.v^�.�R'��
1.. � •1• ,,. •'.:, . ..e�+•,(7�y�'..r��.)C•ajr4'�,�,:I'�1�.'N Yi��JT�r, as�' '.:. -�-.r'1t�!.R'.\•.��-1 C�if1��,.
t. Vi•'S('•.,�d''�:�J.��i '�'I�tl(' `ty,�;r r r�:�'r 1jP-�'�Cl�,)�'i:R` `'vti••.�. �J'v.li��;_V;�
'/"�.�-I ./. .• I' ,!'_:•.+ �z..+.{� r.r� l 1 .►ar.�,i4�.. .f4itk,
-_ I'.;- .�.- -I_,--.. �;,LI '' ...,:1•r.. :.;1��;``�.'(::•1, ���.•4. t..�°.'7�r, Lr,; ;.:;n-, V,1..
1.j �'�.)I�r. �`�'i.'I��1; !IIS �� h �F,t � ti�❑"� ..jr���•�.'►�►11'.�.ir. tL
•'.)j�f.J''I'_`�.t.-•'''J' �:11t' `,,'����-.P.',I•. .( ,:t. ��7�• .. i' 1'�)�.�.�!>_�L J'•r.
f•�)ti-r.�'4 vr.; '�:i\..0 �:.Yi'ri v'r-.R'1 vP�J�C•�J�'�. C✓�C•� �-': f. „�••�
`•�"• 'C.�r�'�','(�l.'''�' �(".�;t�.._r�< ,'1. :�1,,�'1.� `V Ya ,.�r�i ``�.{r� ��1,�,�'�.F•�'11���?•vf.. :
�'r I,�1 �• �- '•i ��r I-��. II f t7''-.4-- 11'• I ,IL t� 6-' r•_i ,r r�-('
•,�.�;ila_,�:.7 i��.,_.`!�•',•�i;a,�.'1'I►;.r...��l.�,L,� ,�.��-.1,�'�T,y��r,ec 4+�'`ya{,�,�7r,lt.<<�„I_�
L t
..:�. R. _ .'4'l: a••-'l•:!...i�.-•',!7.'_,1. _..,,:�..•.�,-:: �..t.�.�•,`..%�..•a.'I'.vlr.a`l'.c�,li:.-1{:.•..�.' ,'.�.
,� -� �� :il•.f ��_,�.r,;(. ••=jr '1.�r•r, 1 .`'y'-•y't.'1Y':.rC'f.�� r.• �^ '�Y��` ti' i
;..�I _.-4.!I�N•\.l'�rl:_ .� tr`�i�r�.t•ril .•l .l,Jl-_ .�. ,' 71ij' ,yt'�-r�•._�.��rr�_t.
..1. :4'� .l:^�. .')•. :.��-� ���: :�1. rt''•%�,r� �r
t r,',_”. .. %J.r•• ..• ,1 .:: �.• `'�._ it _.•(.: "� {''� �• t :•_' i11�'•
-41
l I ..���'^r ��):`1�~► .`r:� I. 1 ."� -.l'' _1� 1,_ ';f •-I�ti�l('�. .>,_r /,, ^1`.
r -:�_�� '=-•�'rl'.,r:.`.•(', �r'r{i:. •i�c�(�.-•t:'•-I` .•�:•tit��•�-f'{' 1�- ;:+"` ,'�1����` ��•:rt�
T � -L` u r - -. �_ �I .�• r>` 4` c fir•.;C^,;' 1- 1- ('
:. •-'1':I^`` .''.);'r. •�t! 7�}rl'.,�I�,l�� �•l...l•���tj�l��T, -,� •,`"`� ��11'�,.'�'� •r'•- •Y•:
'•V/' tiC• l+-•.:.f''• •:r•� rr,l�; .' I` r. � T 4✓w.+. .L ti1'• .' t/,. I,_.' �.
�i�-.; fl-
• NEXTAPPOINTMENT
DATE
TIME
WN
r T �}{�+y � h�fi 4 I�J�IFyYLt�t �, X �} � � i ^� �. �; _..•'Y^'��1%S�. �r'y t�§ t7 .`LYj� �"Y l•,_^.
