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Vang, Ricky (2) , � R A T G E N RFcF��, PERSONAL INJURY LAW FIRM J�N �D C�T o2?�� Y c��RK May 30, 2014 ATTORNEYS City of St. Paul Bradley H.Ratgen Attention: City Clerk van Holston 310 City Hall Felix Valanzasca Emanuel Ardeleanu 15 West Kellogg Boulevard St. Paul, MN 55102 j,EGAL SECRETARY/ QFFICE ADMINISI'RATOR Carla Ratgen* Re: Our Client: Ricky Vang Your Insured: City of St. Paul RECEPTIONISTS Claim No.: To Be Assigned Kafiya Abdi DOL: October 16, 2013 pARALEGALS Our File No.: 8720 Jennifer A.Dossenko Gina Best-Smith Am��l�s v�ona Dear Madam or Sir: ADMINISTRATIVE please accept this as our letter of representation in the above-captioned case, ASSISTANTS Mitchell Smith* as well as a demand letter for the same. Our office has been retained to x.x.wetZei represent Mr. Ricky Vang relative to personal injuries he sustained in a motor vehicle accident on October 16, 2013. Main Office As documentation of this claim, I have enclosed a PIP log, a traffic accident Griggs Midway Building report, medical records and medical bills for your review. Suite S-156 1821 University Avenue St.Paul,MN 55104 Telephone LIABILITY (651)646-5840 Facsimile (651)646-5841 On October 16, 2013, Mr. Vang was driving as 1998 Toyota Camry westbound on Marion Avenue in St. Paul. He stopped at the intersection with NORTH METRO OFFICE* Como Avenue and waited to make a right turn onto northbound Como while Telephone cross traffic cleared. As he waited, Mr. Walter Schmitt, driving a city vehicle (651)653-4083 owned by your insured, failed to see our client stop at the intersection and Facsimile rear-ended his Camry. Mr. Schmitt was cited at the scene for Inattentive (651)653-6571 Driving. As a direct result of this accident, Mr. Vang was injured. As you have not disclosed your policy limits to us, we will assume our client is entitled to recover up to $1,000,000.00 for the injuries he sustained in this accident. INJURIES On October 29, 2013, Mr. Vang presented to Capitol Chiropractic with complaints of neck pain, upper back pain, middle back pain, and lower back pain. He was subsequently diagnosed with cervical sprain/strain, thoracic sprain/strain, lumbar sprain/strain, lumbosacral sprain/strain, cervicalgia, thoracic spine pain, lumbago, and muscle spasm. Mr. Vang continued treating with Capitol through Apri123, 2014. Dr. David Cole, DC referred Mr. Vang to Voyageur Imaging, where he presented on November 20, 2013. X-rays were taken of his cervical spine, thoracic spine, and lumbar spine. The X-rays revealed: - Post-traumatic restricted cervical range of motion; - Post-traumatic ligamentous insult involving the C3-C4 and C4-CS vertebral motion units; - Post-traumatic cervical levoscoliosis; - Post-traumatic thoracic dextroscoliosis; - Post-traumatic lumbar dextroscoliosis; and - Congenital posterior ponticle at C 1. Dr. Cole also referred Mr. Vang to Arcade Pain Center, where he presented on December 6, 2013. His primary complaints were pain in his middle and lower back, which radiated into his abdomen. He described his symptoms as sharp, shooting, knife-like pain that is exacerbated with minimal physical activity. Mr. Vang was subsequently diagnosed with post-traumatic thoracic pain, post-traumatic lumbar pain, post-traumatic abdominal pain, and post-traumatic muscle spasm. Dr. Susan Murray, PA referred Mr. Vang to United Medical Imaging, where he presented on December 11, 2013. MRIs were taken of his thoracic spine and lumbar spine. The MRIs revealed: - Broad-based central disc protrusion, as seen at the mid thoracic spine, measuring approximately 2-3 millimeters, with mild central spinal canal stenosis; - Straightening of lumbar spine lordosis; and - Scoliosis of the lumbar spine. On February 20, 2014, Mr. Vang presented to Mobile Rehab for physical therapy. His primary complaints were pain in his right shoulder and elbow, mid back pain, low back pain, and headaches. He was subsequently diagnosed with cervical sprain/strain, thoracic sprain/strain, lumbar sprain/strain, and lumbosacral sprain/strain, all comprising whiplash syndrome. MEDICAL EXPENSES As a direct result of the accident, our client incurred the following medical expenses. Provider Total No-Fault Paid Outstandin Ca itol Chiro ractic $ 6,235.00 $ 4,520.00 $ 1,715.00 Voyageur Ima in $ 630.00 $ 630.00 $ 0.00 Arcade Pain Center $ 714.00 $ 714.00 $ 0.00 United Medical Imaging $ 3,513.00 $ 3,513.00 $ 0.00 Mobile Rehab $ 1,856.20 $ 1,856.20 $ 0.00 Totals $ 12,948.20 $ 11,233.20 $ 1,715.00 SETTLEMENT DEMAND Based upon the facts and circumstances of this case, as well as the nature, extent and severity of Mr. Vang's injuries, we have been authorized to demand the sum of $45,000.00 for a full, final and complete release of the claim against your insured. We respectfully request that you contact the undersigned following receipt of our demand package to negotiate a settlement of this claim. Thank you. 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F-, O � M d' O In [� �O CO f'1 IA N �p �-1 rl �'7 rl a N O �1 `-' cV O� O �� ''a' pq t� O _7 N o � H � ��,7 � U �-a7 a W W � N � °w a� r� � a N a P4 PG � � N � w u .a (9 .7 Vr£1 .n w w '�p, � � , Q W tU-i H H f�?.�, w �¢ rai �-Ui rVi r-Vi v . b z 2 U U U £ W M a U U U � � � W W �a�' � � � � � � a � °a '� 6 �e °z °x °x c°c � � W •p ..�. ~ �7 �. 5. o H O � �7 a'i �". b� °� . U fs+ U m u u u w a s [� � v a 3 � a m � o 0 0 o w °w w o 0 0 � � H H � H °a � a H H H x a a a r-i c> >. a a a u a w � u � � �a' H > c� U U a Received Time Apr. 9. 2014 2:52PM Na. 2494 From:Katie 41son Fax;I551}35f-2932 To: fax: +t t877�590-@i88 Page i�of 3��tf21720'13 1:1H Vang,Ricky printed on 1 1121120 1 3 Gapitol Chiropract� �Dr Exam Farm Service Date: 1{u29/2013 SPIN'E FINdING.ris: Spinal7`endemess Level 1:G1-7(4} Spinal Tenderness Location 1: Left, Midlir�; Right Spinal 7endem+ess Level 2:T1-12(4) Spinal Tende�ness locafiort 2: Left, Mitlline,Right' Spina!Tenderness Level 3: L1-S1{4) Spina[Tendemess l�cation 3: Left, Midline, Right S�FT TtSSUE: Soft�ssue Area 1:c�rvica[,thoracic and lumbosacral paraspinal, occipital,trapezius, tevator scapul�e, SCM,scalene,€hombczid,and quadratus lumborum rrtuscles Saft Tissue Area 1 5ide: Left Soft Tissue Area 1 Hypertonicity(4�i :5 Soft Tissue Are� 1 7er�derness (1-A):4 Soft Tissue Area 2:cervical,thoracic and lumbosacral pawaspina(; occipital,trapezius, levator scapula�, SCM,scaler�e, rhomboid,and quadratus lumboriam mtascles Soft Tissue Area 2 S'ide: Right Soft Tissue Area 2 Hypertonicity(O�j:5 Soft Tissue J4rea 2 Tet�demess ('t-4): 4 RANGE t3F MQTfUN&PAEN: Cervical Fiexion (50 degrees normalj. Modsrate decr�ease C�tvicai�lexi€�n Pain Qescriptian��harp C�rvica!Flexir�n Pain Lcca#ion: Left, �tlidtirte, Right �ervic�€I'F�exion Pain Levef:cenrica!and upper thoracic spirie Cen�ical �xter�sion (7Q degrees no�tnai): maderate ciecrease Cervical Ext�nsion Pain��scriptia�: Sharp Genricaf Extension Pain�oc,ation: Left, Midline, Righ# Cenricaf Extension Pairt Le�el: cervical and upper thoracic spine G�rvical Lt 4.at Flex{45 degr�es normal}:rnod�t�ate decrease G��vica[Left La#eral Flexian Pain t7escript�on:Sharp Cervical L.eft L�t�ral�(�xion Pain Lc�catio�t: Le#�, Nlidtine,;Righ# G�rvical k.eft Lateral�lexian Pain Level:eervical and upper thoracic spine �ervical Rt. Lat Ftex{45 degrees r��rmal}:moderate decrease �ervical Right l�terat Fiexia�n Pain�escription:Sharp Cervi�i Righ#Lat�ra��texic�n Pain i_ocatiorf: Lefit,Midline, Right Cervical Right Latera�Flex�n Pain Leuet:cervicat and upper thoracac spine Pag�2o#5 �t�m:Katle Olson Faz:t651)35i-2982 To:;, Fax.'+1�877}590-6188 Page 14of 3211t21CL613 1:t$ Vang,f2icky printed an i il2112013 �a{htol Chirbpractic Cervicai L.t. Rotatian(85 degrees narmal):mild ta moderate decreas� Ceruicai Left Ro#atian Pain Description:Sharp Cervical Left Ratation Pain Location: Left, Midline�Right Cervical Left Rotation Pain Leuel:cervicai and upper thoraac spine Cervical Rt. Rota#ian (85 degree�s narmal}:mild to moderate decreas$ Cenri�l Righ#Rotation Pain Description:Sharp Gervical Right RQ#ation Pain i..c�c�ttion: l.eflk,Midlir�,Right Cervical Right Rotation Pain Levr�l:cervical and up�er tharacie spine Lumbopelvic Ftexion (90 degrees nom�al�; modera#e decrease L.umbvpelvic Flexion P�in Qescription;Sharp Lum�petvic Fkxion Pain Lacatian: LefE, Midline, Right Lumbr,�pelvia Flexion Pain Level: lumbosacwal spine Lumbopelvic Extension,(St}degrees norm;al}; moderate decrease Lumbopelvic Extension Pain Descriptivn:Sharp Lumba�elvic Extensian Pain Location: Left,Midline, Right l.umbapelvic Extension Pain L.�vel: lumbosacral s}�ine Lumbopetvia Left Laterat Flexiar�{35 degcees normal}: tt�oderate decrease Lumbopetvic Left Latera! Flexion Pain De.scription: Sharp Lumbctp�elvic Left Lateral Flexian pain Location: Left, Midline,Right Lumbapelvic Left Laterai Flexiort Pain Level: lumbosacral spine E.um�opelvic Right Latera(Ffexion (35 d+a�rees normal): mod�rate decrease Lumbopelvic Right Lateral Ffexion Pain Llescription:Sharp Lumbo�elvia Right Lateral Flexian Pain Lacation: Left, Midline, Right Lumbr�p�eluic Right L.ateral Flexiot� Pain i.,�vel: lumbosacral.spine l.umbapelvic Left Rotati�an(30 degrees narmal}:mikf#o moderate decrease ' Lumbopelvic Left Rotation Pain t�escription:Sharp Lumb�peivic L.eft Rotation Pain Locatia�►: Left, Midtine, Right i Lutxtksopetvic Left Rotation Pain L.�ve1; lumbosacrat spine � Lum[s�petvic Rigttt Rcta#ion(�O:degrees ncrmal�:mild ta mocierate decrease I� L.urr�bc�pelvi�Right Rot,atiott Paiin Description:Sha�p I, Lumb�pelvic Right Rotation Pain Lvcatian: Left,�Viidline, Right � Leimb�pelvic Right Rotation Pain l�vef: [umbosacral spine ' _ i C1Rl'HGIPEDI�ANQ htEUF;+E�Lt1GICAEL TESTING: I L�ft Shc�ulder Depression Test: Positive ', Left��oulcier�epressi�n'Rain Type:Sharp l.eft Si�aulder Qepression Pain Location:Left, Midline i_eft Shouider�res�iot� Pain Rad�atian:Cervical,Thora�ic Right�haulder I�epression Test;:Pvsitive Right Shaulder E�epression Paitt Type:Sharp Right Shaulder Depression Rain;Lc�cation;Midline,Right Right�hauitier Depression Pain �adiati€�n:�enrical,Tharacic So#a Hali 1'es�: F'ositive Page 3 of 5 From:Katie Qlson Fax:(651)351-2992 To: Fax: +1(8771 590•Bi88 Page 15of 3211t21fZQt31:t6 Vang,Ricky �infed on 11/21/2t113 Capitoi Chiropractic Sata Ela1l Test Pain 7ype:Sharp Sott��ta{i Test Pain Locatiar�; Lef�, Midkine,Right Soto Hall TestPain Radiation:Cervical,Thoracic i,.eft Ceirvical Compression Test< Fositive Left Ceruical Gampressian Pain Type:Shatp L.eR Cervical Compression Pain Location: Left, Mid6ne L�eft Cecvical Ccmpression Pain Radiation:Cervical,Thoracie Right Cervicai Campression Test: PasiEive Right Gervical Compression Pain Type:Sharp Right Gervical Campression Pain Location:Midiine, Right Right Gervical Compression Pain Rac�iation:Cervical,Tf�r�cic' Left S#raight Leg Raising Degrees wlPain:Approx.30�.BP I,�ft 3traigh#Leg Raising Pain Type:Sharp Left S#raight L.eg Raising Pain L.oc�ation:Left, Midline, Right t..eft Straight Leg Raising Pain Radiation: Lumbar RigFtt Straight Leg Raisin�D�grees w/Pain:Approx.3C?LBP Right Straight Leg Raising Pain Type:Sharp Rwght Stra�ght Leg Raising Pain;Location: Left, Midline,Right Right Straight Leg Raising Pain Radiation: Lumbar Left Bechterews Test`Positive Left Bechterews Pain Type:S1�arp Left��i�terews Pain Lacation; Left, Midline, Right Right Bechterews Test: Positive Right 8echterews Pain'Cype:Sharp Right Bechterews Pain Lacation: Left, Midline, RigFrt Left Kemps Test: Positive Lef�F�emps,Pain Type:Sharp Le€t F�emps F'ain Loca#it�n; Ceft, �idtine, Ri9ht �� Le�K�mps Pair�Radiatian: Lumbar , Right Ketnps Test: Pasi#ive I Righ�Kesnps Pain Type:Sharp ' Ri�ht Kemps`Pain Lacation: l.eff;.Mid3ine, Right Right Kemps Pain Radiation: U.�mb�r Milgrat�rt�Test: Fasitive Mil��ams f'ain Type:Sharp Mi�+�rams Pair�L..ocatian; L.eft, MidCine, Right Mil�rarns F'ain Radiatiort_ Lumbar Va[s�iva Tes#: Negative t�ft Ye€�man Test: Positive F(ight Y�oman Test: Pasitive Neurai�gi��1 Evaluation Notes:'Bitaferal Nachias test:pasitive for pain in the(ower bac}c. PRt?CEC�lR�S: Page 4 of 5 From�fi�ee L'Isun Fax;(651}35�_Zgg� To: Fax: +t(8771590-$188 Page t&of 3.�.1it2t1kU13 1:10 Vang,Ricky p€inted on 11t21l2013 Gap�tol Chiropract� New Patiertt E/M's:(992{l2) Leve[2 Chiropractic Section: {98941}CMT spinaf 3-4 Unattended Modalities:{97014) EMS, (9701(})HottC�old Pack Therap�utic Procedures:{97124} Massage Therapy Number of Massage urti#s:1 tlAassage uttit one time: 1�minutes Provider: David J Cole � , I I � Page 5 of 5 From:lkatia Ols3rt Faxc 1851)35�-�982 Ta: FaM;_t1 tg77j�9fY816$ Page t2of 32 11121 12013 1,tfi Vang,Ricky p€inted o�s i t/21l2013 �apitol Ghiropractic SOAPICIaim Fvrm Service Date: �0/29t2Q13 Subjective: Ricky Vang preser�ts today with neck, u�sper back, midc�le bac}C and l4wer back pain today. He presents these injuries asa direct result of an automobile cailision on 10-9 6-2013. He states that I�;vvas the driver of a vehicie that was stopped in traffic,whe� he was stn,�ck from behind by another vehicte. He states thaf his syr�toms began afte�tF� co[[ision and are constant in nature. He descr�bes the symptoms as sharp and nof changing at this time. He rates that pain as�n$on a 0-10 pain sca[e. He also states that he feefs a tingling ser�sation in his back and neck a#times,but does not seem to radiate into tHe arms or legs at#his time. Objective:See exam.Subluxatioris nnted below. [[�creased Ceruical and i�umbar/Pelvic ranges of motion with pain thraughout.Assaeiated rnuscle spasms;and tightness with trigger points in the r.eruical,thoracic and iumbar paraspina�,upper, middle and l�wer traps„and bi(ateral lats dorsi. Assessment:}�cute injuries as a direct result of 10-16-2i}13 motofvehicle callision. 