The URL can be used to link to this page

Peterson, Sarah RECEIVED MAY 0 2 2014 NOTIC� OF CLAIM FORM to the City of Saint Paul, Minnesota CITY CLERK Minnesotn S/ate Slattrte 466.05 stnte.r dTnt " ...everY persnn...who clnims damnge.r fran anv»u�nicipnlity...sl�u//enrr.re to he prese�rted tn dte go��erning budy of�the municipa/iry withift /80 duys nfter(he nlleKed lnss or injury is discovered a notice staNng t/�e trn�e,p/nce,ancl circwn.stances tF�ereof,nnd dte amntrnt of compensation or olher relief demnnded." Please complete this form in its entirety by clearly typin�or printing your answer to each questioa If more space is needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. You will rrceive a written acknowledgement once your f'orm is received. The process can take up to ten weeks or longer dependin�;on the nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name�� Middle Initial�Last Name�P�'��\ 1�' - Company or Business Name _— Are You an Insurance Company? Yes/� If Yes, Claim Number? Street Address��_�I'��- �n City �� C�� State�� Zip Code�;��`1 Daytime Phone (,j��)��.�Cell Phon� - Evening Telephone ( ) - Date of Accident/Injury or Date Discovered�- a - �y Time��.�/pm Please state, in detail, what occurred(happened),and why you are submitting a claim. Please indicate why or how you feel the City of Saint Paul or its employees are involved and/or responsible for your damages. , �f�L`(`�� S u�l� � c - �e �. �; ` �`i ��,� -�a� � � y lP,�� -r�e_r�e,�c+ n�-�, �'��,-��a��-r��e�a'r�'� e s c eck the box es that most c osel re res t the teason for com et�n thi. fjrm: � My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow �j�p1�Qf� ❑ My vehicle was damaged by a pothole or condition o�'the street ❑ My vehicle was damaged by a plow -��. ❑ My vehicle was wrongfully towed and/or ticketed �'I was injured on City property �\S(� 1F�p�,}f1 ❑ Other type of property damage–please specify `3S��cCaC...''�JC� ❑ Other type of injury–please specify ��e-�� UJ`�X�� In order to process your claim vou need to include copies of all aqplicable documents. �} W�S --�-�-.2 C� S For the claims types listed below, please be sure to include the documents indicated or it will delay the handling of,P,r�� your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a ��1 copy for yourself before submitting your claim form. O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds $500.00; or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other property damage claims: two repair estimates if the damage exceeds $500.00; or the actual bills and/or receipts for the repairs; detailed list of damaged items �njury claims: medical bills, receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2–Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-niease complete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names, addresses and telephone numbers:�!'l�P Cl�1'C�(1� ` �o�'o��J�`�q p� Were the police or law enforcement called? Yes No Unknown (circle) If yes, what department or agency? ase#or report# Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility, closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. \�\��{1r1 (D��C� , ��c��L� t � ��P��- 1�� S o � c"'�Y�2t-\n ('�_C'� (�f1a-r-�r�CL �� Ple�e ndica�e th�o�u�nt yo�1 arC e�eeki� in compensation or what you would like the City to do to resolve this claim to your satisfaciion.��' ��,,Q(1'�' M��,�'�� b:1�S C_('llj�� vent�ie-f;taiim�=pt��arr[pfete ti�is section , -- U�reci:tso�ir thi�e�ritjrrune�-�t�piy - Your Vehicle: Year Make Model License Plate Number State Color Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) � Area Damaged In'ur Claims- lease com lete this section ❑ check box if this sectio does not a 1 �J� How were you injured'? � � .y�� What part(s)of your bo y were injured? �r ` l�� - Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)�alc��t� h� When did you receive treatment? � ' 3-31 provide date(s)�_XCe� Name of Medical Provider(s): �� a Address Telephone ,.,� � Did you miss work as a result of your in'ury? Yes No �� When did you miss work? � (provide date(s� . r _ � ` - ---- ---- ---- -- - iv<ur�e af your EmpYayet: - Address - �-- .