.."' �'��j !.1„ r (.'C�� r t '`_«" �fi` ..' `I � s r'"'1,. ^.:. s }• ti �'L3, `'i:H x yr; ', '�- Y 6
Reiiiit to:
} Centers for Occupational Medicin '..REMIT FROM.PINK. COPY John P. Gunderson, M.D., Inc-,
Director
Sun Valley Urgent Medical Care RS Medical
#6 IS-0346329
1100 Contra Costa Blvd.,Concord,CA 94523
(510)825-2000 FaX(51o)825-0861 PRIVATEAN RANCE
PATIENT PATIENT I.D. FEE TICKET NO. DATE
WOOD, BRIAN C 14fb034 376978 05/1.3/96
D. O. B. t 04/30/82 JN 12301
TREATMENT . I E.M.COD4 AMT TREATMENT CPT AMT TREATMENT CPT AMT
INITIAL OFFICE VISIT SURGICAL PROCEDURES SUPPLIES
1 Office Visit 99201 81 I&D Subcutaneous AB. 10060 201 Cervical Collar 99070
Officevisit 99202 84 Remove F.B.Subcut 10120 203 Cradle Sling 99070
Otticavisit 99203 87 Debridement of Wound 11000 204 Elastic Bandages inch 99070
Officavisit 99204 88 Bum,Small,Debride&Dress 16020 220 Knee Sleeve(Neoprene) 99070
OfficeVisil 99205 92 Removal F.B.Conjunctiva 65210 205 KneeSplint(Small,Med.,Lg.) 99070
Modifier -25 95 RemovalF.B.Comea 65220 206 Splint,Finger 99070
100 Removal Impacted Cerumen 69210 207 Splint,Wrist 99070
ESTABLISHED PATIENTS-OFFICE VISITS Wrist Wrap 99070
Ot icevish 99211 SPLINTS 208 Air Cast Ankle Splint 99070
yEar OfficeVisit 99212 333 Short Arm Splint 29125 234 Tennis Elbow Band 99070
1 Officevisit 99213. 3351 Short Leg Splint 29515 249 Elbow Sleeve 99070
11 Officevisit i 99214 239 Thumb Spica Splint 99070
1 Office Visit 99215 MEDICAL PROCEDURES-DIAGNOSTIC 217 Eye Irrigation Supplies 99070
Modifier i�'25 1421 ECG with.Interpretation 93000 215 1 Eye Tra99070
01421 Audiometry 99552 1 226 1 E.N.T.Tray 99070
PHYSICAL EXAMINATIONS 210 SurgicalTray 99070
1 Sports/School P.E.Inc.U/A IMMUNIZATIONS/SKIN TEST GYNT GYNTray 99070
1 Work/DMV P. Inc.U/A 1611 Adult Td 90718 Suture Removal Tray 99070
163 M-M-R 90707 Suture Material x 99070
LACERATIONS-SIMPLE REPAIR CPT 1641 Polio 90712 213 Dressing,Small 99070
25 To 2.5cm.Scalp,Extrem.etc. 12001 166 TB/PPD 86580 214 Dressing,Intermediate 99070
26 2.6 to 7.5cm,Scalp,Extrem. 12002 176 Influenza 90724 232 Dressing,Large 99070
27 7.6 to 2.5cm,Scalp,Extrem. 12004 Tetanus Toxoid 90703 221 Crutch/Rental 99070
027 To 2.5 cm.,Face,etc. 12011 DPT
REFERENCE LAB