847.Q,847_1,847.2, 846.0, 723.1, 724.1,72�.2, 72$.85. �lan/Procedure: Plan is to treat at 3x`s per vueek for 4-6 weeks,v�rith re-evatuation after 12 visits.Adjust Cervical,Thoracic and Lumbar/Pelvic spinal regions as indic�ated. Electrical muscle s#imutation with hot pack to the upper and lower back spinal areas biiaterally for pain retief. Mechanical and manual muscle tnassage work with trigger point therapy as indicated for pain relief,decrease muscle spasm and tensian, and increase fEexibility and` mability. Light stretches to the neck and lower backlextrem'tties to aid in flexibility and mobility. Patier►t was trea#ed at home today and tolerated treaimant very uve(t. Il�af Greated�laim:2071�! Adjus#�rtent 5trip:C1,G2, C6, C7, T'[,T4,T�,T8,T9,T12, L4, L5, SIL, S�R, P Pr�svidet: Davie!J Cole DC Page 1 of 5 �r�,:Katie Clson Fax;tsstt sst-2ss2 t«: Fax: +t ta77}s9o-slsE Pa�e lsof 3�fintnots 7;t6 Vang,Ricky {xinted on i 1121/2013 �2pitol Chiropractic SOAP/Clairn Form Seruice Date: 10/30/2Q13 Subjective: Rieky Vang states that he is still very sore alf over today in the neck, upperimi�idie ba�k and especially,the lower back. He still denies any ra�iiatian into the °arms ar legs. Objective:Subluxations nated below. Decreased Cervical arxi �umbarlPe(vic ratiges of mation with pain throughaut.Associated muscle sp�sms and tightness with t�igger paints in' the cervical,thoracic and iumbar paraspinal�,upper,m[ddle and lowertraps, ar� bilateraC lats dorsi. Assessment:Acute injuries as a direct result of 10-16-2013 rrao#or vehicie callision. 847.C�,847.1,8�7.2, 846.0, 723.1, 724.1, 724.2, 7'28.$5,733.1,739.2,.739.3,739.5. Plan/Procedure: Plan is#o treat�t 3x's per vWeek for 4-6 weeks,with re-evaluatior�after 12 visifs.Adjust Cervical,Thoracic and LumbarlPelvic spinal regians as inciicated. Electrica[: muscle stimulation with hot pack to the upper and lawer back spinal areas bilat�r�ally for pain relief. Mechanical and manual muscle massage work wi#h trigger poirtt therapy as indi�ated forpain relief,decrease muscle spasm and tension, and increase flexibility and` mobilify. Vght stretches to the neck and lower backle�ttremities to aid in flexibility and mobility. Patient was treat�d at home today and tolerated treatment very well. iD af Gr�ateri C[aim:2(�72368 Adjustmertt Strip:C1, G2,:C6, C7,T1,T4,T5,T8,T9,T12, L.4, L5, SIL,SlR, P Provider: David.l Cote DG �I Page 1 of 1 Fram:Katia Galsun Fax:{651)351-2992 To: FaK: +t{8777�a9E1$188 Page 20af 32 11 2 1 720'13 1:16 Vang,Ricky printed on 11l21l2013 Gapital Chiropractic �OARl�laim Fc�rm 5ecv�e Date: 111t31l2Q13 Subjective: Ricky Vang states that he i�abaut the same#�ay: H�:states that he sti![is having a lot of bwer back discomfarf. He hurt his left ankle ar�d foot last night,so he is having a tough time walld�g today. Qbjective:Subluxations noted below. Qecreased Cervical arid LumbarlPelvic ranges of matian with pain throughout.Assaciated muscle spasms and tightness wiEh trigger poir�ts in #he cenrical, kf�oracicand lumbar paraspinals, upper, middi�and lowertraps, and bilateral lats dorsi. Assessment':Acute injuries as a direct result'of 10-'16-ZQ13 tt�farvehicle caEfisian., 847.0,84T.1,847.2,846.0, 723.1,724.1,7242, 728.85, 739.�,739.2, 739.3,�39.�. i Plan/Procedure: Plan is#o treat at 3x's per week for 46 w�ks,with re-eva[uation after 12 I visits.Adjus#Cervical,Thoracic and_Lumbar/Pelvic spinal regiorts as indicated. Electrical ', muscle stimulation with hot pack fa the,upper and lower back spirra}areas bilateralty for ' pain retief: Mechanical and manua[rnuscle massage work wi#tr b'ig9er poirrt iherapy as indicafed far pain relief,decrease muscle spasm arxi t�nsion,and increase flexib"rEity and mobility. Light str�tches to the neck and lov,�er backlextremities tu aid in flexibility an�i i mobilit�r_ Patier�t was treated at horr�e today and talerated treat�nen#very welL ' ID of Created Claim;2474037 Adjustment Strip:C1, C2, C6,;C7,T1,T4,T5,T8,T9,T12, L4,L5, SIL,SIR, P ; Pr�vider. David J Co(e[3C � � � I �I II I I Page 1 0#1 FrSm:Ka6e Olson Fax:(8.�+1}35t-2992 To: Fax: +t�$]7�59Q-81&8 Page 22of 33 i1r112G13 1:1& Van�;Rie{ry P�nted on 11l2112013 Capit�t;Chiropractic SOAP1�Iaim Form Seruice Date: 11/05i�013 Subjective:Ricky Vang states that h�is stilLvety sore in the�xtiddle back and in the law�er ba�k today.He continues to have some dis�rnfort in the neck as well. Objective:Subl�ncations noted below, Decreased Cenrical and Lumbar/Petvic ranges of matron with pain throughout.Associafed muscle spasrns and,t�ghtness with trigger poir�ts in fhe cervical,tharacic and lumbar paraspinals, upper, middle and lower traps, and bilat�erai lats dorsi. Assessment:Acute inju�ies as a direct result t�f 10-t6-2073 motor vehicls catlision. 847;t3, 847.1, 847.2,846.4, 723.1, 724.1, 724.2, 728.85, 739.1, 738.2,739.3,739.5. PtanlProcedure: Plan is to treat at 3x's perweek for 46 weefcs, with re-ev�fuation after 12 visits.Adjust Cervical,Tharacic and Cumbar/PefviG spinal regions as indicated. Electrical rnuscle stimulation witk�hat pack to the upperand lower back spinal areas bi3ateraliy fAr pain retief. Mechanical and trranual muscle massage work wi#h�igg�r point therapy,as indicated for pain relief,decrease muse(e sp�sm and tension;and increase flexibility and mability. Light stretches to fhe neck and lawer back/extcemities to aid in flexibility and mabilily. Patier�t was treated at horne#oday and toferated treatmerrt uery well. 10 r�f Created Claim:207716� Adjtastmer�#Strip;C1, G2,�6, C7,T1,T�,T5,T8,T9,T12, L4, 1.5, SIL,S(R, P Provider: [Y�vid J Gale DC f'age 1 of 1 From:Katia fllson Fax;1651}351-2932 To: Fak: �1�87?p 594-6188 Page 24at 92i112112Gt3 t:i8 Vang,Ricicy prir�ted on t t12112013 t'apitol Chiropractic SOAPlClaim Form Service Date: 1't/06J2t313 Subjective: Ricky Vang states that he cantinues#o have the same discamfort in the fower back and in the middle back areas. He states#hat his neck and upper back alsa are causing some discornfort today. i�bjective:Subluxations noted belnw. Decreased Cervical and LumbarfPe[vic ranges of mafion with pain throughaut.As�ciatecf muscle spasms ar�tightness with trigger points in the cenrical,thoracic and Iumbar paraspinals, upper, middMe and lawer traps,and bilateral` lats dor�i. Assessment:Acute injuries as a direct result of 1Q-16-2013 motor vehicle collision. 847.Q,847.1,847.2;$46.0, 723.1, 724.�, 724.2, 728.85, 739.1,739.2,739.3, 7395� Plan/Rracedure: Plan is t�treat af 3x's per vv�ek for 46 w�eks,with re-evaluation after 12' visits.Adjust Cervical,Thoracic and Lutnbar/Pelvic spinal regions�s indicated. Electrical muscle st'stnulation with hot pack ta the upper and lower back spirral areas bilaterally far pain relisf. Mechanical and`manual muscie massage work with#rigger poirrt therapy as indicated for pain relief,decrease muscle spasm ar�d#ension,and increase flexibitity and tt�bility. Light stretches to the neck and lower back/�xtremi#ies to aid in flexibili#y and mobilify. Patient was treated a#fZOme to�3ay and to[erated treatmertt very welL Ii7 of'Greated C[aim:2077'(74 Adjustment Strip:C9, C2, C6, C7, T1,74, T5,T8,T9,T12, L4, L5, SIL,SIR, P Pravider: C'�avid`J Cole DG Pa�e 1 of 1` From;Katie Ofson Faz:(851}351-2892 70: Far; +1�877p 59u-818$ Page 2fiof 3�11l2f 12Qi�1;t6 lfang,Ricky pnnted on 11/21/2043 Capitoi Chiropractic SCaAP/C�aitn Form 5eruice Date: 91l07/2013 Subjectfve: Ricky Vang states tt�at his lower ba�ck and middle back are still causing a 1a#af discomfo�t taday. He aiso has discomfort in'the neck as welL Objective:Sub(uxations r�ated below, Decreased Cenricaf ar�d LumbarlPelvic ranges of` mo#ion wifh pain throughaut.Associated muscle spasms and ti�htness with trigger poi+�ts in the cenrical,thoracic and lumbar paraspina�, upper,middle and lowertraps, and bilateral I�ts darsi: Assessment:Acute injuries as a direct result of 1Q-1�-2013 motor vehicte callis[on. 847,0,847.1,847.2,846.�, 723.1, 724.1, 724.2, 728.85,739.1, 739.2,;739.3, 739.5. �tan/Pracedu�e: Plan is to treat a#3x`s par v�ek far A�G6 weeks,with re-evaluation after 12 visits.Adjust Cervical,Ttwracic and LumbarlPelvic spina! regic�ns as indicated. Electricat muscle stirnulation with hot pack to the upper and lower back spinal areas bilaterafly for pain relief: Mechanical ar�d manual muscle massage work with triggerpaint therapy as ', indicated for pain relief,decreasemuscle spasm and tension, ar�l increase flexibility and ' �bNity. Light stretches to the neck and lower back/extremities to aid in flexibi[ity and �I mabiliiy. Patient was treated at home today and#olerated tre�tment very well. i 1�of Created Ciaim:2078263 Adjus#ment Strip:C1, C2, C6,C7,Ti,T4,'t"5,T8,T9,`T12, L4, L5, SIL,SIR, F' j � Provider: David J Cole DC '� I � � I � i Page 1 of �; Fram:f��ti�+Qlson Fax:f651}351-2992 To: Fax: +t�$77}�a90-81$$ Page 280(3211t21J2Q13 f:'i& Van9,Ricky printed an 11l21I2018 Gapitol Chlropractic St,1APiCiaim �orm Service aate: 71J19/2013 Subjective: Ricky Vang stafes that he continues to have pain-in tf�e lower back and the rt�iddle back mo�tly today. He also has sorr�pain in the neck and uppe�badc. t�bjective:Subluxations no#ed belaw. t�ecreased Cervical and Lumbar/Pelvic ran�es of mation writh pairr throughout.�ssociated muscle spasms and tightness with trigger points:in the cervic�l,thoracic and lumbar paraspinals,upper,middle and Ivwer traps, and bilateral' lats doFSi. �4SSessrnent:Acute irtjuries as a direct'res�t of 1Q-16-2013 motor vehicle collisian'. 847.0,84�7.1,84�:2, &46,C}, 72�.1, 724.1, 724.2, 728.8b, 739:1, 739.2, 739.3, 739.5, Plan/Rracedure: Plan is to treat af 3x's per week for 4�i weeks,with re-evaluatian after 12 visits.Adjust Cervical,Thoracic and:l.umbar/Pelvic spinal regions as`indicafed. Electrical muscte stimulatidn w�tFt hot paek to the upper and tower back spirra[areas bifater�tiy for pain reiief. Me�hanical and manual muscte massage work with trigg�r poirr#therapy`as indicated for pain relief',decrease muscle spasm and tension, and increase flexibility and mability. Light stretches to the r�edc and low�er back/extremities to aid in flexibility and mobility. Patierrt was treated at home faday and talerated treatmenf"very well. !�of Greated C[aim:2t�81175 Arljustrnent Strip:C1, C2, C�, C7, T1,T4,T5,T8,T9,T'i2, L4, L5,SIL,SIR, P i Provider:David J Cole DC �I � � I I � I Pa�e 1 of 1 Fr�m:Ka6e Olstm Fax:(65i}351-2992' To: fax.:+1�877}�9tF818$ Page 3€7at 32 t7t21t2Q13 t:16 Vang,Ricky printed on 11/2112Qf3 CzpiYal Gniropractic SOAPI�Iaim F'orm S�rvic+�Date: 1111212Q13 Subj�ctive; Ricky Vang states that he is feeling a little befter today,but cc>ntinues to have pain thraughout his back and up into the neck today, Objecti�e:Subluxatiartis noted below. Decreased Cervica!ar�d Lumbar/Pelvic ranges"of motion with pain throughout.Associated mt.�de spasms at�d tightness with trigger pc�ints in the cervical,thoracic and lurnbar paraspinal�,;upper, middle and lawer traps,and biEateraC lats dorsi. Ass�ssment:Acute injuries as a direct resui�of 1 U-16-2013 motor vehicle collisian. 847.{},8d7.1,847.2,846.0, Z23.1, 724:1, 72d.2, 728:8�, 739.1, 739_2, 739.3, 739:5: Plan/Procedttre: Plan is fo Ereat at 3x`s per week for 46 weeks,with r�e-evaluation�t�er 12 visits.Adjust Cervical,Thor`acic and LumbarlRelvic spinal regians as indicated. El�ctricat mus�[e stirr�la�ion vvith hot pack to the uppe�'and lower back spirral areas bit�terally for pain relief. Mechanical and'manual musele massage worK with#rigger poir�t therapy as indir.�ted for pain re(ief,decrease rr�sc#e sp�asm ar�tensian, and increase flexibitity and mobiii#y. Light stretches to th�neck and lower back/�xtremities to aid in flexibility arid mobiliiy. Patier�t was treated a#home taday and tolera#ed treatmen#very wefl. ID of�reated Clairr�::2081472 Adjus#ment S�#rip:C�,C2;C6, CZ, T1,1'4,T5,T8,T9,T12, L4, L5, SIL,SiR, P ; � Proviefer. Dauid J Cole DC � I i ( F"age � �f"1 Fr�m:Ka6e t3[son Fax:(651}361-2892 To: Fax: +1(8�?j 58U-8188 Fage 32of 3211t21YLGt3 t:tv Vang,Ricky printed on 41/21l2Q13 Capitok Chirapractic , �I Pa�e 1 of 1 From:td�ce Ffarris Faz:(651}:57-1400 To: Fax: +t(877)59Q-818$ Page & oC td 122t�9t3 1 t:10 i/ang;Ricky printed an 1 2/02120 1 3 Capita{GhiropFactic' S+aAP/Ctaim �orm Service Da#e: 11118I�013 Subjettive: Ricky Vang states tf�at he continues#o h�ve pain and'discomfart throughout the whale back today,especially in the lower back and in the middle back.Fie is aiso feeling same diseomfort across the upper shoutders and in ihe neck today; Objective:S�bluxa#ions nated below.C7ecreased Cervical and Lum�rlPelvic ranges nf` motion with pain thraughout.Associated muscle spasms and tightness with�rigger poirits in the cervical,thoracic and lur»bar paraspinals,uppe�,middle and lower traps,and bilaterat lats dorsi: .Assessmerrt:Acute injuries as a direct resu(t of 10-1�'r2013 mo#or vehicle coltisian. 847.0,847.1,$47.2,846.0, 723.1, 72�.1,724.2, 7'2$.