� Telephone��1- -]�� l.�� 5 tv��S ❑ Check here if you are attaching more pages to this claim form. Number of additional pa�es��. I3y signing tliis form,yor� are stating that all information yoc� have provided is trr�e and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can resielt in proseccction. Date form was completed Print the Name of the Person who Completed this Form:��^�,��G�� Signature of Person Making the Claim: Revised February 201 I �"�� __�_ '� '�--�-��►�� --�C'�-��-� ` ��(Y`�� --� -�2�.�-�-`��P��.� . --------- ---��I��-- ��-- __�U�� --�L�-�--�-�+--��1-� -�.��'.��--�-��\ Q�-L.��-- -- --- - ---- ___�-o�--�--��d-�� --�� -��--�-��--- , - -C�.,�\ _C��_�'Y`�'�CY1 •--�r- �Ga`-�=�_�-�--��-�-\�_C��_ _t�_ ------ _ - -_ _ ��d ��'.--��1�1�--�'��1-�- -�--�=�C�-_�L.0��Q.-� ----- - --_ _ __ _ �p��C`� Ss'��.=��'G� �`�-''��-��-- c��►�b��-- -- . '�' - - � __��,,��-�- �,��-�-r-�� -�..-�_�r--�— _ _ . __ __ _ _��_ _�- _ ��[��.� �Y�-�-�=��-�-��- -- -- -- __ - -- - --- �� _ Y'r�� -- ��d--�-'��`c�-`�'�- �� _ s�- �-- _ -- ---�-� -- - --- _ _ _ti0��\�'��Q ��r�:,�-��c��C1�__�,.��_��n�SO��C-� _� n - _ --- - _ _ ��.��____ -- `�'� ��-�-Q��__ � _�� L��,,r�� t��.�--��-fi}-�- ---- - -__ �.��---��;►�� --�-�c�-�an�- ��.._�tac..� - _ . - - ��1��---u�a� ��-��-_�� _ _ -- --- ��- � - ��-�`�-_�� -- � _ � �'�--.- , - �----��--�- _\_-��- _��- ��n_.�rn�_-- - -- _��__ ___ _ ___ --�- ��r;.�-� _��'�-__��l��1� �� - �s� -- _-- _ _. --_� _�_��1-�--__��_�_�I�__� --a�"c---�L�--`�--�-�;-�� t\� -��_--'��?�'�_��• -�� __L._ �3�--�_ -a��-'r-- ��'�� _��`�'-��4=��!k�- ��`l��-��,��-��--- __- -__ -�s �.oc`-c-Q-�� --�n _�'a��-�-��--- -- -- -- ___ ___ --��-�1`��-_��1 .Q�-- - --'��4�_ � - -- --__- ��- __ -- — _ _ _-__ _ - __ --- - - _ - - --_ _ ---- _ ___ _ -- --- ----- ------ r c..rnwa,r��vu i ocwvv. CHECK CARG US�ti�FOF FAVN�tiT ' T TWIN CITIES ORTHOPEDICS � o�TER�ARO 0 °��EA �sA °A ""�Aar °ER��AV�x��ESs P O BOX 9188 cnr.o NuMeEr� si�NnTURE cooE� MINNEAPOLIS,MN 55480-9188 32491-858Y `�c�NnruAE rxP onrE � r=r,�r��cnaor�o�oEe NnME � TEMP-RETURN SERVICE REQUESTED STATEMENT DATE ACCT# PAY THIS AMOUNT 000asa o,o, Office Phone: 952-512-5625 PAGE: 1 of 1 4/09/14 317431 $214.26 *M/C.DISCOVER&VISA- �ast 3 digits on back of card SHOW AMOUNT PAY YQUR 6IL(� QNLINE AT WWW.TCQMN.COM AMERICANEXPRESS- PAID HERE � Last 4 digits on back of card 65�056C linil�i��li�iil�ll�nr�lr�l�i�li�ii�lln��li��il��li�li�lli�� Ili�l�ilri�lli�lii�l�i�i�u��i��lnn��il�l�ii��lil��i��, SARAH J PETERSON TWIN CITIES ORTHOPEDICS 3015 HEMNLOCK LN P O BOX 9188 HAM LAKE, MN 55304-4853 MINNEAPOLIS, MN 55480-9188 32491-85 BY*T1 HOAQBY1000933 CPlease check box'rf address is incorrect or insurance STATEMENT pLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMENT information has changed, and indicate change(s)on reverse side. _ ___ ___ __ _ _____ _ ACCOUNT NUMBER STATEMENT DATE TOTAL DUE PATIENT NAME 317431 4/09/14 $214.26 SARAH DATE DESCRIPTION AMOUNT INSURANCE PATIENT AMWNT PATIENT ENCWNTER CHARGED PAID PAID ADJUSTED BALANCE NUMBER SUMMA WITH Peter D Holmberg, MD 252.00 -37.74 214.26 46058228 3/18/14 OV NEW PATIENT LEVEL 3 252.00 � � > I I I I i PLEASE REMIT PAYMENT WITHIN 30 DAYS. TO PAY'�'OUR BILL CURRENT: 214.26 ON-LINE, VISIT OUR WEBSITE AT WWW.TCOMN.COM� IF YOU HAVE OVER 30 DAYS: .00 ANY QUESTIONS, PLEASE CALL 952-512-5625 BETW EN 8:00 - 5:00. OVER 60 DAYS: .00 j OVER 90 DAYS: .00 ' OVER 120 DAYS: .00 j TOTAL DUE: $214 .26 i�e��mi PLEASE UPDATE ANY INFORMATION THAT HAS CHANGED SINCE YOUR LAST STATEMENT �ABOUTYOU: ABOUTYOUR INSURANCE: YOUR NAME(Last,First,Middle Initial) YOUR PRIMARY INSURANCE CCMPANV'S NAME POLICY HOLDER'S NAME PRIMARY INSURANCE COMPANY'S ADDRESS ADDRESS CITY STATE Z�p CITY STATE ZIP POLICYHOLDER'S ID NUMBER GROUP PLAN NUMBER TELEPHONE MARITAL STATUS ❑Separeted ❑Single ❑Divorced � � ❑Married ❑Widowed YOUR SECONDARY INSURANCE COMPANY'S NAME POLICY HOLDER'S NAME EMPLOYER'S NAME TELEPHONE � � SECONDARYINSURANCECOMPANY'SAODRESS EMPLOYER'S ADDRESS CITV STATE ZIP CITY STATE ZIP POLICVHOLDER'S ID NUMBER GROUP PLAN NUMBER L _ _ I CREDIT POLICY If you have questions regarding this statement contact 952-512-5625 All charges are due and payable upon receipt of this statement. If you cannot pay the balance in full, please contact our Business Office Customer Service Department (952-512-5625) to arrange a payment plan or to review an application for Twin Cities Orthopedics, P.A. uncompensated � -- - - care program. Copayments are due at the time of service. After 60 days, interest is accrued at 6,0% annually on the unpaid balance. IN CASE OF ERRORS OR INQUIRIES ABOUT YOUR BILL The Federal Truth-in-Lending Act requires prompt correction of billing mistakes.To preserve your rights under the Act, follow these steps to insure a prompt reply.Your written inquiry must be received within 60 days after the bill has been mailed to you. Your inquiry must include the following: -Write your inquiry on a separate sheet of paper that can be attached to the bill. t�e sure to identity yourseir by name, account number and address. -Explain the mistake and why, in your opinion, you believe there is a mistake. -Be sure to state the dollar amount of the mistake. IF PAYING BY VISA,MASTERCARD OR DISCOVER,FlLL OUT BELOW �� SUMMIT 710 Commerce Drive ❑VISA v ❑MASTEfiCARD O ❑DISCOVER� S��Q 200 GAR�NUMBEfl �E%P DATE NMOUNT �� ORTHOPEDICS Woodbury, MN 55125 SIGNATUflE MUST INCLUDE 3 DI61T SECURITY COOE FROM BACK OF CARD TEMP-RETURN SERVICE REQUESTED . .�. . : �r� '��t�". :s - -,�.. Billing Phone: (651) 968-5050 03/24/2014 $263.66 1122271 Office Hours: 8:OOam-S:OOpm CST Web Address: www.summitortho.com CHARGES AND CREDITS MADE AFTER S7ATEMENT SHOW AMOUNT � Tax ID#: 41-1762331 DATE WILL APFEAR ON NEXT STATEMENT. PAID NERE Stmt ID#:511314183 �MAKE CHECKS PAYABLE/REMIT TO:� ii��l��ilii�i��lii�llliiiiii��ll��lllii�i��i��l�illl� �»�-93 summ�t Orthopedics g SARAH J PETERSON PO BOX 860240 � � 3015 HEMLOCK LN NE MINNEAPOLIS PR�1 55486-0240 HAM LAKE MN 55304-4853 ��u��n�n��u�n��u��nn��i�u��uu�u��nm�� Page 1 of 1 � Please check box if above address is incorrect or insurance � PLEASE DETACH AND RETURN TOP PORTION WITH information has changed,and indicate change(s)on reverse side. YOUR PAYMENT IN ENCLOSED ENVELOPE Reflects transactions posted through 03/24/2014 DATE CPT DESCRIPTION fEE UNITS FEE INSURANCE PATIENT TOTAL Ammar Khashan PAC Summit Orthqpedics Ltd 824.8 Unspecified closed fracture of ankl`e $.00 .00 $.00 $.00 03/06/2014 Coder 10 $.00 1.00 $.00 $.00 $.00 03/06/2014 99203 Office or other outpatient visit for the $287.00 1.00 $28'7.00 $287.00 $.00 evaluation and managem 03/06/2019 73620 Radiologic examination, foot; two views $70.50 1.00 $70.50 $70.50 $.00 03/06/2014 '73600 Radiologic examination, ankle; two views 573.50 1.00 $73.50 $73.50 $.00 .'3/21/2019 Contractual Adjustment from Preferred One $.00 .00 $.00 $-167.39 $.00 03/21/2014 Transfer from Insurance to Patient $.00 .00 $.00 $-263.66 $263.66 Responsibility � i CURRENT 31-60 DAYS 61�0 DAYS 91-120 DAYS VER ZO DAYS ACCOUNT INSURANCE p�E FROM PATIENT BALANCE BALANCE $263.66 $.00 $.00 $.00 .00 $263.66 $.00 $263.66 PAY YOUR BILL ONLINE WITH A CREDIT CARD OR DEBIT CARD OR AN ELECTRONIC PAYMENT FROM YOUR CHECKING OR SAVINGS ACCOUNT. VISIT US AT www.summitortho.com ; Summit Orthopedics i ,,,, SfATEMENT �w��• SFF RFVFRSE SIDE FOR IMPORTANT BILLING INFORMATION 111809-93-3433884