LACERATIONS-INTERMEDIATE REPAIR MEDICATIONS(IM,IV,SUB-0,INHALATION,ORAL) 301 Collection&Handling 99000
322.6
.5cm.,Scalp,Extrem.,etc 12031 410 Pulmonaid 94640 317 CBC&Platelets
3o 7.5cm.,Scalp,Extrem. 12032 2ndTreatment 340 SMAC 25(Lab Scan) 80019
q2ol2.5cm..Scalp.Extrem. 12034 400 Injection 90782 Sed Rale
4 .Scm.,Neck,Hands,Feet 12041 402 Epinephrine 99070 604 Mono Screen 836084 .5 cm.,Face,etc. 12051 406 Demerol/Vistaril 99070 305 Urine,Culture/Sensitivity 87086
407 Rocephin 99070 346 Culture/Sensitivity OtherSite 87070
X-RAY LABORATORY-IN OUSE 296 Stool culture/sensitivity 87045
5 Chest,2 Views. 71020 3031 Rapid Strep Test 87060 Stool ova/parasites 87177
5 Ankle 73610 3091 KOH Prep&Wet Mount 87210 DNA Probe 87178
5 Foot 73630 311 Urinalysis,Dipstick 81002 360 HSV Culture 86695
5 Knee 73562 312 Urinalysis,Complete 81000 306 RPR 86592
5 Toes 73660 314 Pregnancy Test,Urine 81025 086 HIV Ab 86701
5 Elbow 73080 644 Fingerstick Glucose82947 600 Urine Drug Screen 80100
5 Finger 73140 0644 Fingerstick HCT 85013
58 Hand 73130 Occult blood in feces 82270 "
6C Wrist 73100 MISCELLANEOUS
0352 Dictated Report 99080 PHARMACY
Medical Records 9000
Holiday Surcharge -
DIAGNOSIS
i i Abcess/Cellulilis 682.9 ❑Shoulder 923.00 ❑ Otitis Media,Acute 382.9 ❑Upper Respiratory Infection 465.9
i Abdominal Pain 789.0 ❑Toe(s)And Sub-ungual 924.3 ❑ Otitis Media,Serous 381.4 ❑Urethritis,Nonspecific 597.80
!! Abrasion,Corneal or Scleral 871.9 ❑Wrist 923.21 ❑ Paronychia .681.9 ❑Urinary Tract Infection 599.6
! Allergies/Hay Fever 477.9 ❑ Degenerative Disc Disease 722.6 ❑ Pharyngitis 462 ❑Vaginitis 616.10
i i Allergic Reactions 995.3 ❑ Dermatitis:Allergic/Contact 692.9 ❑ Pharyngitis,Strep 034.0 ❑Viral Infection 079.9
! Bronchitis,Acute - 466.0 ❑Poison Oak 692.6 ❑ Pneumonia 486 ❑Warts,Any Kind 078.1
Bronchitis,Asthmatic 493.9 ❑ F.B.Eye 930.9 ❑ Pyelonephritis.Acute 590.10 ❑Wound(Puncture,Laceration,
i.I Burn,Any Site 949.0 ❑ F.B.Soft Tissue 729.6 ❑ Rash 782.1 animal bite,etc) ❑Arm 884.0
I Cerumen,Impacted 380.4 ❑ Fracture:n Ankle 824.8 ❑ Sinusitis,Acute 461.9 ❑Face 873.40
i! Chest Pain 786.50 ❑Finger(s) 816.0 ❑ Sprain&Strain:Anklefloot 845.00 ❑Finger(s) 883.0
!: Conjunctivitis,Acute 372.0 n Foot 825.20 d Arm/Shoulder 840.9 ❑Foot 892.0