$5, 739.i, 739.2,739.3,739.5: P[aNProccdure: Pian is to freat at 3x's per week for 4-6 weeks,w"rth re-evaluation a#ter 12 visits.Adjust Gervical,Tho�cic and LumbarfPeivic spinal regions as indicated.Electr�al muscle stimulation wi#h hot pack to the upper and lower back spinai areas bilat�ralty fior pain refi�f. Mechanical and manual musc(e massage work`with trigger point therapy as indicated for pain relief,decrease muscle spasm and tension,and increas�flexibility and mability.Ligh#stretches to fhe neck and lower back/ex#remities ta aid in flexibilify and mabil�ty.F�atient wa5 treated at home today and tolerated treatrr�ent very well. tD�f Great+�d Claim:2t385792 Adjustmen#Strip.C1,C2,C6, C7,T1,T4,fi5, T8,T9, T12,L4,L5,SIL,S[R,P Provider. C}avid J Cale DC i � Page 1 of 1 From�FAika Hsrris Faz:1651}951-1400 To: Fsx. +i(877}59G-8188 Page $ o(101212I2Dt3 11:15 Vang,�?icky printed an 12l02t20'[3 Capitol Chirdpractic SC�aPlClaim Form Service Dat�: 11119J2013 Subjectiue:Ricky Vang states tFrat he is doing a!'rttle better,but continues to have pain in the same areas today. Mastty pain`in the lower b�ck and in the middle back, but a#sa in the neck today. Objectiae:Subluxations no€ed bebw. aecreased Cervical and Lum�rlPelvic range�of motion with�ain throughout.Assaciated muscle spasms and tightness witt►trigger points in the cerv�al,tt�oracic and lumbar paraspinals,upper,middle and lower traps,ar�d bilateral lats dorsi; As�essmerrt::Acute injuries as a direc#result of 10-16-2Q13 mo#ar vehicl�collision. 847.0,847.1,847.2,846.0, 723.1, 724.1, 724.2,728.85, 739.1, 739.2; 739.3,7395. PlaniPrccedure:Plan is ta tceat at 3x's per week far 4-6 weeks,with re-evaluation a�ef 1� visits.Adjust Cervical,Thoracic and L�mtrar/Pelvic spinal regions as indica#ed.Electrical muscle stimulation with hot pack to the upper at�lower back spinaf areas bilaterally for pain retief.Mechanicat and r»anuat muscle massage work'with trigger point therapy as indicated for pain relief,decrease muscle spasm anct tension,and increase flexibility and mobility.Light stretches to the ne�k and lawer backlextremities fa aid in fiiexibility antl mability.Patient was treated:at home today and tolerated treatrnent very'vvell. ID of Greated Claim:2087272 Acljust�nentStrip:C1,C2,C6, C7,T1; T4,T5, T8,T9,T92,L4,'L5,SIL,SlR,P ' Pravider: �avid J Cole DC Page 1 of 1 Erum:Mike Harris Fax:l651i�51•140U To: Fax: +1 t87Tj 59a81$8 Paga 19of't012/112�J13 11i7S Vang,Ri�ky printed on 12/f3212013 Capitol Chiropractic SOAPlGlaim Farm Senrice Date: 19I20/2{�13 5ubjective; Rieky Vang states that he continues to have a lot of lawer l�ck pain.He has some discomfart in the middla a�upper back,as weti as,the neck,but not as bad. dbjecti�re:Subluxa#ions na#ed below.Decrease+d Cervi�al and Lumbar/Pelvic ranges of` motion with pain throughou#.Associated tnuscie spasms and tightness with;trigger poirrts in th�cerv[cal,th�racic and Iumbar paraspinals,upper, middl�and lower traps,and bilateral lats dorsi'. Assessmerrt;Acute injuries as a d�rect result of 10-16-2013 mator vehicle c�llision. 847.0,$47.1,847.2,846.0,:723.1,724.9,724.2, 728.85,739.1, 739,2, 739,3,739.5. P(aNProcedure: Plan is to treat at 3x's perweek for�t-6 wesks,with re-evaluatian after 12 visits.Adjust Cervical, Thoracic and �umbar/Pelvic spinai regions as indicafed. Electr�al muscle stimulation with ho#pack to the upper and lower back spinal areas bilaterally for pain reli�f. Mechanicat and manual'muscle massage work with trigger paint therapy as indicated for pain relief,decrease muscle spasm and tension,and increase flsxibili#y ar�d mobility.Light stretches to the neck and lower back/extremities to aid in f�xibility and mobility.Patient was treated at home today and#olerafied treatment very well:Pa#ient v�i41 be referred foc massage therapy and physical therapy in the next week or so. [�of Cr�ated Claim.`2Q87729 Adjustrnent Strip;C�,C2.C6,C7,T1,T4,75,T$,T9,T12,L4,L5,SIL,S1R, P Pr�vider.David J Cale DC Page 1 of 1 From:htike Natris Fex:f&57)351-id00 To: Faz: +�(877}590-$i$8 Paga 5 af 7 ,12±9121i93 1:37 Vang,Ricky printed on 12/09/2013 CapiEol Ghiropractic SQ1��11f1't FQI'i't'i Service Date: 11126/2£�13 Subjective:Ricky Vang states that he�ontinues ta have considerable disc€�mfort and pain �n the bwer back and in the'middle baekattimes::He aiso has some rteck pain as wel[. Objective<Subluxatians tx�ted belaw.Decr�ased Cervical and l.umbartPelvic ranges of' mo#ion wsth �in throughau#.Associated muscle spasms and tighMess with trigger poirits in the cervical,thoracic and tumbar paraspinals,up{ser,middle and bwertraps,and bilateral [ats dorsi: Ass�ssmerrt:;Acute injuries'as a direct result of�0-16-2Q13 motor vehicle caltision. 847.d,8�47.1,847.2,846.0, 723.1, 724.1, 724.2, �28,$�, 739.1, 73�.2,739.3,739.5. AbQUt the same#aday. Ptan/Pracedure:Plan is to treat at 3x's per week for 4-6 week�,with re-evafuatian after 1'2 visits.Adjust Cenr`�ca(,Thoracic and LumbarlPeNic spinal regians as indicated.Electr�cal rnuscte s#imulatian with hot pack ta the uppe�and lower back spina[areas bilaterallyfo� pain;re(ief.Raller inter-segment tract�on table whert treating in#he of�ice.Mechanica!and' rrtanua!muscle massac�e work with trigger poirrt therapy as indicated for pa in relief, decrease muscfe spasm and t�nsion,and increase flexibility and mobility.Light stretehes to the neckand bwer bacWe�rtrertaities to aid in flexibility and mo�ility_ Patier�t was treateQ at the affice today and tolerated trea#ment very well. Patierrt will f�e refened for m�ssage therapy,physical therapy and pain tnanagement'as needed. ID of Greated C[aim:20.�2647 Adjustment Strip:C1;C2,C6,£7,T1, Td,T5,T8,T9,T1:2, L4,L5,SIL,'Slft, P 'Provider. Qavid J Co[e DC Page 1`of 1 From;Wtike Hsrris Fex:f.851)9�1-14Qu Tc: Fax: rt(877j:590-8188 Page 7 af i 12�9�2Q13 t.37 Vang,Ricky printed an 1?1Q92013 Gapitol Chiropr2ct� �tJAPICIa�m Form Service Date: 11�7/2013 Subjec#ive:Ric{ry Vang s#ates tha#he has a lot of lower E�ack pain nnce again. He sta#es that his lower back pain is right along the bottom"of his lower back and the ttap of the pelvis. He does no#comptain af radiating pain at this time. He also has same discomfort in the micfdle lrack and a Gttle pain in the necktoday. �bjective:Subltixa#ions noted be�w. [)ecreased Cervicai and LumbarlF�elvic ranges;of nr�otion with;pain throughout.Assaciated muscle,spasms and tightness with trigger points in the cenrica(,'#horac�and luml�r paraspinals,upper,middle and lower traps,and bilat�ral lafs clorsi. Assessmerrt:Acute injuries as a direct result of�{?-16-2013 motor vehic[e cc�lfision. 847.0,847'.1,847.2,846.0,723.'I,"724.1,724.2,728.85, 739.1, 739.2, 739.3, 739.5. About the same today. I�b changes today.Re-evafuate on Monday. Ptan/Procedure:Plan is to treat at 3x's per week for 4-6 weeks,with re-evaluation after 12 vi�its.Adjust Cervical, Thoracic and Lumbar/Pelvic spina!�egions as indicated.Roller inter-segment traction table wF�n treating in the affice: Meehanical and manuat muscle massage work with tngger paint therapy as indicated for pain refief,decrease muscle spasm and tension,and increase flexibility and mobility. Light stretches to the neck and lower backfextremides to aid in flexibility and ma6ility. Pa#ie�t was treated at home today and tolerated treatment very weli. Patient wilf be referred for massage therapy, physical therapy artd was referred for pain managemeM t�day. ID af Created Claim:2093644 Adjustment Strip:C1,C2,C6,C7,T1,,T4,T5, T8,T9,T12, L4,:L5,SIL,,SiR,P F'�ovider.�avid J Gole DC Page 1 of 1 �rGm:t�like}{arris Fax:tS51};51-14D6 To:; Fax: +9�87��,590-$188 Fage $ oE 2312J19t2013 4"�:03 Vang,Ricky prinTed�12/i9t2013 Capitoi Chiropractic SGG►APtC�aim Form :Service flate: 12f(Y2/2013 Subjective:Ricky Van�states that he continues to have pain in his lower l�ack,but�,Iso has some in the upper back and micfdle back today. �bjective:See re<exam.Suble�catians noted beic�w. [?ecreased Cervical and Lumbar/Pe[vic ranges of modon with pain throughout,especiaily in the[ower back. Assacia#ed muscte tigh#ne5s with trigger points in the cervical,thoracic and lumbar paraspinals, upper,middle and tawer traps,and bitateral lats dorsi_Mild improvemer�ts in A�i��at�tiPathit�yinjuries as a direct resutt of 1Q-1�-2013 m�tor veh[ele collision. 847.0,847.1,847.2,846.U; 723.1, 724.1,724.2, 728.85,739.1,739.2, 739.3, 739.5. Slight improvements. PIarUProcedure:Can�nue treating at�x's per week for 2-4 w�eks,with re-evatuation after 12 visits.Adjust Cervical,Thor�cic antl LttmbarlPelvic spinal regions as ind�ated. Ro11er inter-segment traction table when treating in the 4ffice.Mechanical and:manual muscle massage work with trigger point therapy as ir�dicated for pain relief,decrease musele spasm and tension,and increase flexibilit�r and mobility. Light stretches to the nPCk and lawer backiextrerrti�es to aid in flexibility anct'mability.Pa#ient was�eated at home today` and tolerated treatment very w�ll. ID af Cr�ated Claim:2095838 Adjustment Strip:C1,C2,C6,C7, T1,T4,T5,T8,T9,T12, L�,�S,SIL,S1R, P Prouider:David'J CoEe OC Page 1 :of 5 �ram:fJiike Hattis Fax:(654)351-14fl0 To: �ax: �f t87Tj SSQ8188 Page 7Qof t31211912Q13 1�:09 Uang,Ricky printed an 42/19l2013 Capitol Chiropractic CDr Exam Farm S�rvice�Iate: 12l02/2013 Si�INE FfIdDINGS: ' Spina(Tenderness LeveF 1:C1-7(3) Spinat Tenderness Location 1:Left,Midline,Right Spinat7enderness Levet 7:71-12{3-4) Spina[Terx��rness I�ocatian 2:Left,Midline,Right Spinat T�nderness Leve13: L1-S1 (4) Spinal Tenderness Location 3:Left,Midlin�,Right S�FT'TISSUE: Sat�Tissue Area 1:cervicat,thoracic anc!lumbosaeral paraspinal,o�cipital,#rapezius, �vatar scaputae, S�M,scalene,rhomboid,and quadratus lumborum muscles Sa�t Tissue Area 1 Side: Left Satt Tissue Area 1 Hypertanicity(0-5}:4 Soft Tissue Are�1 Tet�derr�ess(1�t):4 Soft Tissue Area 2:cervicaf,'thoracic and Iumbosacral paraspinal,occipital,trapezius, levator scapulae, SCM,scalene, rhomt�oid,and quadraius[urrrborum muscles Sofit Tissue Area 2 Side:`Right Soft Tssue Area 2 Hypertonicity{0-5):4 Soft Tissue Area 2 Tenderness`(1-4}:�4 RAN�E�F MOTtON 8 PAi1V: Gervicai Flexian(50 degrees narm�{): miid to moderate decrease Cervica(FlexioR Pain Description.Qull �ervicat �lexion Pairt i..ocatior�:Left,MICIIIf1�.',Right C�NiCaI FI�XIOT'�P�It1 L�V�I;cenricai and u�per thoracic spine- C�rvical Extettsi�n{70 degrees narmal): mild to moderate decrease Cervica! Extensian Pa�nDescription: L?�Il Cervical�xtensian Pain Location: Left,Midiine,Right Cervical Extensicn Pain L�ve1:aeroicaCand upperthoracicspine Gervicat Lt.Lat�lex(45,degrees normal):mild''#o mocl�rate decrease Cervical L.eft Lat+eral Fleatiat�Rain Descriptior�: [3ul1 C�rvical Left l.aferal Ftexiars Pain L.ot�tiur�: Left,Midfine, Righ# Cervical Left t.ateral Flexio�t Pain Levet:cervicai and uppe�thoracic spine Cervical Rt.Lat Fte�445 degrees narmal}:mild to moc#;rate decrease Gecvicn! Right L.ateral F�exion Pain De�criptian:Dull Gervical Right Lateral F1ex€on Pain C,ocatian:Left,Midtine,Right Cervical Right Lateral F(exion Pain i.evei:cervical and upper#horacic sp[ne Page 2 0€5 €rom::Srlike Harris_ fex:(851)351-14Q0 7a �ax: �I i87Tj 590-8188 Paga'ti o4 2312iq9[2413 t3'.Q3 Vang, Ricity printed on t2l19/2013 Capitot Chiropractic Cervica! Lt. Rotatian(8s degre�es normai):�nik{to moderate decrease �ervicaf Left Ra#ation Pain C?escripti�n:Dufl Cervical Left Rotation Pain LacaEion:Lefit,Midfine, Right Cervical Left Rotation Pain Level:cervical and upper thoraac spine' Cervical Rt.Rotation(85 degrees natmal):mi{d to moderate de�crease ' �ervicai Right Rotation'Pain descriptic�n: Dult �ervicai Right Rotation Pain I�c�cation;;Left,Midline, Right Cervicai Ri�ht Rctation Pain Leve[,cervica[a�d upper thoracic spine Lurr�opelvic Flexi�n{9Q degrees normal}:moderate decrease: Lurr�apelvic F(�xian P�in Description:Sharp Lurr�opelvic Fl�xion Pain Locatien:Left,Midline,Right Lurr�opelvic Ftexion Pain Levei: lumbosacral spine Lumbapelvic Extension'(3�degrees normal�: mild to moderate decrease L�umbapelvic Extensivn Pain Qescription:Sharp L,urrtbopelvic E�ttension Pain Lccatian. Lef�,Midline, Right t�,urnbopelvic E�ension Pain Levet: lumbosacral spine Lumbopelvic Left Lateral Flex'tbn(35 degrees normalj: mild to maderaie decrease Lumbopelvic Left Laterai Flexian Fain�escription:Sharp Lurr�pelvic Left Latera(Fl�xion Pain Location: Left,Midlir�e,Right i.urnbapelvic Left Lateral Flexion Fain Level: lumbosa;�ral spin� Lumbop�lvic Right,La#eral Flexion(3a;clegrees nor►nal):mild#o m�tlerate�fecrease l.umbopelvic R'►ght Laterat Ftexion Pain D�scription:Sharp Lumbopelvia Right Lateral�lexian Pain Lcar,ation: LeR, Midline,Ri�ht Lumbapel�ic Right�ateral'Ffexian Pain Levei: lumbosacral spine `Lurf�laopelvic�eft Rotation(3Q degrees norrna!):mild decrease Lumbopelvic Left Rotation P�er�Descriptien:Sharp Lumbapelvic Le�t Rotatian Pain Locatior�:Left, Mitiline, Right Lumbopelvic l.eft Rot�#ion Pain L.�vet:lurnbosacral spine �.urr�bogelvic Right Rofation{�t!degrees ttarma!