Contusion:Ankle 924.21 ❑Hand 815.00 ❑Cervical 847.0 ❑Hand 882.0
Arm 923.9 ❑Wrist 814.00 ❑Elbow/Forearm 841.9 . ❑Leg 891.0
!1 Back 922.3 ❑Toe(s) 826.0 ❑Finger(s) 842.10 ❑Scalp 873.0
I Chest Wall(Ribs) 922.1 ❑ Gastritis 535.5 ❑Hip/Thigh 843.9 ❑Wrist 1. 814.0
Elbow .923.11 ❑ Gastroenteritis;Acute 558.9 ❑Knee/Leg 844.9
i.Finger(s),Sub-ungual, 923.3 ❑ General Medical Exam V70.3 ❑Lumbosacral 846.0
::Foot 924.20 ❑ Headache,Tension 784.0 ❑Thoracic 847.1
Hand(s) 923.20 . ❑ .Headache,Migraine 346.9 ❑Wrist 842.00
Head/Neck/Face 920 r7 Insect Bite 819.4 d Tendonitis Elbow 727.09
Knee 924.11 o Laboratory Test V72.6 ❑Hand/Wrist 727.05
Leg 924.5 ❑ Otitis Extema 380.10 `❑Shoulder -- 726.10 CO-Pay: s. '
DIAGNOSIS IF NOT LISTED ABOVE PLEASE PRI DIAGNOSIS CODE _ZIPT g -�'-
+ :TODAYFEES
• v ! a Ctd%C v
T PHYSICIANS SIGNATURE i NURSE S SIGNATURE TIME OUT a ash
Credit $
Check SInk <�
rev��1q/„3,t 1/9L'�.'rr i Ab-�?<Xc7' •67i. y-`{i`a..'s J.�;4� -`�7Y 5 `� '�1.1.' t p"�..'.x*� "a Y� } � � ( t r„ x'�^a 4 S,y. 4 a �r Fti'�,a" '.'•COMPAAOt HIL T NYCO L "{�[�
t
ff
• ALLERGIES
■ •• ■YES
_L:AST TETANUS
_�;.:•7-••.•r '.`.'rii �:�F:�r'• �c�l�fi-..�.y}y.'• iP'n',e;. r>. +- -i v•.vw i
' .11� f•1=•,_�;�'� -.!��,I .j�ti�i'�+ 't!`f' t.-.J1f;("1'••=•t� }�% 1}:..I,7:�11. / -ri.,IJ:• 1.c•J'll-�..11„„r ,�MEDICATIONS
'li--•ir't:il ..� ,1 :. ,I iA!'A':I ':<ci'!r'N �:i;�'fl �''' �.l;�i='�'�•r• ��r1 -•r:
1'�_.._fd_.C•��.�! L' �•..-v i, '.•�-r._�.J'�.- 1_�t...`ll'-(_^t_:�_•�1i•�fJ.:•1r�.I)�•_ d11�.I'�
•lr♦V �.••• t`_1-i• `Cr,:,;,,1','' "f;•:.:;A(=.`,t; ^..a �•r ``T_', ��1=-4, '0
_ iL�. 7r.;-.��Y���;-�����-'!�!��;��I��i♦1••.►�..'�G1'I�_,,ilG�7.�;'IO.�iS✓.�y.,�'�L.•:�7.;�►-� —
f '-11.'�-'R'- 'a:r..,�'',C:t'(=.0aa'r:l�. :vr:r- �Ct._�'� ''.,C.•�J%'1S�` .r;. �'.��y
.•}.+ -411. .i"._-il. .:�`.,I`^1;:;)".'';l�i'1t'.'.r:;-;t-ii::'.;' �,'v�'�i•.'r .•1:•.:'L .r-1(_l(r'•;}•.a(�'�:'•^.:
i��'ir'1�`” .•����I�t-.r.!j•..���y��l:L,-r'.1.•1f�a'1_.l r�-�♦•'��1:SSI J ♦••'�..� ,'r. '�- I t�' II
LL �.Lrr •. �
- '1�,-.�'�-- rr •! (,- J e�'l--y�%1�'r-r'�"1^i-�..'- r�' Lr•.�- 11 r"r•I:• 1 '+!. r-i�l(:••
,� ��. a -'1 .C.�.>1 :. .�':. t'�•J�: :�' ,1. :n y it•�.r.:n 1! Ir'. ->�` :)i •
,C _.fP '! :+1*- :L r:- '(- `. �!l �?::1..1. ••1�-�� :u. ..'V'.c�h. ,�'^�'�,�:rl_-�.�
';J�'r.a- •:-_'�. . ;�-.' .�: a '•i'`.� .r '•7.�'�,+_fj'.-: �•1�'Jt/1�n._'�:;1G_ ._I'�.-"•_rY r.'.\:1.,�)�
.�_,1•, •Ky..�f' t,'i� ...J,_''••�C-^J.- �_• .:y' .,. �� ,'..('',-y.r�.-al•J.!1-�./,-iJ`. a�;1_Jt,..J :i ' / .• /
,�._"',• -1\�.��' ._" 't.'=I1. ``!t."i'.-:�� .• =,t:-• ►-r3�-'.-_._:`?`ri,'�••.'-ir��
�.�. •�-:� `p •, � ..'.;�1 nYa .Ix.` '_I`-./:�,Y'r f'.'t_u�•.11--•�r^ ��1• ��i--. �.I r.•�r )t
`��r.i,C�`,r'•rJ.� '1` .J��j�^R-.. •vy:�lri�'•M(�::1�'� ':��%'•�, I ���•�f•-_I.r •L f^.L•v,i-_�` ` _
.- a- ,. '.•.•:'- A_'\✓rl_ J1_ 1r.• .u�•w i- ..�•`I.. ,,� ,Jf1-..mac S- /•�J
v�.' L ';''•�'�"' -'; .,�;V�'t7�7�'..�4�•►,'(tl4'r,.,.�l'��4'�,.�i�])T� �..^�' .;.-:-.r'�t!.�'.1.�•.1(,A'.h' �
t. ./?.�"i •i/�-�Ji!'�/�.-';�,y�ryr►:ll�t^.���,'I�i��P-/!�Ct'�Jl%'��R'�fyvS'-.`� �%�1%:�1'i�;;VY�
a I .�- .;i.. .i-,-•..,�:�I '` ..,,)",;•V•f:.'.1'"`��'i.:'1" �II`(r. ,►•�:.�r, L,:, .:;A- �..-n�; ��-t
IJ = {♦ �. I,t.1�.",)J _.� 1 ; 1 t j 1 'l ♦.JIB ���,'►•0
� + 1 ), 1 � r 1.��,'.1 1:i 1.Y`JI'��.•.1•'�S'`Y'11�+1.'.�. • 1 '�' •`� 4� V + \J'� .C�t
�'.1-'•.�''�v:;�:'; ;j,. •i,i1.%.y�,�.._i�•�r 1:-.�.�,i'^�7��1.�• ,:�,h�►'-•� •Jn.,��� ��,1:�.
r 1 k' S J "lt R,• 1 1 1}'••' -•� )t.' ,•� ..L.�;,L ,1.• ���L : �� , 't. '
��r t,C:
J'n -4,, ::.•.'i l.•• :. ..i�.;�...c 1�.'1:•l`�ti::'7'���''l,•� r!'r�� ��t• �••�1��'�'.1•.�d`'�-i'" •
1. �- t. '!�!- c '�•� i f ♦ SI'- ♦ c � I T ..:--1 1 t' �• I. � ^ � � i
.�.� 'il ..;►.J i -.r,,• '�i.;, �.'1�1, ..�+.1 e: L � t'1;T.y/ ♦ z i t, i
�t:J • ,r �.c- av ,. _� } ��� -'.?+. 'r �r�..4,�,►. 1:���i JJ .-cam.'. ,
�!!�';��.ti�j•�%►�Y'!1G;�. ,?l�l�,t�_t.i l��°��ryi 'ir+���;��•l�i�•,"i:����'il;•�,y '�t��;��'� Y:�;�.
',� .,•; � .: �4-•. ' ' ill '.fir r- .^may l�r'r �4' '.'Ya; -"%• �:��..1-7�: :�r;rl-•'��;��rl'r
T�;:-:( •� ; rte'-�1-}ly :.�.IIJ� � I'�1 ~- II•i_ ��I.-r.� ♦ .'•'' . -
•�"• r•. •/-'gni �.-.��,•, ` ••l.�f.• �.r..�}1 �. ; . ,, ._ ,.�.(',v%.c)R;�:..'('�'.:.r.`)t`..•. i._1•. 1�.r1:'�- .
1Ji=:i±.-, 1:�''.:~j%. `'.;: .f',1. =• _ .T �r Ir�T.f '1;���.� ��� "r•^-d�
• ,rte JI . r.�• .t'
=c., 7 :li •.'C:t r•- 1'.: I^r •".t�.�.� •. 1•-.�-..1. _ .1. _�'.��� .c-J�••
j �4.• .-•, I' •.y� ,1r�: ids+( ._�,:,; •1,�•.�-f..{_ i`L i' .�Y ,-r "')A_� �:-
ir :_ •)� �, "�-� r" vr: `•lr•4• !r.�••+ f:.�•. :•-;-�.•.��' I^V.Vii-,1r1,1.