};mifd deerease Lurr�apelvic Righf Rata#ion Pain Des�ription:SErarp �..Ut"t�JQjJ�IViC Rl�I'1�RO�tlC1T1 F��ift LOCa'FfIOTI. Le�#,Midline,Right Lezrr�opelv�c Ftight Ro�aation Rain E.evel:Iumbosacra[spine C?R�"H�?PEDiG AND NEURt)L.O�ICAL TFS�"ING: E.eft:Shc�ulder Depression Test: Pvsitive LefE Shc�utcler Qepression'Pain`TYpe:Dull Left Shauld�r Depr+�ssion Rain Lacation:Left.Midl"sne �eit 5ho�alt#er[)epression Pain ftadia#ion:Cervicat,Thoracic Right Shou[tler�eptessian Test;Positive Righ#Shoutder Dep�ression Pain Type.QuIE Right Shoulder DepressionPain Location: Midline, Right �tight a�►oulder[3epression Pain Radiaticn.Cervical, �`horacic Sotc'Hatl Test: Posi#ive Page 3 af 5 Fr�m:1�ike Harris Faz:(6511 351-t4Ch� To: fax: ti i877j 590-8188 Page 12of 3312F3SI2Qt3 t�:#13 Vang,Ricky printed�12/19120�3 Capital Chiropractic Sota H�f! Test Pain Type::Dull Sota Hail Test Pain Lc>cation: Left,Midline,Rig�t Soto Hail Test Pain Radiatian:Cer�ical,Thoracic Left Cervical Corrr�xession Test'; Positive Left Cervical Corr�ression Pain'TYpe:Oull Left Cervicai Campressian Patn Locatian:Lefi�, Midline Left Cervical Compressiatt Pa'tn.Radiation:Cervical,7'horacic Righ#Cervicat Compressian Te�t: Pos�ive Right C�rvical Compression Pain Type; Duli Right Cervical Compression Pain Location:Midline, Righ�# Right Cervical Cornpression Pain Radiatian:Cerv�caf,Thoracic LeftStraight Leg Raisin$,Degrees w/Pain:;4pprox.3a!BP l�eft Straight Leg Raising Pain TYpe:Sharp' Left Straight Leg Raising Pain l.:oca#ion:Left, �lidline,`Right Left Straight Leg Raising pain Radiation; Lumbar Right 3traight�.eg Raising degrees w!Pain:Approx.30 f.BP Right S#raight Leg Raising P�in'TYp�e:Sharp Right 3lra�ight Leg Raising Fain Location: Left,Midline,Right Right 5traight�eg Raising Pain Radiatian:Lumbar L�eft Bechterews Test:Positive Left Bechterews Pain Type;5harp LefE Bechtece�rs Pairt Locaticn:Left,Midline,Right Right Bechter�ws Test:Posi�ve Right Bechterews Pain Type:Sharp Right Bechterews Pain�ccatior�: Left, Midline,Right l.eft Kemps Test: Positive l.eft Ke�r+ps Pain Type:Sharp �ef�,Ketnps Pain Lacation:L�ft, Midline, Righf Left Kerr�ps.:pain Ratiiati�n: Lumbar Right Kemps Test;Pasitive Righ#Kemps Fain TYFSe;Sharp Fiight Kemps Pain Lacatifln: Left,Midline, Right Right Kemps Pain Radiatiort:Lum�r Mitgrams Test: Pasfive �lil��ams Pain Type:Sharp Mil�rams P�in Locatiott: Left,Mi�ine, Right- �+filgrams Pain Radiatian: Lumbar Valsalva Tes#:Negative L.e�Yecman Test:Positive Righ#Yearnan Te�t:Pos�ive Neura(c�gicat Evatuati�n Notes:Bilaterat Nachias test positive�or pain in the lawer back, Pain wiih pressure to ihe iower back area. Pain�s bealized to the lower backfpelvic/sacral area. �R�CEDUF3�S: Pac�e 4 of 5 Frem:Mike Hatris Fax.f65t)951-S4DQ Ta: Fax: +�i877j 58Q-6188 Psge 13of 2312i13t2E}13 72�03 Vang;Ricky prinLed on 12/19t20'E3 Capitol Ghiropradic EStBb�ISheC1 F:3ffe1'!t EEtM'S: (99212) �eVB�2 Ghiropractic Section: (98941}CMT spinai 3-4 Unattended:Macialities:(97014} �11AS, (97010}Hot/�o�i Pack Therapeutic Procedures:(97124)-Massage Therapy Mumber a#Massage units; 1 M�ssage unit ane time: 15 minutes Pravider:David J Cote DC Page S of 5 Ftom:P1�ike Hairi� Fax:(651)35t-1dfl0 Ta: Fax: +1�8T7j 590-818& Page 15of Z3 12119J2013 t:.:E23 Van�s,Ricky printeci on 17J1�/2013 Capittsi Chiropractic SC�AP/G�aim Form servrce Datei 12ro3/2a13 Subj�ati�e:Ricky uang states that he is still pretty sore in the bwer back ar�a today. Som�discamfart in the nnidd�e back, upper badc and in the n�k teday; Qbj�ctive:Subluxations noted befow. Decreased Cervica!and LumbarlPeNic raru,�es of. motian with-pain throughout,especially in the lower back;Associated rttuscle tightness with trigger points in the cervical,#I�racic and:{umbar paraspinats, upper, tniddte and lower traps,and bi�ateral lats dorsi.Mild improvements in flexibili#y and mobility. Assessmerrt:Acute injuries as a direct r�sutt of'1Q-16-2013 ma#or vehicle collision. $47:0,847,1,847.2,846.Q, 723.1, 724.1,'724.2,728.85,739.1,739.2,73J.3, 739.5. About the same today. PiartlProcedure:Continue treating at 3x's per week far 2-4 weeks,witF�re-evaluation after 12 visits.Adjust Cervical,7horaci�and LutnbarJPelvi�spinai regions as indi�ated.Roller inter-segment trac�tion t�b1e when treating in the office. Mechanicaf and manual`muscle massage work with trigger point tt�rapy as indicated for pain relief,decrease muscle spasm and tension,and ittcrease flexibilil�r antl mob�ity.Light stretch�s to the neck and {ower back/extremi�es#o aid in flexibility and rr�obility.Patisnt was freated a#home today and tolerated treatment very v�rcelL ID of Created Ciaim:2096�50 Adj�stment Strip:C1,C2,C6, C7, Ti, T4,TS,T8,T9, T12, L4,L5,SIL,SfR, P Prouider:D�vid J Cole DC I I � � Page 1'of'1 From_tA�ce Herris Faz;ffiS1)�51-14R4 Ta Fax: +t(877y 59o-8#88 Page 17ot 2�12f�yt2013 t�:t33 Vang,E2icky printed Qn 12/19/2013 Capitol Chirapractic SO►AP1CIaim Farm Service Date; 12/04f2013 Subjecti�e:Ricky Vang states that his p�in is about the same taday,t�ut states that he has been getdng refief from the treatments khat last severai hours. He states#hat his pain retums, bu#maybe nat as severe as befare. Objective:Subfuxations nated bebw. Decreased Cervical and LumbarfPelvic ranges of' motian with pain throughout,especially in the lower�ck.Associated muscle tightness'vvith trigger points in the cerrrical,thoracic and lumbar paraspinals, upper, middle and Irnver traps;and bi�teral lats darsi. Mild improvemen#s in f[exibility and mobility. Assessmer�t:Acute injuries as a direct result of 1'Q-16-2013 mator vehicle coilision. 847.fl,847.1,847.2,846.0, 723.1, 724.1,72�,2, 728.85,739.1, 739.2, 739.3,739.5. Mild improvement. Plan/Procedure:Con#inue treating at�'s per wveek for 2-4 weeks,with re-evalu�tion after 12 visi#s.Adust;Cervical,Thoracic and LumbarlPeivic spirral regions as indicated. Roller inker-segment traction table when treating in the affice. Meehanicaf and manuaE muscle: massage work with trigger'paint fherapy as irxficated for pain reiiefi,decrease muscle spasm and tension,and increase fl�cibiliiy and mobiiity.l�ight st€etct�s to the neck and lower back/extremities to aid in flexibilify and mobility.Patie�was h'eated at the off�e today ar�d taferated treatment very welL Patient also had massage therapy to�ay. iD of Created Ciaim:20�742� Adjustmenf Strip:C1,C2, C6, C7,T1,74,T5,T$,T9, T12,L4,L5,SIL,SlR,P Provic#r. David J Ct31e DC i� � Pag� 1;:of 1 frem:iv9�Ce Eiar�is Fax:(65`t)351-14C�3 70: Fax: rt t8771 58o-8188 Page 1Saf 2312t�9/2413 i�A3 Vang;Ricky pclnted on 1'7J79i2013 Capi#oI Chirapracnc St3A�'/Claim Farm aervice Date:'12/0912013 Subj�c#ive:Ricky Vang states that he is about t�e same taday with retief fallawing treat►nent,then pain retums in the lower back,mos#ly.A�o,has'pain and discomfort in the midd(e back,u�er b�ck and in the neck. Objec#ive`Subluxations noted below. Deereased Cervicat and Lumbarll�etvic ranges 4f mation with pain throughout, especially in the lower back.Associated rnuscle�ightne�s w�th trigger points in the cerrical,#hc�racic and lumbar paraspina�s, upper, middle and law�t traps,and bilateral lats dorsi.Mild improv�ments in ftexibility and mobility. Assessn�errt:Acute'injuries as a direct result of 10-16-2013 motor vehicle:cotlision. 847.0,847.1,847.2,;846,0, 723.1, 724.1,724'.2, 728.85,,739.1, 739.2, 739.3,739.5. About the same today. PlanlProcedure:Cantinue treating at 3x's per week for 2-4 vreeks,with re-evaluation after 12 visits.Adjust Cervical,Tho�acic�nd�nmbar/Pelvic spinal regions as indicated.Roller inter-segmenttractian table when treating in the affice.Iulechanical and manual muscle massage work with#rigger point therapy as indicated for pain reiief,decrease musele spasm and tension,and increase flexibiiit}r and mobility.Light stretches ta the neck and lower back/ex#remities to aid irt flexibiiit�r and mobitity. Patient rnras treated at Frome today and to[erated treatment very well. ID of Created C[aim:210Q5�7 Adjustment Strip:C1,C2,C6,C7,71, T4,T5,T8,T9,T12, L4,L5,S1L, SiR,P Prouider: E?avid J Cv[e QC Page 1'af 1 fcam:hiikeHatris Fax�,(651}351-1400 70:; Fex: +1(877�59p-81$$ Fa�e 21of331Z�79t20131�:03 Vang,Ricky printed on 12J19/70'[3 Gaptiol Chiropraci� St�AP'fClaim Form Seruice Date:12l1012013 Subjective;Ricky Vang states that he went inta the emergency roo►�n last night with same lower back and stomach pain.He was treated and r�leased and given some medication ta treat s#omacFt and intestine prablems.He states that his low�r track is stilt causing a lot of pain and discomfort. t�bjective:St�bluxations noted below. Decreased Cervical and LumberlPelvic ranges of ' m�tion with p�in throughout,espe�ially in the lowe�back;Associated muscle tigh#ness with tr�99er points`throughout#he'neek�nd whofe back. Assessrn�nt'Acute injuries as a riicect resul#of 147-15-2413 motar vehicJe coEtisian. 847.0, 847.1,$47.2,846.0';723.1,724'.1,724.2,�'2$.85,739.1,739:2,739.3,739.5. No change today. P9ari/Pracedure;Continue treating at 3x"s per week#ar�-4 weeks,with re-evalua#ion,after 12 v�sits.Adjust Cervical,Thor�cia and I..umbadPelvic spinal regions as indic�ated. Rofler inter-segmeni traction table whe�trea#ing in t}�e affice. Mechanicaf and manual muscle massage wark w�th trigger poirrt therapy as indicated for pain�elief, de�rease muscle spasm and tension,and increase ftexibility and mobility._Ligltt stretches to the nect�and lower back/extremities to aid in flexibilit�r a:nd mobility.P�tient was#reated at t�ome today and to(erated treatment very well. ID of'Created Claim:2101311 Adjustr»ent'Strip:C1,C2,C6,C7,T1, T4,T5,T8,T9, T12,L4,L5,SIL,SIR,P Provider:�avid J Cale DC � I Page 1 of 1 Fiom=t��ke Hatris Fax.tESt)351-1A�0 Ta: �af: +S�877�5�0.H788 Page 23of�3 i2+t�f2013 72ti33 Vang,FZicky printed on 12I19/2013 Capitof Chiropractic SOAPICIaim Farm Seruice Date: 12/11I2€�13 St�bjective:Ricky Var�g sfates ttrat his lower'Exick is hurting him again totfay.His middl� back is also causit�g pain today. �bjective:Subluxatians noted below. �ecreased Cerv�a1 and Lumbar/Pelvic�nges of motion with,pain throughou#,especial(y'in the lower back;Associated muscle tightness with trigger point�throughaut the'neck and whole back. .Assessment:Acute injur�es�s a direct result of�0-16-20i3 motor vehiels callision. $47.0,847.'t,847.2,84G.0, 723.1,'724.1,724.2,`728.85,739.i,7392, 739.3,739.5. Nc�Ghange today. P(anlPracedure:Con#inue treating a#3x's per week fo�2-4 weeks,with re-evaivation aftsr 12 visifs.Adjust Cervical,Thoracic and LumbarlF'elvi�spinal regions as indicated. Roller inter-segmen#tractian#able when treating in the office. Mechanica!and manual rrtuscle massage work with trig�r point tf�rapy as indicated far pain relie#,de�c�ease muscfe spasm and ten�ion,and increase flexibility and rrtob�ity.Light st�e#ches ta the neck and low�r backfe�remities to aid in flexibility and mobility. Patient was treated at tf�e office today and tolerateti ireattt�ent very welt.Patient a�so had massage therapy taday. ID of Created Glaim:2103323 Adjustmen#5tri�:C1,C2,C6, C7,T1, T4,T5,T8,T9,T12,L4,L5,S1L,SIR, P Provider:C3avid J Cole DC � Page 1='af 1 From�Mike Harris fax:f$51)35t-i40t7 To: Fax: +1�877�58�8168 Page 6 of t01!'�_f2014 tQ;21 Vang, Ricky printed on Q1/02l2p'f4 Cap�tof Chiropr��ctie SCJ►APl�laim Form s�r��r��: 12/16J2013 Subjective:Ricky Vang states that he has been having a lot ofi stt�mach pain and will be going to see his family dactor tomorrow.He staEes that he c�rttinues to have same discomfort and pain in the lower back and in the upperlmidd[e k�ck areas. Llbjective:Subluxatiorr�nated 6elow. Decreased Cervical and Lumbar/Relvic ranges of motian with pain th�oughout,especially in the lower back:Associated muscts tightness with trigger paints throughaut the neck and whofe back. Assessmer�t:Acute injuries as a direct result of 10-16-2Q13 motor v�hicie collision. f347.0;847.�,:$47:2,$4�.t};723.1, 724.1,7�4.2, 728.85,739.1,739.2;�39.3,739,5. No change t�ay. Plan/Procetlure:Continue treatin�at 2-3�c"s per week for�-4 weeks,with re-evalua#ic�n after 12 visits.Adjust Ceroicai,Tharacic and LumbarJPelvic spinal regians as indicated. �oller inter-segmenttraction fiable when treating in tf�affice.Nfechanicai and manuat rt�usc[e massage work with trigger point therapy as indicated far pain relief,decrease muscfe spasm and tensio�,and increase flexibility at�d mobility.Light�tretches to i�te neck a�d lower back/extremities to aid in flexibifity and mobility. Patient was treated at home today and toierated treatment very wetl. ID t�f Created Claim:2105823 Adjustment Strip:C1,C2,C6, C7,T1, T4>T5,T8, T9, T12,1�4,L5,SIL,SIR, P Prdvider. Qavict J Cole DC � I � f�age 1 of� �rotit:tr4ike'Harris Faz:tn"StY 351-tAOu To: Fax. +1�87J�590-8188 Page$ vf 101t^J2014 10�1 Vang,Ricky printed an Oif02I201d Capitol�hirap�at�ic:: SC)APICIaim �orm Service Qate:12l18/201.3 5ubjective:Ric[ry Vang statesthat lte(eels a 1ittle befter after his treatmenfs for a short time,but he�s stiN having a lot of,pairt,in the lawer back and micidle back areas�. He also notes that he has been having a lot of stamach pain,which he has t�een seeing a medical doc�ar far. Qbjectiue:Subluxatrons noted below.D�creased Cervica(and Lumbar/Pelvic ranges of rnotion with pain t�roughout,esp�cial(y in the lawer back.Associated rnuscle tigh�ess with trigger points throughout the neck and whote back. Assessmer�t:Acute`injuri�s'as a direct result of 10-16-2013 mator vehicle caNision. 847.Q 847,i,847.2,846.d,'723.1,�24.1, 7�4.2, 72$.8a,739.1,739.2;739.3,739.5. Mitd impravement. PiaNP�ocedure:Treat at�'s per week.Adjust Cervical, Thoracic and Lumbat/Pelvic spir�I regions as ir�dicated.Roller inter-segment traction table when treatirtg in the o�ce, Mechanieal and rr�anual muscle massag�work with trigger point ther�py as ir�icated for pain relief,decrease muscle spasm and tension,and increase flexik�ility and rt'►obility.Light stretches to the neck artd lower backlextremities#o aid in flexibility and'mobili#y.'Pa#ient was trea#ed at the office today and ta(e�ated treatment very well.Patient had massage therapy today as well. ID of Created Claim:21Q8335 Adjustme�t'S#rip:C1,C2,C6,CT,T'l,T4,T5,T8,T9,T12,L4,L5,SIL,StR,P Provider: David J�ule DC Page 1; of 1 �rorri:Rd�cca Harris Fax:(65i}3:1•t4Du To: Fs�: f1 i$�7�5946f88 Page't0af 1G 1!'