- :. i ;.'t7) •� ,, .Jq'r. ,�i�.{("}^ r_ •�)tl^�•l•- i-r•-c�,�- `gid • �.• „�.: r. `:�; .._• ' �,,
'' i!'+r •r-'
fr'l�►r�•.1♦I��' r. .l .�• It� � )T1.,.' #' .� i �t' ..�., .(�•r.f..
v:' 1:-•.=.f., .. .6 v„ r.. +• :s•n► -t.,.,,.C. .� �v1'• 1
Jl•'�!!:.�'- ,.♦. _• 'Jr;tR•..J..'IrJitV.:...':..1��_+-: (.. .`n t/r- 1�.���j.•'
APPOINTMENTNEXT
DATE—
/ // Y
Remit to. � • �• -� ¢r .- ': _ �� :� r` _ ,� ,4 ';x
C�ntersforOccupational Medicine p' REMIT FROM PINK COPY „John P. Gunderson, M.D., Inc
�. ,
'Sun galley Urgent Medical Care •.Medical DirectorIRS#68-0346329
1100 Contra Costa Blvd.,Concord,CA 94523 „ f
(510)825-2000 Fax(510)825-0861 KPRIVATEA URANCE. ! '
5+'
PATIENT PATI FEE TICKET NO. DATE < `�
WOOD, >3RIAN C 240034 . 376675
D.0..8. c 04/30/82 JR 6:38
TREATMENT I E.M.C004 AMT I TREATMENT CPT AMT TREATMENT CPT AMT
❑ INITIAL OFFICE VISIT SURGICAL PROCEDURES SUPPLIES _
., 1 Office Visit 99201 ( 81 1&D Subcutaneous AB. 10060 201 Cervical Collar 99070
Officevisit 84 Remove F.B.Subcut 10120 203 Cradle Sling 99070
OfficeVisit. 99203 87 Debridement of Wound 11000 204 Elastic Bandages inch 99070
Officevisit 04 88 Bum,Small,Debride&Dress 16020 220 Knee Sleeve(Neoprene) 99070
Otficavisil 99205 92 Removal F.B.Conjunctiva 65210 205 KneeSplint(Small,Med.,Lg.) 99070
ModAier •25 95 Removal F.B.Cornea 65220 206 Splint,Finger 9W70
1001 Removal Impacted Cerumen 1 69210 207 1 Splint,Wrist 99070
❑ ESTABLISHED PATIENTS-OFFICE VISITS I I I Wrist Wrap 99070
Officevisit 99211 SPLINTS 208 Air Cast Ankle Splint 99070
OfficeVisit 99212333 Short Arm Splint 29125 234 Tennis Elbow Band 99070
10 OfficeVisit 99213 335 Short Leg Splint 29515 249 Elbow Sleeve 99070
I t OfficeVisit 99214 239 Thumb Spica Splint 99070
1 Office Visit 99215 MEDICAL PROCEDURES-DIAGNOSTIC 217 Eye Irrigation Supplies 99070
Modifier -25 142 ECG with Interpretation 93000 215 Eye Tra99070
01421 Audiometry 99552 E.N.TTray 99070
PHYSICAL EXAMINATIONS 210 Surgical Tray 99070 -r
1 Sports/School P.E.Inc;U/A IMMUNIZATIONS/SKIN , L" GYNTray 99070
1 Work/DMV P.E.Inc.U/A 1611 Adult Td 90718 Suture Removal Tray 99070 1
163 M-M-R 707 211 Suture Material x 99070
LACERATIONS-SIMPLE REPAIR CPT 1641 Polio 90712 Dressing,Small 99070
25 To 2.5cm,Scalp.Extrem.etc. 12001 166 TB/PPO 86580 214 Dressing,Intermediate 99070
2 2.6 to 7.5cm,Scalp,Extrem. 12002 176 Influenza 90724 Dressing,Large 99070 ^`
2 7.6 to 2.5cm,Scalp,Extrem. 12004 Tetanus Toxoid 90703 221 Crutch/Rental 99070
02 To 2.5 cm.,Face,etc. 12011 DPT
REFERENCE LAB
LACERATIONS-INTERMEDIATE REPAIR MEDICATIONS(IM,IV,SUB-0,INHALATION,ORAL) 301 Collection&Handling 99000
3E2.6
m.,Scalp.Extrem.,etc 12031 410 Pulmonaid 94640 317 CBC&Platelets
3 .5cm.,Scalp,Fxtrem. 12032 2nd Treatment 340 SMAC 25(Lab Scan) 80019
028 .5cm.,Scalp.Extrem. 12034 400 Injection 90782 Sed Rate
m.,Neck•Hands,Feet 12 402 Epinephrine 99070 604 Mono Screen 83608
4 m.,Face.etc. 2051 f ' 406 DemeroWistaril 99070 305 Urine,Culture/Sensitivity 87086
407 Rocephin 99070 346 Culture/Sensitivity OtherSite 87070
X-RAY LABORATORY- IN OUSE 296 Stool culture/sensitivity 87045
5 Chest,2 Views 71020 303 Rapid Strep Test 87060 Stool ova/parasites 87177
5 Ankle 73610 309 KOH Prep&Wet Mount 87210 DNA Probe 87176
5 Foot 73630 311 Urinalysis,Dipstick 81002 360 HSV Culture 86695
5 Knee 73562 312 Urinalysis,Complete 81000 306 RPR 86592
5 Toes 73660 314 Pregnancy Test,Urine 81025 086 HIV Ab 86701
5 Elbow 73080 644 Fingerstick Glucase 82947 600 Urine Drug Screen 80100 '
5 Finger 73140 0644 Fingerstick HCT 85013 "�" >`
5 Hand 73130 Occult blood in feces 82i70 ~.
60 Wrist 73100 MISCELLANEOUS '
0352 Dictated Report 99080 PHARMACY :x'; r;ti
k:4
Medical Records 9000 " h"
Holiday Surcharge
DIAGNOSIS "
.:-
n Abcess/Cellulitis 682.9. ❑Shoulder 923.00 ❑ Otitis Media,Acute 382.9 ❑Upper Respiratory Infection . - 465.9
n Abdominal Pain 789.0 ❑Toe(s)And Sub-ungual 924.3 ❑ Otitis Media,Serous 381.4 ❑Urethritis,Nonspecific - 597.80 '
('i Abrasion,Comeal or Scleral 871.9 ❑Wrist 923.21 ❑ Paronychia 681.9 ❑Urinary Tract Infection 599.0
[! Allergies/Hay Fever 477.9 ❑ Degenerative Disc Disease 722.6 ❑ Pharyngitis 462 ❑Vaginitis 616.10 "*,•'llf
!:! Allergic Reactions 995.3 ❑ Dermatitis:Allergic/Contact 692.9 ❑ Pharyngitis.Strep 034.0 ❑Viral Infection 079.9
Li Bronchitis,Acute 466.0 ❑Poison Oak 692.6 ElPneumonia 486 ❑Warts,Any Kind 078.1
!! Bronchitis.Asthmatic 493.9 ❑ F.B.Eye 930.9 ❑ Pyelonephritis.Acute 590.10 AAound(Puncture,Laceration,
1 Bum,Any Site 949.0 ❑ F.B.Soft Tissue 729.6 ❑ Rash 782.1 /1 animal bite,etc) ❑Arm 884.0 '
i! Cerumen,Impacted 380.4 ❑ Fracture:nAnkle 824.8 ❑ SinusAis,Acute 461.9 WFaoe 873.40 '
!i Chest Pain 786.50 ❑Finger(s) 816.0 ❑ Sprain&Strain:Ankle/foot 845.00 11 Finger(s) 883.0 r?
I! Conjunctivitis,Acute 372.0 r.3 Foot 825.20 ❑Arm/Shoulder 840.9 �/Faot '892.0
Contusion:Ankle" 924.21 ❑Hand 815.00 ❑Cervical 847.0 and 882.0
!Arm 923.9 ❑Wrist 814.00 ❑Elbow/Forearm 841.9 Leg 891.0 r °'
I Back 922.3 ❑Toe(s) 826.0 ❑Finger(s) 842.10 ❑Scalp 873.0 ti
I!Chest Wall(Ribs) 922.1 ❑ Gastritis 535.5 ❑Hip/Thigh 843.9 ❑Wrist 814.0
!!Elbow 923.11 ❑ Gastroenterltis,Acute 558.9 ❑Knee/Leg 844.9
!!,Finger(s) Sub ungual 923.3 .❑ General Medical Exam V70.3 ❑Lumbosacral 846.0. 1
aI Foot 924.20 ❑ Headache,Tension 784.0 ❑Thoracic 847.1 r r
i Hands) " 923.20 t7 Headache,Migraine 346.9 ❑Wrist 84200 # x A
t t'HeadMecklFace920 f7. Insect Bite 919.4 ❑ Tendonitis Elbow ;727.09
+ Knee ; + 924.11 t7 Laboratory Test V72.6 ❑Hard/Wrist
¢t� +!r t'Leg " r , x �.'"•,";, 924.5 0 Othis Fxtema 380.10 ❑Sf+oulder }r �` -§72610 k
r
•.,:l.e..','11 :..•:.°x ...-xc:..n. ,7aui�-, ?? =..: f,s �. •CO'Pey ' .. i.