�12Q14 1027 Vang,F2icky printed an{Ytf02/201d �apitol Chiropractic= .5`i(��P�ti�11t't"1 �OCt1'1 Service Date: 12l23f2�13 Subjective:Ricky Vang sfates that he continues tv have some �ain in the lower'back and in the r�idslle back mostly.He does have some discatn#ark in the neck and upper;back areas,but nat as bad;.He states that he feets a little better after treatments for a while,then pain will return. Clb�ctive.St�6tuxations noted betow. Decreased Cervic�al anc!Lumb�rlF'elvic ranges of motian with pain thrc�ughout,especially in tfie tower back.Associated muscle tightness with trigger pr�ints throughout the'neck ar�d whole bac�. qss�ssmer�t:Acute injuries as a direct resu�t of 1t}-16-2�13 mator vehicle collisian. &47.Q,:847.1,847 2;$46,0, 723.1,724,1,724.2, 728.85,739.1,739.2,?39.3,739.5. About the same today. PIaNProcedure:Treat at 2x's perweek.Adjust Cervical,Thoraci�and Lurr��r/Petvic spinal regionsas indicated.Roller inter-segmen#traction table when trea#ing in the uffice. Mechanica!and mar�ual muscle massage work with trigger paint therapy as indicated for pain relief,decrease muscle s�asm and tensior�,and incr�ase flexibility and mobilify.Light stretches ta the neck and lower back/extremities to a'sd in flexibility and mobility.Patient was treated at the office today and folerated treatment very well.Patient had massage therapy today as welL Id vf Crea#ed-Ctaim:211Q392 Adjustment 5trip:C1',C2,C6, C7,T1,T4,T5,T8,T9,T12,L4,1�5,SIL,SIR, R Rravider: David J Cole DC Page 1`af 1` From:tdike Harris Fax:t8�11351-140t? To: �ax:+1 j877�590-5188 Page S af 7 1/13i20i4 1:Qo Vang,Ricky printed un Ot713J2014 Capital Chiropractic SQAPICIaim Farm Se�uic�C}ate:1213Qf2�13 Subjective:Ricky Vang states#hat he that he has same lawer Irack and middle back discomfort once a�ain.He states that his r�eck and upper t�'a�k are a[ittle improved today. pbjective:Subluxatior�s noted belov�+. Dec�eased Cervical and Lumbar/Pefvic ranges of mation with pain thraughout,especially in tt�lower back.Associated muscEe tighfiess with trigger points thrdughout the neck and whale b�ck. Assessment:Acute'injuries as a direct result of 10-16-2013 motor vehicle callision. ' 847.0,847.�,847.2,846.0, 723.t, 724.1,724.2, 728.85,739.1,739.2, 7'39.3,739.5. l�tlild improvement today. PIaNProcedure:Treat af?x`s per week.Adjust Cervicai, Thoracic and Lumbar/Pelvic spirrai reg�ns as indicated. Fioller inter-segment traction tabl�when tteating in the offic�. Mechanical and manual muscle massage worlc with trigger,pain#therapy as i�icated for pain re�ief,decrease musc{e.sp�sm and tension,and increase flexibility and mobility.�.ight stretches to th�nacic`and Eawer backfe�ctremifies to aid in flexibiti#y and mabi(ity.Pa#ient was#teated at the office taday and tolerated treatment ve�r welt.Patieht h�d massage therapy today as wel1. I�of Greated Claim:2113547 Adjus�trnent'`St�ip:C1,C2,G6,C7,T1,T4,T5,78,T9,742, L4,`L5,SIL,SlR,P Pravit�x:Qavid J Ct�le UC Page 1 of 1 fram:tvitka Hxtis Fax:{&51�351-i4Qfi To: Fax. r1(877t 58Q-8188 Page 7 af i 11t8F?Qid i:US Vang;Ricky priflted an 0'EF131201A Capikof Ghirvpradic � SC�APICIaim farm Senrice Date:01i�812a14 Subjective:Ricky Vang states that he continues ta have some�wer baek and stamach> pain at times.He states that fie feels a titt[e better after each treatment, but that the pain continues to come back.He reports that he will not be avai�able#a trsat for the neact few weeks,but wilt be treafing again ance he g�ts back ir�ta town. Objective.Sublux�tians noted below.Qe�reased Cervical and Lumbar/PeMvie ranges of' motion w�h pain throughout,'especia[ly in the lower back.Associated muscle�ghtness with trigger points througtxiut the neck and whole back, Assessment:Acute injuries as a direct resuit of 1Q-16 2013 motor vehicle callision. 847.0;847.1,847.2,$46.0,723.1,724.1,724.�, 728.8�.739.1,739.2,73�.3,739.5. Mild improvement taday. PIaNPracedure:Treat at 1-2x's perweek.Adjust Cervical,Thoracic and Lumbar/Pelvic spinal regions as indicated.Rolterinter-segment#raction table when#reating in the office. Mecl�tanical and rr�anual muscle massage work wi#ti trig,ger poirtt therapy as�indicated for pain re_fie#,decrease mus��e spasm and tension,and increase flexibility and mability.Light stretches to the neck and lower back/ex#�emities to aid in fiexibility and mobility.Patient was treated at tlie office today and tolerated treatmeM uery weq.Pa6ent had massage therapy taday as well.Patient will be out o(tawn until mid February.Treatmet�t wilF start back u�r ance he retums. ID!of Greated Ctaim:2123Q65 Adjustmen#Strip;C1,C2,Cfi, C7,T1,T4,T5,T8,T9,T12, L.4,�5,SIL,;SIR,;P Provider:Davic!J Cola DC Page 1 of 1 � fr�m_Fdike Harris Fax:f65tp951-4440 Ta: Fax: +t�87Tj 59G-8188 Page 5 0[i 212g�«U147:1� � i Van Ric printed c�02I28/2014 �apifvl ChiropracFic � 9, � �Y i i St'}APl�laim Fo�rm Servic��ate.02/17I2014 Subjectiv+�: Rieky iLang states that he was an a#rip out of tt�country for the past sevetal weeks. He states that his lawer back co►titinuss to cause some significattit'discomfort at tirnes.He states that his neck and upper back haue improved greatly and at this time,are nvt causing any pain. He states tha#he feels very sare and stiftin the[ower back area and sametimes has shoating pains. �bjective:Subtuxations nated bebw.lmproved Cervical and�umbar/Pelvic ranges of motion with pain it�the lower back. Pain stays bcai in the lower bac�C area. lt does not radiate down tt�e legs.Associated musc[e tightness with�rigger pairits thrr�ughout the neck and who(e back. Assessment:Acute injuries as a di�ect result af 1a-16-2013 motor vehicfe colGsion. 847.t1,847.1,847.2,846.Q, 723.1,724.1,724.2, 728.85,738.1, 738_2,739.3,739.5. Impraved in the neck and upper back areas.Cantinued lower back pro6lems with intermittent ta frequent pain. Plan/Pracedure:Treat at 1-2x's per week.Adjust Cervica[,Thoracic and I�umbadPelvic` spinal regions as int{icated. Roll�r inter-segmerrt traction table when treating in the o�ce. Mechanicai antl mar�uaf muscle massage workwith trigger point therapy as indicated for pain relief,deaease muscle spasmand tension,and increase flexibilityand mobility.Ligh# stretches ta the neck and�awer backlextremities Eo aid in flexibility and mobiliiy.Pa#ient was trea�c#;at the office today and tolerated treatmer�t very well.Patien#had massage therapy today as t�vell. [p o#Created Glaim:2151{l�3 Adjustmet�t Strip'C1,C2,C6,�7,71,T4,'T5,T8,T9,T12, L4,L5,Slt_,SIR,P Provider:�avid J Cale i]C Page`1 af 1 I i From�:hA��Nartis fez:t&5ft 351-14th7 70: �ax: +1{877)590-8188' Rage 7 of i '-J''�?014 7:i2 ' , Vang,i�icky printed on�2t282014 Capitol Chiropracfic � �t�APlClaim �aCm Service Date:0212U/2C114 Subjecti�+e:Ricky Vang states that he cor�tinues t� h�ve same disoomfa�t mostly in the 'lower back and middle back.He st�ates tFrat he con#inues to feel better in the neck and upper back are�s. Objective:5ublu�tatiaris noted betow. Improved Cerv�a[and LumbarlPelvic ranges'of mation with pain in the bwer back. Pain stays bcal in the iower back area. I#does not radiat�dQwn the legs:Associated muscle tightness with tric„�er points throughout the neck and whole back. Assessrner�t:Acute injuries as a direct resuit of 10-1fi-2�13 motor vehicle collision. 847.fl,847.1,847.2,84fi.0,`723.1; 724.1,724.2, 728.85,739.1� 739.2, 739.3,73J.5. Improved in the neck ar€d upp�r back areas.Contin�:ci lower back problems with intermittent to frequent pairr. RlanlProcedure:fireat a#1-2x's per we�k.Adjust Cervical,Thoracic and'LumbarlPelvic spina[regions as indica#ed.Roile�inter-segment traction ta�e when treating in the aff�ce. Mechanicaf and man�,ral muscle massage work with trigger point therapy as indicated for pain reGef,decrease muscle spasm�nd tension,and increase flexibility and mobiiity.`Light stretches io the neck and lower backlextremities to aid in flexibility`and mobility.Pafient was�eated at the office taday and to�rated treatment very rvell.Patient was scheduled'to have a rrtassage today and also to be evaluated for physical therapy today. lD of Created Claim:2153684 Qdjustmen#Strip:C1,G2,C6,C7;T1,T4,T5,T8,T9,T12, L4,L5,SIL,S1R,P Provider;Dauid J Cole DC �ge 1 of� Va�g.F�icky D�nted or►:03I1fli2016 Cap�ol Chir�raclic I t�1��--�;�-`''�,'o='�v-�-�d ��—�s'::�l � S�APtCI�im Form Servlce Date:02l2sf20�4 :SubjectiYe:"Ricky Vang states that he is feeting'pre#€y'good today,but states that his lpwer back stili:�s giving him the;most discomtart.He states that his ne�k and upper ba�k are fee}ittg a tittle bettet. QkaJective: Subtuxatians notsd below. Impraued CsrvicaE and LumbadPelvic ranges of ' motion with pain in the lawer back.Pairt stays kscal in the lower back area.it does not radiate dowR the l�gs.Ass4ciated muscl�tightness with trigger paints thrvughaut the neck and whote b�ck. Assessme�t:Acute inju�ies as a direct result of 10-16 2013 ma#orvehicle coElision. 847.0, 847.1,847.2,84�.0,723.1,724.1, 724_2,726.85.739.1,739.2, 739.3, 739_5. Improved in the r�eck and upper baGlc areas.Continue�lawer back prablems with : inteimittent to frequenCpain. plan/�'rocedure:Treat at 1x per week.Adjust Gervical,Thoracic and Lurnbar/P�Ivic spina[ ' region5 as indicated.�o#ier inter-segmeni Vaction tabie wi`�e�i trrating��Ehe v�F�. ,.__ _ t�lechanical and manual musd�massage woric with trigger paint therapy as En sca e �r pain relief,dec€ease muscle spasm and tension,and incxease flexibilit5r and mobility. Light stretches to�e neck an+d lawer bacWe�ctremities tn aid in flexibitity and mvbility.Patient was treated at the a�ice#oday and t�le�'ated Ereatment very welL Paiient was scheduled ta have RhYsica!thetapy today. ID of Created Claim:2157812 Adjustment Strip: G1, C2,C�,C7,Ti, T�,1`5.T8,T9,Tt2, L4,L5*SiL, SER, P Prcvid�r: Qavid.i Cofe DG Page 1 af 1 Vang.Ricky pririted on 03itO12014 ' Capitol Chiropracilc" �-�-a�---4'��`�" �—�ir�s4 w "�`� sa��ct�►�� Fa� S�rvice[)aEe:Q3i(}512t314 Sub}ectivet Ricky Vang states that he is having sQme cc�ntinued lower badc and midd(e back pain and discomfart tafay. He states that the pain in his neck and upper back have im�taved. abjective: Sub[uxafions nated beiow. Improved Cervicat and LumbarlPeivic ranges of ' motion with pain in the lawer back.Pain stays locat in the lower back area. ft daes nat radiate dau4rn tf�e{egs.Assocaated musde tightness with'trigger�ints thrc�ugh4ut t�e neck and whole back. pssessmeM:Acute injuries as a direct result of it?-16-2013,motor vehicle co3tision. 847.Q.84T.1, 847.2,846A,723.1,724:1,724.2,728.85, 739.1,739.2,739.3.739.5. lmproved in the neck and uRper back areas.Continued loarer back probfems:with intermitten#to frequent pain.Abau#the sarr�today., P1an/Proc�edure:7reat at 1 x per week.Atijust Cervical,Thoracic and 4umbar/Pelvic spinat` i�yicit��as i�li,iie:ate�.RCsli�r inter-��grtieni tr��c,n tab�E when tre�tit�y ir�t�o€�ce. Mechanicai and manuaf mu e massage wa fngger polnt erapy as m �cate or pain reiief,decrease musde spasm and tensaon,and increase�exibility and rr�obilitiy.Light' stretches to fhe rie,cic and tower backlextremfies to aid in flexihitity and mobifity. Patient was treated at the office t�clay and#olerated treatment uery wel1.Patien#was scheduled to have physica!fherapy today., 1�of Created Cfaim: 2'i�i2554 Adjustment Stt'ip:C1, G2,C6,C7,71,T4,'i5,T8,79,T12,L4, �5,Sll.,SIR,P Provi�er: David J Cole dG Page 1 of 1 From:Mike Hairis Fax:{651)351-i400 Ta: Fax: +t y877J,590-8i89 Paga 6 of 10Q41EI212014 9:d2 Vang:f2icky printed on D410il�014; Capitol Chirapractx:; SO�P/Ciaim Form Service Date:�3f1212a14 Subjective:Ricky Vang states that'he is doing better at this visit,but con#inues#a have sorne discomfort in the lower back and in the middle back areas today. tJbj�ctive:Subluxatrons nated below. Improved Cervical and C,umbar/Pelvic ranges of motian with pain in#he low�r back. Pain stays local ir�the lawer back area. It does not radiate down the�egs.Associated muscie tightness with trigger poirds thraughaut the neck and whole back. Assessrnerrt:Acute injuries as a direct result ofi 10-16-2413 motorvehiele collision. 847.�,&37.1,847.2,846.0, 723.1, 724.1,7242;728.85,73�.1, 739.2, 739.3,739.5. Improved in the neck;and upper back areas.Continued bwer back problems with intermitteni to frequent pain.About the same today. PIaNProcedure:Treat at�x per we�k.Adjusf Ce�v�a(,Thoracic and LurnbartPelvic spinal regions as indicated.Raltet intet-segment traction table when treating in the office. Mechanic�l and manual muscl�mas�age work with trigger paint therapy as indicated for � pain relief,decrease muscle spasm and tension,and increase f�xibility and mobility,Light stre#ches to the r�eck and lower backlextcemities ta aid in flexibility and mobility.Patienf was trea#ed at the office today and#olerated treatment very well. 1Q af Crea#ed Claim:217Q030 Adjustment Strip:C1,C2,C6,C7,T1,T4,T5,T8,T9f:.1'12, L4,L5,SIL,SIR, P Provicter:�avid J'Cole['�C E'age 1 of 1 Ffom:Mike tiarrES Fax:(651)35f-140� To: Fex: +1(877)5348188 Page B of 1 Q04R}22014 9:42' ; Vang,Ricky p�inted o�Odtbif2054 Capitol Chiropractic 5�AP1C�aim Form 5etuice`Qate:03/19f2014 5ubjective: Ricky Vang states that he is not feeling very well at th+s visit.He states that he has s�me should�r pain,as well as,some neck,upper back and lower:back today, C3bjective:Subfuxations noted below.Sam�decrease in Cervical anci Lumbar/Pelvic ranges o€mation with continued pain in the lower back with movemer�t.Associated muscte tightness with trigger points fhroughout the neck and whale back. Assessmer�t:Acute injuries as a direct result of 10-7fi-2013 motor vehicle c411isian. 847.0;$47.1,847.2,$45.0,:723.1, 724.1, 724.2,728.85,739.1,739_2,739:3,739.5. Improved ir�#he neek and upper back�reas.Contint�d lower back problems wifih intermiittent to frequent pain.Abau#the same today. PIanlProcedure:Continue treatit�g at 1x per week.Adjust Gervical,Ti�oracic and LumbarlPelvic spinal regions`as indieated, Roller'inter-segment traction ta61e when tr�a#ing; in the affice.Mechanical and manuaf muscie rnassage work witis#rigger poir�therapy as indicated for pain reGef,decrease muscle spasm and tension,and increase flexibility and triobility.Lig#�t stretches to the neck and lower�ck/extremities to'aid in flex'tbility�nd mobility.Patien#was trea#ed at the off[ce today and toleratecl treatment very wel!_ iD of Created Claim:2174849 Adjustment Strip:G1,C2,C6,C7,T1,T4,T5,T8,T9,T12,l4,L5,SIL,S1R,P Provider: Davic!J Cole C}C Page 7 of 1' Fram:Mike Nattis Fax:(651j 351-i404 To: F�: tt(87�}590�81$8 Page tOaP 1004A2f2014 9A2 Vang,Ricky printed on 04101l2014 Capito!Ghirnpractic S��`/�I�,it1'1 FOt711 Service C?a#e:03l26/2014 Subj�ctive: Ricky Vang stat�s that he is t�aving some pain in the middle back area and:in the lower back area once again. Qbjective:Subluxa#ions noted below.Some decrease in Cervica!and Lumbar/PeEvic ranges af motion with continued pain in#he lower back with tnovement.Assaciated muscle tightness with trigger points througk�utthe neck and whole back.Qbjective findings are#he same taday, Assessment:Acute injuries`as a direct result af 10-16-2013 rr�tar vehicle collisian. 847.0, 847.1,$47.2,846.6, 723.1, 724.1,724.2, 728.85, 7�8,1, 739.2, 739.3,739:5. Improved in the neck and u�er track areas.Cc��ttinued lawer back problems with intermittent to frequent pain.Abaut the same today.No changes. P#arURrocedure:Continue treating at 1x per week,Adjust Cervical,Thora�ic and Lumbar/Pelvic spina!regions as indicated. Roller.irrter-segme►�t t�actian tabfe wt�en treatPng irt the office. Nteehan�al and manual muscle massage work with�ig�er poitit the�apy as; indicated for pain retief,decrease musc{e spasm and tension,�nd inccease:flexibitity and mobility.l.ight stt`etches to the neci�and lower back/extremities#o aid in flexibility and mobility.'Patient was#reated at the office#oday and tolerated treatment very well. Id of C�eated Claim:218023$ Adjustment Strip.C1,C2,G6, C7,T1,T4,T5,T8,T9,T12, L�,L5,S1L,SIR, P Provider.David J Cole DC Page 1 of 1 Fr�m'Mike Flarris Fax:(657135t-140t} To: Far: +1(877j 590�8968 Page 5 of 7 04�15l2014 2:05 Vang,Ricky ptinted on€k!/15J2014 Capitol Ghiropractic S�AP/Claim Form Service Date;04/02i2014 Subjective:Ricky Vang states that he is feeling pretty sick today.He states#hat his lawer back and middle back continue to cause discomfort af times. His neck and upper back seem to be doing a little bette�. Objective:Subluxatior�s noted below. Decreases in Cervical and�umbarlPetvic ranges of motion with some pain in the lower back with movemerrt.Associated muscle tightness with trigger points throughout the neck and whole back. Assessmerrt:Acute injuries as a direct result of 10-16-2013 motor vehicle collision. 847.4, 847.1,847.2,846.0, 723.1, 724.1,724.2, 728.85,739.1, 739.2, 739.3, 739.5. Intermittent pain. PlanlProcedure:Continue treating at 1x per week.Adjust Cenrical, Thorac�and �umbadPelvic spinal regions as indicated. Raller inter-segmerrt traction tab�when treating in the office. Mechanical and manual muscle massage work with trigge�point therapy as indicated fo�pain relief,decrease muscle spasm and tens�n,and inc�ease flexibility and mobility.Light sVetches to the neck and lower back/extremities to aid in flexibility and mobility.Patient was treated at the office today and toierated treatment very wel1. ID of Created Ctaim:2185904 Adjustment St�ip:C1,C2,C6,C7,T1,T4,T5,T8,T9,T12,L4, L5,SIL,SIR,P Electronically�eviewed and signed by: David J Cole DC Page 1 nf 1 Frem;M�Ce Harris �ax:(85t}351-140u To: Fax: +i�877j 598-8188 Page 7 of T 04115I20t4 2:05 Vang,Ricky printed on D41152014 Capitol ChiropraCtic St3AP/Claim Form Service Date:Q4/09/2014 Subjective: Ricky Vang states that he is feeling a little better today,with some discamfort in the lower back and middle back once again. Objeetive:Sublwcations noted below. Decreases in Cervical and l.umbar/Pelvic ranges of motion with some pain in the lower back with movement.Associated muscle tightness with trigger points throughout the neck and whole back. Assessment:Acute injuries as a direct result of 1Q-16-2013 mator vehicle collision. 847.0,847.1,847.2,846.0, 723.1, 724.1,724.2, 72$.85,739.1, 739.2, 739.3,739.5. Intermiftent pain. PlanlProcedure: Continue h'eating at 1x per week.Adjust Cervical, Thoracic and LumbartPelvic spirral regions as indicated. Rolter iryter-segment trection table when treating in the office. Mechanical and manuaE muscle massage work with trigger poir�t therapy as indicated for pain relief,decrease muscle spasm and tension,and increase flexibility ar�d mobiliry.Light stretches to Ehe neck and lower backlextremities to aid in ftexibility and mobility.Patient was Ereated at the office today and toferated treatmer�t very well. ID of Created Claim:2191355 Adjustment Strip:C1,C2,C6,C7,T1,T4,T5,T8,T9,T12, L4,L5,SI�,SIR, P Electronically reviewed and signed by: David J Cole DC Page 1 of 1 From:ldtke Harris Fax:(651)�51-14ih7 To: Fax: +7 i877�590-8188 Page 4 of 4 0412412d74 10:35 Vang,Ricky printed on 04l24l201A Capitol Chiropractic SOAPfClaim Form Service Date:04/16l2014 Subjective:Ricky Vang states that he corrtinues to have pain and diseomfort mostly in his tower back, but that he is feeling a fittle better tatJ�ay. Objective:Subluxations noted bebw. Qecreases in Cervical and Lumbar/Pelvic ranges af motion with some pain in the lower back with movemertit.Associated muscle tightness wi#h trigge�paints throughaut the neck and whole back. Assessment:Acute injuries as a direct result of 10-16-2013 motar vehicle collision. 847.0,847.1,847.2,846.0, 723.1, 724.1,724.2, 728.85, 739.1, 739.2, 739.3,739.5. Intermittent pain. Mild improvement today. PlantProcedure:Continue treating at 1x per week.Adjust Cervical, Thoracic and Lumbar/Pelvic spirnal regivns as indicated. Roller inter-segment tractian table when treating in the office. Mechanical and manual muscle massage work with trigger poir�t therapy as indicated for pain relief,decrease muscle spasm and tension,and increase flexibility and mobiiity. Light stretches to the neck and lower backlextremities to aid in flexibility and mobiiity. Patient was treated at the office today and tolerated treatment very we0. ID of Crea#ed Claim:2996865 Adjustment Strip:C1,C2,C6,C7,Ti, T4,T5,T8,T9,T12, L4,�5,SIL, SIR,P Electtonically review�ed and signed by: David J Cofe DC Page 1 of 1 Capitol Chiropractic & Rehab, PC 1959 Sloan Place, Suite 230 Saint Paul, MN 55117 �� : a�e�:=��;t}�121�2��F.:� ,. . �� ,..:... : Ac�ou� 40�-�4��3(l� .,, : ; �[i�ti p�trtert��:��i��re�es�or��€��r,t��as.idr�rss��€!��. , > , � F . Pa#i�Name:'��/rlfl�; ��Ckjf Ratgen, Bradley ,a,,,o��,�io�as �'�� °' 1821 University Ave, Suite S-154 Saint Paul, MN 55104 - F�TeaSe includ±��#Arc�unt#on yocir checic[ _ ___________________°-°°---°-_________.---°---PIease Detach and Return The Above Por�ian With Your Payment«-°-----°_____°--------._______-_-______________ Claim#:2071504 O�ce or other outpatient visit for the evaluation ��0 99202 $190.00 $190.00 10/29/2013 and management of a new patient,which requires Claim#:2071504 Spinal,three to four regions 8470 98941 $80.00 $270.00 10/29/2013 Claim#:2071504 Electrical stimulation(unattended) gq�0 97014 $40.00 $310.00 10/29/2013 Claim#:2071504 Application of a modality to one or more areas;hot ��0 97010 $30.00 $340.00 10/29/2013 or cold packs Claim#:2071504 Payment by Nationwide Insurance 12/18/2013 $190.00 $150.00 Claim#:2071504 Payment by Nationwide Insurance $80.00 $70.00 ' 12J18/2013 Claim#:2071504 Payment by Nationwide Insurance 12/18/2013 $40.00 $30.00 Claim#:2071504 Payment by Nationwide Insurance $30.00 $0.00 12/18/2013 Claim#:2072368 Spinal,three to four regions 10/30/2013 ��0 98941 $80.00 $80.00 Claim#:2072368 Electrical stimulation(unattended) gq�0 97014 $40.00 $120.00 10/30/2013 Claim#:2072368 Application of a modality to one or more areas;hot ��0 97010 $30.00 $150.00 10/30/2013 or cold packs Claim#:2072368 Massage,including effleurage,pertrissage and/or ��0 97124 $35.00 $185.00 10/30/2013 �Potement(stroking,compression,percussion)per Claim#:2072368 Payment by Nationwide Insurance 12/18/2013 $80.00 $105.00 Claim#:2072368 Payment by Nationwide Insurance $40.00 $65.00 12/18/2013 Claim#:2072368 Payment by Nationwide Insurance $30.00 $35.00 12/18/2013 Claim#:2072368 Payment by Nationwide Insurance 12/18/2013 $35.00 $0.00 Claim#:2074037 Spinal,three to four regions 8470 98941 $50.00 $80.00 11/01/2013 Claim#:2074037 Electrical stimulation(unattended) g470 97014 $40.00 $120.00 11/01/2013 Claim#:2074037 Application of a modality to one or more areas;hot ��0 97010 $30.00 $150.00 11/01/2013 orcold packs Claim#:2074037 Massage,including effleurage,pertrissage and/or g470 97124 $35.00 $185.00 11/01/2013 tapotement(stroking,compression,percussion)per Tota1 Charges= 'fis#aF Payments 'ia 1N�7te-O�s :;='MTnfmu�►Dae`' Aimt I)�+a ' �. :' , � ,. , �..' ; � k� �: � �� ' � ' .: < ,. �..�.. . Capitol Chiropractic & Rehab, PC 1959 Sloan Place, Suite 230 Saint Paul, MN 55117 �� ee:'0�121/2Q14':. ': account�: 405-445302 . . �il all p�ym�nts�nd correspnndenc�fa t�ie adciress abaual Patient Name•' �/r1tt�;,}�IC{C�( Ratgen, Bradley ,an,w,rrt E�r,e��!S�� '�� °' 1821 University Ave, Suite S-154 Saint Paul, MN 55104 _Plea§e include the Accouni#ori yoc�r cMeck! � -°°--°°---_____-°°°----°°----------------PIease Detach and Retum 7he Above Po�tion VYith Your Payment---°--------------------------------°-°------- Claim#:2074037 Payment by Nationwide Insurance $80.00 $105.00 12/18/2013 Claim#:2074037 Payment by Nationwide Insurance $40.00 $65.00 12/18/2013 Claim#:2074037 Payment by Nationwide Insurance $30.00 $35.00 12/18/2013 Claim#:2074037 Payment by Nationwide Insurance $35.00 $0.00 12J18/2013 Claim#:2077165 Spinal,three to four regions ��p gggq1 $80.00 $80.00 11/05/2013 Claim#:2077165 Electrical stimulation(unattended) 8470 97014 $40.00 $120.00 11/05/2013 Claim#:2077165 Application of a modality to one or more areas;hot ��0 97010 $30.00 $150.00 11/05/2013 or cold packs Claim#:2077165 Massage,including effleurage,peRrissage and/or ��0 97124 $35.00 $185.00 11/05/2013 tapotement(stroking,compression,percussion)per Claim#:2077165 Payment by Nationwide Insurance $80.00 $105.00 12/18/2013 Claim#:2077165 Payment by Nationwide Insurance $40.00 $65.00 12/18/2013 Claim#:2077165 Payment by Na6onwide Insurance $30.00 $35.00 12/18/2013 Claim#:2077165 Payment by Nationwide Insurance $35.00 $0.00 12/18/2013 Claim#:2077174 Spinal,three to four regions �70 gggq� $80.00 $80.00 11/06/2013 Claim#:2077174 Electrical stimulation(unattended) gq�0 97014 $40.00 $120.00 11/06/2013 Claim#:2077174 Application of a modality to one or more areas;hot ��0 97010 $30.00 $150.00 11/O6/2013 or cold packs Claim#:2077174 Massage,including effleurage,peRrissage and/or �70 97124 $35.00 $185.00 11/O6/2013 tapotement(stroking,compression,percussion)per Claim#:2077174 Payment by Nationwide Insurance $80.00 $105.00 12/18/2013 Claim#:2077174 Payment by Nationwide Insurance $40.00 $65.00 12J18/2013 Claim#:2077174 Payment by Nationwide Insurance $30.00 $35.00 12J18/2013 Claim#:2077174 Payment by Na6onwide Insurance $35.00 $0.00 12/18/2013 Total Charg� : Total;Paym�rits To 1 W�Ite-0ffs' ;:Minimum�ue : Amf.Due. Capitol Chiropractic & Rehab, PC 1959 Sloan Place, Suite 230 Saint Paul, MN 55117 �� :`Q5/21T��'I� :: � Accour�#: �{}��J�� :;, ; . tl�ii paym�rr��tt�s�� a�€�tes t€s ti�e a�dr��v�� • " ,.�.., � � �, � ,�;, _ �„ � � I�atierrt Natne: �/�Clt,�x �1G}�t Ratgen, Bradley ia�,�,��„�osea� .,. �°�� °' 1821 University Ave, Suite S-154 Saint Paul, MN 55104 � = . . .. Please incTude#he Acc�unt�on you�check! _____________________°°-°°-._______--°____.