�-�'DIAGNOSIS IF NOT OSTEOABC0WW3F;-2AA1
5 { t DIAGNOSIS CODE' RECEIPT ' t
's T,ODAY'SFEti " rates- �% e:rCr dt Ca
P SICIANSSIG �-
NURSE'S;SIGNATU Ol'JT Wasaar
j• _
INSTI
• t
M UU1 M i
i *f
6V Medical Ccae
John P.Gunderson,M.D.
•'Uf�Ilt Core-OccupationW Hedth Medical Director
1100 Contra Costa Blvd.,Concord C :94523 .
(510)825=2000 FAX(510)825-0861
Work Comp.Coordinator(510)825-2748 C ,
RISKS OFTION
INTRODUCTION
Modern immunization techniques are safe and effective. The risk of the disease against which you are to be
immunized in general far outweighs the risk of the procedure itself. Nevertheless, all immunization
procedures carry a small risk of undesirable side effects. The questions asked in this clinic are designed to
screen out those individuals at greater than normal risk. The information presented here is designed so that
you will be properly informed in deciding to accept these procedures for yourself or your dependent child.
Examples of some of the possible although infrequent complications occurring with immunization include: 1)
immediate or delayed allergic reactions ranging in severity from mild irritation to total collapse and death;
2)actual illness similar to the disease itself,which may be of the nervous system causing damage to the brain
of paralysis; 4) a localized infection;. 5) mild flu-like illness characterized by a low grade temperature,
headac bndyne s;. 6)failure to develop any protection at all from the vaccine.
VACCINES
These include diphtheria,tet ,pertussis(whooping cough),cholera,typhoid,typhus and plague. Many
of the above-listed po les may rarely occur with these vaccines. Commonly , there may be some pain
at the si injection, headache,body aches, and low grade temperature for a day or two.
LIVE VACCINES
These include yellow fever, polio, mumps,measles,rubella. These may be associated with all of the above-
listed complications. These vaccines should not be given during pregnancy, or in the presence of an altered
immune state, which is discussed below.
ALTERED IMMUNITY
Individuals with cancer, leukemia, lymphoma or who are receiving treatment with cortisone, anti-cancer
drugs,or radiation,or who have any other altered immunity state should not be immunized against small pox
or receive any other live-virus preparation.
SEVERE FEBRILE ILLNESS
You should not receive any immunization if you currently have any illness with a temperature. A minor cold
does not necessarily preclude immunization.
LIVE VACCINATIONS AND PREGNANCY
On the grounds of a theoretical risk to the developing baby the live-virus vaccines listed above should not be .
given to a pregnant woman.
PLEASE KEEP THIS PART OF THE INFORMATION SHEET FOR YOUR RECORDS
1 have read the information on this form. 1 ha ve had a chance to ask questions which were answered to my satisfaction.
I believe I understand the benefits and risks of immunization and request that the vaccine checked below be given to
me or to the person named below whom I am auth ized to make this request.
Vaccine to be given
INFORMATION OF THE PERSON TO RECEIVE VACCINE(Please Print) FOR CLINIC USE
�.�0c
Last name First name MI Birthdate Age Clinic Ident.
0 3
Address s Date Vaccinated
City County State Zip Manuf.and Lot
Signature of person to receive vaccine or. Date Site Irt,
person authorized to make the request
SVUC 1022-05 rev 2/15/93
F
,r _ t