___Pfease Qetach and Return The Above Po�tion l�ith Your Ra ment---°-°-°______._°--------________°°-°_____. Claim#:2078263 Spinal,three to four regions 8470 98941 $80.00 $80.00 11/07/2013 Claim#:2078263 Electrical stimulation(unattended) 8470 97014 $40.00 $120.00 11/07/2013 Claim#:2078263 Application of a modality to one or more areas;hot ��0 97010 $30.00 $150.00 11/07/2013 or cold packs Claim#:2078263 Massage,including effleurage,pertrissage and/or g470 97124 $35.00 $185.00 11/07/2013 tapotement(stroking,compression,percussion)per Claim#:2078263 Payment by Nationwide Insurance $80.00 $105.00 12/18/2013 Claim#:2078263 Payment by Nationwide Insurance $40.00 $65.00 12/18/2013 Claim#:2078263 Payment by Nationwide Insurance $30.00 $35.00 12/18/2013 Claim#:2078263 Payment by Nationwide Insurance $35.00 $0.00 12/1 S/2013 Claim#:2081175 Spinal,three to four regions gq�p ggg41 $80.00 $80.00 11/11/2013 Claim#:2081175 Electrical stimulation(unattended) g470 97014 $40.00 $120.00 11/11/2013 Claim#:2081175 Application of a modality to one or more areas;hot ��0 97010 $30.00 $150.00 11/11/2013 or cold packs Claim#:2081175 Massage,including effleurage,pertrissage and/or �� 97124 $35.00 $185.00 11/11/2013 tapotement(stroking,compression,percussion)per Claim#:2081175 Payment by Nationwide Insurance $80.00 $105.00 12/18/2013 Claim#:2081175 Payment by Nationwide Insurance $40.00 $65.00 12/18/2013 Claim#:2081175 Payment by Nationwide Insurance $30.00 $35.00 12/18/2013 Claim#:2081175 Payment by Nationwide Insurance $35.00 $0.00 12J18/2013 Claim#:2081472 Spinal,three to four regions �q�� gggq� $80.00 $80.00 11/12/2013 Claim#:2081472 Electrical stimulation(unattended) gq�p g7014 $40.00 $120.00 11/12/2013 Claim#:2081472 Application of a modality to one or more areas;hot g470 97010 $30.00 $150.00 11/12/2013 or cold packs Claim#:2081472 Massage,including effleurage,pertrissage and/or �� 97124 $35.00 $185.00 11/12/2013 taPotement(stroking,compression,percussion)per 7�tai� T�tal': Pa� To�a1 W�te-O�s' lf��n[ieiurri DUe �� a' �a � � � . «. Capitol Chiropractic & Rehab, PC 1959 Sloan Place, Suite 230 Saint Paut, MN 55117 n��'��,��1�1�2��4'�� ,; Accou� ,�{;}5-�4�30� .` ��1�!i paymsn�anz��rrr��r��r•;�r��€�.��r�cir��s abrsvel Patienf Nam�• �/all£�;RIC�Cjf Ratgen, Bradley ;a,,,nu�.��o�ds �'�� To: 1821 University Ave, Suite S-154 Saint Paul, MN 55104 Pl�ase i�ide the llccount#oo y,oa�check! ------------- ---°°---°---°°-°-°°-°---Plsase Defach and Return The Above Portian With Yaur Pa�rment-----°-------_________---°-----°-------°______ Claim#:2081472 Payment by Nationwide Insurance $80.00 $105.00 12/18/2013 Claim#:2081472 Payment by Na6onwide Insurance 12/18/2013 $40.00 $65.00 Claim#:2081472 Payment by Nationwide Insurance $30.00 $35.00 12/18/2013 Claim#:2081472 Payment by Nationwide Insurance 12/18/2013 $35.00 $0.00 Claim#:2082619 Spinal,three to four regions ��p gggq� $80.00 $80.00 11/13/2013 Claim#:2082619 ElecVical stimulation(unattended) gq�0 97014 $40.00 $120.00 11/13/2013 Claim#:2082619 Application of a modality to one or more areas;hot ��0 97010 $30.00 $150.00 11/13/2013 or cold packs Claim#:2082619 Massage,including effleurage,pertrissage and/or ��0 97124 $35.00 $185.00 11/13/2013 tapotement(stroking,compression,percussion)per Claim#:2082619 Payment by Nationwide Insurance $50.00 $105.00 12/18/2013 Claim#:2082619 Payment by Nationwide Insurance 12/18/2013 $40.00 $65.00 Claim#:2082619 Payment by Nationwide Insurance $30.00 $35.00 12/1 S/2013 Claim#:2082619 Payment by Nationwide Insurance $35.00 $0.00 12J18/2013 Claim#:2085792 Spinal,three to four regions g470 98941 $80.00 $80.00 11/18/2013 Claim#:2085792 Electrical stimulation(unattended) gq�p g7014 $40.00 $120.00 11/18/2013 Claim#:2085792 Application of a modality to one or more areas;hot ��0 97010 $30.00 $150.00 11/18/2013 or cold packs Claim#:2085792 Massage,including effleurage,pertrissage and/or �� 971z4 $35.00 $185.00 11/18/2013 tapotement(stroking,compression,percussion)per Claim#:2085792 Payment by Nationwide Insurance $80.00 $105.00 12/02/2013 Claim#:2085792 Payment by Nationwide Insurance $40.00 $65.00 12/02/2013 Claim#:2085792 Payment by Nationwide Insurance $30.00 $35.00 12/02/2013 Claim#:2085792 Payment by Nationwide Insurance $35.00 $0.00 12/02/2013 , ... ��, � , q-; % Arfif»DuB�; ,,.e' � 'Fof�1 Ch�rges....,��l �a�€meals ;To. 1,�lliriUe-#3f�` MFnirniurs�[iUe ��IMYI+II��ii��nl��iinul�11111111i��1 �� f��f a. k .rs 5 F, Capitol Chiropractic & Rehab, PC 1959 Sloan Place, Suite 230 Saint Paul, MN 55117 � ��_ 0532;'1/2014; Account#: `�Or'J-+�J��O�' '` �t�all p�yme�fs a�d car�anc�nce��the as�cfr�ss a€�i '�� Pati�rst Naen�:-�a[l �;.RIC ,. � � Ratgen, Bradley �,o�,��io�i�� '��°' 1821 University Ave, Suite S-154 � ,;: .. �� Saint Paul, MN 55104 ° �_ Pt�asi�'ine��the A�count�"cn yoU�ct�kl ' _________________________________________________Fl2ase Detach and Return The Above Portiart W'sth Your Pa ment----._________---.________°-----.______-----__... Claim#:2087272 Spinal,three to four regions g470 98941 $80.00 $80.00 11/19/2013 Claim#:2087272 Electrical stimulaGon(unattended) gq�0 97014 $40.00 $120.00 11/19/2013 Claim#:2087272 Application of a modality to one or more areas;hot g470 97010 $30.00 $150.00 11/19/2013 orcold packs Claim#:2087272 Massage,including effleurage,pertrissage and/or �� 97124 $35.00 $185.00 11/19/2013 tapotement(stroking,compression,percussion)per Claim#:2087272 Payment by Nationwide Insurance $80.00 $105.00 12/02/2013 Claim#:2087272 Payment by Nationwide Insurance $40.00 $65.00 12/02/2013 Claim#:2087272 Payment by Nationwide Insurance $30.00 $35.00 12/02/2013 Claim#:2087272 Payment by Nationwide Insurance $35.00 $0.00 12J02/2013 Claim#:2087729 Spinal,three to four regions gq�p ggg41 $80.00 $80.00 11/20/2013 Claim#:2087729 Electrical stimulation(unattended) 8470 97014 $40.00 $120.00 11/20/2013 Claim#:2087729 Application of a modality to one or more areas;hot g470 97010 $30.00 $150.00 11/20/2013 orcoldpacks Claim#:2087729 Massage,including effleurage,pertrissage and/or g470 97124 $35.00 $185.00 11/20/2013 tapotement(stroking,compression,percussion)per Claim#:2087729 Payment by Nationwide Insurance $80.00 $105.00 12/02/2013 Claim#:2087729 Payment by Nationwide Insurance $40.00 $65.00 12/02/2013 Claim#:2087729 Payment by NaGonwide Insurance $30.00 $35.00 12/02/2013 Claim#:2087729 Payment by Nationwide Insurance $35.00 $0.00 12/02/2013 Claim#:2092647 Spinal,three to four regions 8470 g8g41 $80.00 $80.00 11/26/2013 Claim#:2092647 Massage,including effleurage,pertrissage and/or �� 97124 $35.00 $115.00 11/26/2013 �Potement(stroking,compression,percussion)per Claim#:2092647 Traction,mechanical 8470 97012 $40.00 $155.00 11/26/2013 Claim#:2092647 Payment by Nationwide Insurance $80.00 $75.00 12/09/2013 � ..., ;, � � 't'`��iGha€±g�=% Tota� Pa�e�ts .l't� ' �iri�rim Due:. ':�m�.[kie � ` �, „ .�,�: .ee��_. �.,. ._ ,._ , _ .. Capitol Chiropractic & Rehab, PC 1959 Sloan Place, Suite 230 Saint Paul, MN 55117 �a� �� ate:'i35IZ1/20:�%�> �►cco�,� 405=��302 . -'. .;[s�ii aEt=�a�yc��nts at��f'�°.r�sj�a� ,` �:�a ti��tlirs�s�la�r��T � ; Pat�erif l�fam� `,� �1G ,. � � � � �� Ratgen, Bradley r►�,��as �#�� °' 1821 University Ave, Suite S-154 Saint Paul, MN 55104 �� F'lease��lude�i�cCOUnt#�n your checit! --°°°-°------°°______________°____________Ptease Qetach and Return The Above P€srtian With Your Payment---°-----~-°--------°-°----_________-°--°__. Claim#:2092647 Payment by Nationwide Insurance $35.00 $40.00 12/09/2013 Claim#:2092647 Payment by Nationwide Insurance $40.00 $0.00 12/09/2013 Claim#:2093644 Spinal,three to four regions 8470 98941 $80.00 $80.00 11/27/2013 Claim#:2093644 Massage,including effleurage,peRrissage and/or gq70 97124 $35.00 $115.00 11/27/2013 tapotement(stroking,compression,percussion)per Claim#:2093644 Neuromuscular reeducation of movement,balance, �70 97112 $40.00 $155.00 11/27/2013 coordination,kinesthetic sense,posture and Claim#:2093644 Payment by Nationwide Insurance $80.00 $75.00 12/09/2013 Claim#:2093644 Payment by Nationwide Insurance $35.00 $40.00 12/09/2013 Claim#:2093644 Payment by Nationwide Insurance $40.00 $0.00 12/09/2013 Claim#:2095838 Spinal,three to four regions gq�p ggg41 $80.00 $80.00 12J02/2013 Claim#:2095838 Massage,including effleurage,pertrissage and/or �70 g��24 $35.00 $115.00 12/02/2013 tapotement(stroking,compression,percussion)per Claim#:2095838 Neuromuscular reeducation of movement,balance, �� 97112 $40.00 $155.00 12/02/2013 coordination,kinesthetic sense,posture and Claim#:2095838 Office or other outpatient visit for the evaluation �� 99212 $100.00 $255.00 12/02/2013 and management of an established patient,which Claim#:2095838 Payment by Nationwide Insurance $80.00 $175.00 12J30/2013 Claim#:2095838 Payment by Nationwide Insurance $35.00 $140.00 12/30/2013 Claim#:2095838 Payment by Nationwide Insurance $40.00 $100.00 12/30/2013 Claim#:2095838 Payment by Nationwide Insurance $100.00 $0.00 12/30/2013 Claim#:2096650 Spinal,three to four regions �� gggq� $80.00 $80.00 12/03/2013 Claim#:2096650 Massage,including effleurage,pertrissage and/or gq70 97124 $35.00 $115.00 12/03/2013 tapotement(stroking,compressio�,percussion)per Claim#:2096650 Neuromuscular reeducation of movement,balance, ��p 971�Z $40.00 $155.00 12/03/2013 coordination,kinesthetic sense,posture and Claim#:2096650 Payment by Nationwide Insurance $50.00 $75.00 12/30/2013 �'otal Gllarges Tot81,;P�n1S Tof�W�ite--�N�^ ' INinimvin Due,';' `;Arnf.Due =s ; f: ��' .. .. .< .,,, _.,, x, . <, .,,. Capitol Chiropractic & Rehab, PC 1959 Sloan Place, Suite 230 Saint Paul, MN 55117 � �� uate: 4�/21/�Q'!4'��," pcc�our�t�: 405-4�5302 ! Wtait atJ p�rments ans!c4rrespans�€ce to the asidress a€bs�v�a6 Patisnt Name:' �/�1'1g, R10EC�/ Ratgen, Bradley a;,;�„��,�i�s - , �,I� To: 1821 University Ave, Suite S-154 Saint Paul, MN 55104 ' ' Please i�c��le the/tcaou►n#oa yaur checkl ---°----°°---°------°°-°---°-----------°-Please Qetach and Return The Above Portion With Your Payment----°-°-----------------------°---------.__.._ Claim#:2096650 Payment by Nationwide Insurance 12/30/2013 $35.00 $40.00 Claim#:2096650 Payment by Nationwide Insurance 12/30/2013 $40.00 $0.00 Claim#:2097421 Spinal,three to four regions 12/04/2013 8470 98941 $80.00 $80.00 C�aim#:2097421 Neuromuscular reeducation of movement,balance, ��0 97112 $40.00 $120.00 12/04/2013 coordinaGon,kinesthetic sense,posture and Claim#:2097421 Traction,mechanical 8470 97012 $40.00 $160.00 12/04/2013 Claim#:2097421 Payment by Nationwide Insurance 12/30/2013 $80.00 $80.00 Claim#:2097421 Payment by Nationwide Insurance 12/30/2013 $40.00 $40.00 Claim#:2097421 Payment by Nationwide Insurance 12/30/2013 $40.00 $0.00 Claim#:2100527 Spinal,three to four regions 8470 98941 $80.00 $80.00 12/09/2013 Claim#:2100527 Neuromuscular reeducation of movement,balance, ��0 97112 $40.00 $120.00 12/09/2013 coordination,kinesthetic sense,posture and Claim#:2100527 Massage,including effleurage,pertrissage and/or ��0 97124 $35.00 $155.00 12/09/2013 tapotement(stroking,compression,percussion)per Claim#:2100527 Payment by Nationwide Insurance 12/30/2013 $80.00 $75.00 Claim#:2100527 Payment by Nationwide Insurance 12/30/2013 $40.00 $35.00 Claim#:2100527 Payment by Nationwide Insurance $35.00 $0.00 12/30/2013 Claim#:2101311 Spinal,three to four regions �� gggq� $80.00 $80.00 12/10/2013 Claim#:2101311 Neuromuscular reeducation of movement,balance, ��Q g��12 $40.00 $120.00 12/10/2013 coordination,kinesthetic sense,posture and Claim#:2101311 Massage,including effleurage,peRrissage and/or ��0 97124 $35.00 $155.00 12/10/2013 tapotement(stroking,compression,percussion)per Claim#:2101311 Payment by Nationwide Insurance $80.00 $75.00 12/30/2013 Claim#:2101311 Payment by Nationwide Insurance $40.00 $35.00 12/30/2013 Claim#:2101311 Payment by Nationwide Insurance $35.00 $0.00 12/30/2013 To�a{Charg�' Total;Paymet�ts ;T Wr#be-0ifs 1WIlnimum Due:' ��` Capitol Chiropractic & Rehab, PC 1959 Sloan Place, Suite 230 Saint Paul, MN 55117 na�: t}�12�/��}74.. .�. ,� ,.,., �oiar�c;��-4$53C?�-%`s �i��#I paym��s a�d�s�r�s�Zan�s�o#��d��ss�I��I ' � ' �° _....., Patl+�nf Hame:,:�al]�,}�l�fi(�l Ratgen, Bradley ��f : �,,,��,t�f►;��osea s $'�� °' 1821 University Ave, Suite S-154 Saint Paul, MN 55104 �� FI�incruae#he i4i�aunl�or►ycur ct�ckt ,;" -_-----°____-°°--°----------------°______---Piease C�etach and Return TFte Above Por�ion VYith Your Payment----------°--°__________________°-___________ Claim#:2103323 Spinal,three to four regions gq�p ggg41 $80.00 $80.00 12/11/2013 Claim#:2103323 Neuromuscular reeducation of movement,balance, �� 97112 $q0.00 $120.00 12/11/2013 coordination,kinesthetic sense,posture and Claim#:2103323 Traction,mechanical gq70 97012 $40.00 $160.00 12111/2013 Claim#:2103323 Payment by Nationwide Insurance $80.00 $80.00 12/30/2013 Claim#:2103323 Payment by Nationwide Insurance $40.00 $40.00 12/30/2013 Claim#:2103323 Payment by Nationwide Insurance $40.00 $0.00 12/30/2013 Claim#:2105823 Spinal,three to four regions 8470 98941 $80.00 $80.00 12/16/2013 Claim#:2105823 Neuromuscular reeducation of movement,balance, ��0 97112 $40.00 $120.00 12/16/2013 �rdination,kinesthetic sense,posture and Claim#:2105823 Massage,including effleurage,pertrissage and/or �� 97124 $35.00 $155.00 12/16/2013 tapotement(stroking,compression,percussion)per Claim#:2105823 Payment by Nationwide Insurance $80.00 $75.00 01/08/2014 Claim#:2105823 Payment by Nationwide Insurance $40.00 $35.00 01/08/2014 Claim#:2105823 Payment by Nationwide Insurance $35.00 $0.00 01/08/2014 Claim#:2108335 Spinal,three to four regions 5470 98941 $80.00 $80.00 12/18/2013 Claim#:2108335 Neuromuscular reeducation of movement,balance, ��p 97112 $40.00 $120.00 12/18/2013 coordination,kinesthetic sense,posture and Claim#:2108335 Traction,mechanical 8470 97012 $40.00 $160.00 12/18/2013 Claim#:2108335 Payment by Nationwide Insurance $80.00 $80.00 01/08/2014 Claim#:2108335 Payment by Nationwide Insurance $40.00 $40.00 01/08/2014 Claim#:2108335 Payment by Nationwide Insurance $40.00 $0.00 01/08/2014 Claim#:2110392 Spinal,three to four regions 8470 g8g41 $80.00 $80.00 12/23/2013 Claim#:2110392 Neuromuscular reeducation of movement,balance, ��0 97112 $40.00 $120.00 12/23/2013 coordination,kinesthetic sense,posture and -� i4rrlf.t?� 'C�tal Gt�arges` Tolal;P��nts 7' Wr�te�'"Minf�nufn�uue�<` �, � ,;r Capitol Chiropractic 8� Rehab, PC 1959 Sloan Place, Suite 230 Saint Paul, MN 55117 �� :'05/2"I/2014' nccor,nt�: 405-445302. ', €�it a6J payments and c4rr�sponc#�ttc�to t�e atidr�ss abr�v�t Patient Name• �/�t19,�lCEC�L. Ratgen, Bradley �,,,«,��„�b�s �'�� °' 1821 University Ave, Suite S-154 Saint Paul, MN 55104 ` �lease i�clude the Accantrtl�on you�check! -°_____-°°---°-------°___________________---Please Detach and Return The Above Portion W'sth Your Ra ment---°-----°---°---_________--°_____.------... Claim#:2110392 Traction,mechanical gq70 97012 $40.00 $160.00 12/23/2013 Claim#:2110392 Payment by Nationwide Insurance $80.00 $80.00 01/08/2014 Claim#:2110392 Payment by Nationwide Insurance $40.00 $40.00 01/08/2014 Claim#:2110392 Payment by Nationwide Insurance 01/08/2014 $40.00 $0.00 Claim#:2113507 Spinal,three to four regions 5470 98941 $80.00 $80.00 12/30/2013 Claim#:2113507 Neuromuscular reeducation of movement,balance, ��0 97112 $40.00 $120.00 12/30/2013 coordina5on,kinesthetic sense,posture and Claim#:2113507 Traction,mechanical gq70 97012 $40.00 $160.00 12/30/2013 Claim#:2113507 Payment by Nationwide Insurance 01/17/2014 $80.00 $80.00 Claim#:2113507 Payment by Nationwide Insurance $40.00 $40.00 01/17/2014 Claim#:2113507 Payment by Nationwide Insurance 01/17/2014 $40.00 $0.00 Claim#:2123065 Spinal,three to four regions 8470 98941 $50.00 $80.00 01/08/2014 Claim#:2123065 Neuromuscular reeducation of movement,balance, �70 971�Z $40.00 $120.00 01/OS/2014 coordination,kinesthetic sense,posture and Claim#:2123065 Traction,mechanical 8470 97012 $40.00 $160.00 01/08/2014 Claim#:2123065 Payment by Nationwide Insurance 01/17/2014 $80.00 $80.00 Claim#:2123065 Payment by Nationwide Insurance $40.00 $40.00 01/17/2014 Claim#:2123065 Payment by Nationwide Insurance $40.00 $0.00 01/17/2014 Claim#:2151023 Spinal,three to four regions gq�p gggq� $80.00 $80.00 02/17/2014 Claim#:2151023 Neuromuscular reeducation of movement,balance, ��0 97112 $40.00 $120.00 02/17/2014 coordination,kinesthetic sense,posture and Claim#:2151023 Traction,mechanical gq70 97012 $40.00 $160.00 02J17/2014 Claim#:2153684 Spinal,three to four regions �70 gggq� $80.00 $240.00 ov2oi2o�a Total Charges Total Payments .Tota W�1fe-O�s ' MInimum D�.; Amt.Due' � Capitol Chiropractic & Rehab, PC 1959 Sloan Place, Suite 230 Saint Paul, MN 55117 .. ��:,�1512'1-/20�4: , �.. a .. ,. .. ��; 405 Capitol Chiropractic & Rehab, PC 1959 Sloan Place, Suite 230 Saint Paul, MN 55117 o�.,.�5T�1J2�94' _;. , , . ac�our�- %4Q�-�45302 . l�laii�E�p��€��i�az3�t��tre��#ca fta�as�ctr��v�l ' Patient N�ne: �/�C1�, �ICEC�f Ratgen, Bradley �►o�,�t�,�io�� '�� T°' 1821 University Ave, Suite S-154 Saint Paul, MN 55104 �� - �� Please iae�de the llccaun��i jtour e�reckt ..-°---------°---°------------------°-°-°°-Flease Qetach and Return The Above Portion With Your Rayment°-°°------°------_.-°________.-°------°--__ Claim#:2191355 Spinal,three to four regions 8470 98941 $80.00 $1,330.00 04/09/2014 Claim#:2191355 Traction,mechanical 8470 97012 $40.00 $1,370.00 04/09/2014 Claim#:2191355 Massage,including effleurage,pertrissage and/or �70 97124 $35.00 $1,405.00 04/09/2014 tapotement(stroking,compression,percussion)per Claim#:2196865 Spinal,three to four regions gq�p ggg41 $80.00 $1,485.00 04/16/2014 Claim#:2196865 Traction,mechanical 8470 97012 $40.00 $1,525.00 04/16/2014 Claim#:2196865 Massage,including effleurage,pertrissage and/or gq70 97124 $35.00 $1,560.00 04/16/2014 tapotement(stroking,compression,percussion)per Claim#:2201514 Spinal,three to four regions �� gggq� $80.00 $1,640.00 04/23/2014 Claim#:2201514 Traction,mechanical 8470 97012 $40.00 $1,680.00 04/23/2014 Claim#:2201514 Massage,including effleurage,pertrissage and/or �� 97124 $35.00 $1,715.00 04/23/2014 tapotement(stroking,compression,percussion)per -7otal ChaFges:; Total Pa�t�fs '1`c� W�s,' l�iimum 1�'';' �� - �1,715.t�3 $6,235.00 $4,520.00 $0.00 $1,715.00 � � � � � � , s� s � �� a� � �. _ � _. ,.. .. � � �v � .. �� „f �.� ,..._ ° °Apr. 18. 2014 2: lOPM ZC7'I.�S-'7'1-1i5"L7:l1Y:Otl(tSMI) .°°'�No. 8890 '°TP 6 �"'°'""„ � � ■ VOYAGEUR IMAGYNG, Pr,LC �i-1ZAY �2E�ERRA� Central Mcdical,393 Nonh Dunlap Street LL40,Saint Peul,Minncso�a 55(04 Tcl :(651) 647-0000�ax: (6S1)64�-I I 1 I PATIENT: �i Q/� DATG:��'Z9-I� DOB: �1S PH NE: �OS/- Z!)Z �I � MALE: FEMAl.6: kEF6RRIPtGPHYSICIAN: R�,c�{ !)I� ^' s, � p ' e Gt AbDRESS: ( � Sdt,.^� �q �-„� a_,. � � �"�7y �� ^r. '� �j PHONE: �0�� ,I- Zl�l Z f �S L- e.C10� F X: �� ' �7 . � 3!�(► _�cl� CERVCCAL SPtNE YIPPER/LOWER E7CT�MYTTES ;a( AP-Open mouth �: INT-Shoulder L - R _' AP-Knee L- R � AP-Cervical =" EXT-Shoulder Y.- R " LAT-Knee L-R ?� LAT-Cervica!neut�al .: Baby arm L-R =� Tunnel vicw knoo C.- �I LAT-Ccrvical flcxioq � AP-Elbow L- R R X1 LAT-Cccvical extension .= LAT-�lbow L- R -: Ap-Anklt L-R )b Obliques "� PA-Wrist L- R .- LA'r ankl� C.-R .: LAT-Wrist L- R �� AP-Foot L-R ° AP-Hand L-R �: LAT-Foot L-R '. LAT-Hand L—R :-: THORACiC SPINE LUMBAR SPINE �f APT-Antcrior-hosttrior � p►p�-p �1 C,T La�eral Thoracic I.LS-Lateral lumbosacral � PA-Chcst-Posterior-Anterior � Lumbar Obiiques ,� �aT•Chest L AP-Hip 1 Ribs: (: Lumbosacral � Othcr: . Auorncy: Y LT /� f'hOnc=� [�'�� ^�� — Insu�an�e Company: �Q ' n + "�'�S ' Address: rol` �� 6 �� ' Claim Num�eNlD v �'r Phonc: SYGNIFYCAI�tT HISTORY, SXMP'X'OIViS ANb CL�NZCA�. FrNDINGS TYPE OFTRAUMA: AUTO INIURY�WORK INJUItY,� SLIP ANb FALL OTHER� •NECK PAIN THORACIC PA1 -DLCREASED RO -SCIATICA -LUMBnR PaIN -NEAbACHE � •AAM TINGUNG -MUSCLE SPnsM pATE OF TRAUMA: I��'�b�l� 1ST0 Y 'S G Y/MALIGNANCY: YES NO T � ,� l� PHYSICIAN SIGNA URC. C Received Time Apr. 18. 2014 2: 14PM No. 2710 � Ap r. 18. 2014 2: l OPM Na. 8890 P. 4 11/22/2013 10:20 AM FROM: Fax T0: 651-6dT-1111 PA6c.: 002 OF 003 `V'OYAGE�T�1GING, PLLC . Cen.trat e icnC Br�ilding 393 N Aa�nlap Stree�, Surte LL40 Saint Pattl, M1Y SS.X 04 O: 65Z.647.0000 V.ANG , RICKY PATIENT ID : 101969 DOB : 10/19/69 DATE : 11/20/13 REFERRIN(� PHYSICIAN: David Cole, D .C . TYPE OF EXAMINATION: X-rays : Cervical series dated 11/20/13 Thoracic s�ries dated 11/20/13 Lumbar series dated 11/20/13 FINDINGS : These fiYms demonstrate a left lateral convex cervical curve. This apparently' is due to post-traumatic muscle spasm resulting from the recent motor vehicle crash on 10/16/13 . A right lateral convex thoracic curve Ys present . This apparentl�' �s due to post--traumatic muscle spasm resulting from the recent motor vehicle crash on 10/l6/13 . A right lateral convex lumbar curve is present. This apparent].y is due to post-traumatic muscle spasm resu�ti.ng from �he recent motox' vehicle crash on 10/16/13 . The cerviCal flexion and extension views demonstrate a restzicted cerviCal range of motion. This apparentl�r is due � to post-traumatic muscle spasm resulting from the recent motor vehicle crash on 10/16/�3 . The posterior v'ertebral body' line is disrupted at the C3�C4 and C4-05 levels on the cer�u'ica1. ex�ension view. This represents post-traumatic ligamen�ous insult resulting from the recent motor vehicle crash on 10/16/l3 . The cerv�caY oblique views demonstrate � patent intervertebral foramen, bilaiceral.7.y, at all levels throughout the cervical spine. Ea�rly degenerative changes are present at the c5 level. Earl�r degenerativ'e dzsc disease is present at the L3-I,9 level . Calcifi.cation of the oblique atl.anto-occipital ligament is noted as an incidental finding. Received Time Apr. 18. 2014 2: 14PM No. 2770 Apr, 18, 2014 2 ; IOPM No. 8890 P. 5 ��ZZ�ZOi3 io:zo � x�on: xaM ro: 6si-sa�-illl PAG�: 003 OF 009 'V"O'YAGETJ�R YMAGIN�, PLLC en.t��c Med'ic�rC Luilding 993 N. 1�►rnlap Street, Suite LL40 � Sai��l Pa��l, MN SSI04 O: 651.647.D000 VANG , RICKY PATIENT ID : 101969 DOB : 10/19/69 DATE : 11/20/13 (CONTINUED) IMPAESSIONS : 1) Post-traumatic restricted cervical range of motion . 2) Eost-t�aumatic liqamentous insult involving the C3-C4 � and C4-05 vertebral motion units . 3) Post-traumatic cervical levoscoliosis . 4) Post-traLUt►atic thoracio dextroscoliosis . 5) Post-traumatic lumbar dextroscoliosis . 6) Early degene�ative changes at the C5 level. 7) Early degenerative disc disease at the L3-L4 level . 6) Congenital C1 posterior ponticle . 9) Clinical correlation for musculoligamentous injury is recomrt�nended. 10) These films reveal no definite evidence of a recent fracture, dislocation, or osseous neoplastic change to the extent visualized. , Scott J. Murray, D. C . , D.A.C . B . R s�TM:.bk14 d : 11/21/13 t : 11/21/13 Received Time Apr. 18, 2014 2: 14PM No. 2770 Ap r, 18. 2014 2: 11 PM No. 8890 P. 7 Voys�qeur Im�qinq 393 North Dunlap St LL90 St. pavl, MN 55104 6S1-6A7-0000 Iu�1: 45-316344a 8tavan yohnaon M.D_ NPI�f: 1053390899 Friday Aprii 1B, 20�4 ''atient : liicky vang i1912 =Cem.ized 3tatemexit: l.1/20/2013 - 09/18/2019 DOB : l0/19/1969 �nset date : 10/16/2013 Mail to: Riaky vnr►g 37$ �Arsington st_ �S 8t. PBUl 2� 55103 Inavrmd Inauranoe Carrier (primisryl ?.icky vatog Nationwide Znsurance SPi1Nr .'.•75 Farrington SC. iiE P.O. Sox 26005 Gz- QauJ. MN 55103 Daphne AY. 36526-5005 �OB: 10/19/1g69 k�olicyll; 72222010050910].62013oi Attorney �mp].oyes �radley 1zaCgen NOT FOUND _621 University Ave„ tl$-156 St_ Paul MN 55109 Cur,zent Diagnoais ,23.], CERVICAI,CyzA -24_1 PAIN TN TAOI�ACic SPiNE 2 9 .2 LCTM�AGO 397. 0 NECK SPRATN �d�e DescripCion Amount 11/20/13 72052 Cervical Comp/Flx/Ex S 310.00 '_1/20/13 72070 ThoraciG AP/LAT $ 190.00 _1/20/13 72100 Zumbar Ap/T.AT S 180.00 _?/23/13 Payer paymel�t Chkif72502063 applied to svca: 11/20/13 � 11/20/13 5 630.00 ':'otal Sales Tax : 5 0.00 _ot�1 Late Chargeg : $ 0.00 '_'otal Ir�texest Charges : S 0.00 ?at,ients-Cash Rc�rd _ $ 0_00 FAtients�Chks Rcvd : 8 0.00 F'at�.ents-Crdt Crd : S 0_00 -�ayer eayments : 5 630.00 '!'otal chaxges : S 630.00 ':oCal Received _ S 630.00 =otal Rdjustment : 3 0.00 Ealance (based oin search) : S 0. 00 Received Time Apr. 18. 2014 2: 14PM No. 2770 Arcade Pain Center 651-3403549 p.3 � Arcade Pain Center 651 Arcade Street St. Paul, MN 55106 Phone(65!)340-3546,Fax(651)340-3549 New Patient Consaitation PATIENT: Ricky Vang DATE: 12106/13 REFERRING PHYSICIAN: Patient is seen in consultation at tbe request of Dr. Cole. ffiSTORY OF PRESENT ILLNESS: This is a 44 year old male who presents for an Interventional Pain Mana.gement evaluation secondary to a�notor vehicle accident that occurred on ]0/16/2013. The patient was the restrained driver_ He was sitting at a stop light and�vas rear ended by a very lazge city construction truck. No EMS was called to the scene. The patient did not seek any medical aitention after the accident_ He denies having any previous motor vehicle accidents. Since the accident, he has been complaining of mid to low back pain that radiates into the abdomen. He denies any similar s5�mptoms prior to this accident. He describes the pain as a sharp; shooting, knife-like feeling that is exacerbated with minimal physical actiti�ity, sitting for extended periods of time, or bending. It improves ��ith sleep. He rates the pain an 8!10 on the numeric pain scale_ Current treatments include therapy. MEDICATION ALLERGIES: NKDA. CURREI\�T MEDICATIONS: None. PAST MEDICAL HISTORY: Significant for high blood pressure and stroke. HOSPIT.ALIZA,TIONS: He was hospitalized in Apri12011 for stroke. PAST SURGICAL HISTORY: Negative. FAl�IILY HIS1'ORY: Noncontributory. SOCL4L HI�TORY: Patient denies tobacco, alcohol or illicit drugs. RADIOLOGY: As per HP�. R�VIEW OF SYSTEMS: Positive for: High blood pressure, abdominai pain, back pa.in, joint pain and stiffness, loss of range of motion, and cold intolerance. Negative for: Const -weight change, weakness, fatigue, fever_ Eyes - vision, pain, tearing, double vision. EI�-T-heazing trouble,tinnitus,vertigo, sinus pain,colds, sore throat. Received Time Apr. 18. 2014 3: 14PM No. 2784 Arcade Pain Center 651-3403549 p.4 Cardio -rheumatic fever,murmurs, shortness of breath, chest pain, paipitations. Resp- cough, sputum, coughing up blood, wbeezing,asthma,bronchitis,chest pain. GI -trouble swallov��ing, heartburn, vomiting, diarrhea, blood,constipation. GU-pain with urination, urination at night, blood in urine, urgency, hesitancy, incontinence. 11-TSK-neck ache, cramps,weakness. Skin - rash, lwnps, itching,dryness;color change,hair changes,nail changes. Neuro - fainting,blackouts,seizures, paralysis; weakness,numbness, memory-ioss. Psych-nervousness, tension,mood changes,depression, anxiety. Endo-heat intolerance, sweating,thirst,hunger,changes in urination. Hem/Lynnph-bruising, bleeding,transfusion reactions. Al1/Imrnuno- drug pmduct. other allergies, childhood immunizarions_ PHYSICAI, EXAM: General: Patient is a very pleasarzt well developed, well nourished male in no acute distress. The patient appears to be of the stated age. Vital signs: BP 131/94, pulse 72, respira.tory rate 20. HEENT: Normocephalic, atraumatic. CardiovascuEar; Regulaz rate and rhythm; without murmur. No periphera! edema, varicosities, skin warm. Pulmonary: Lungs aze clear to auscultation bilaterally. Abdomen: benign. Extremities: No cyanosis, clUhbing or edema. Musculoskeletal: Muscle tone normal in both upper and Iower extremities without spasticity, atrophy, cogwheeling, dislocation, misalignment or abnornial movements. Vtuscle strength is rated 0 to 5 v�zth 5 being active range of motion agains� gravity with felt resistance. Muscle sVength of the upper extremities are 5/5 bilaterally including intrinsics, vs,zist flexors, wrist extensors, biceps, triceps, deltoid, and trapezi�s. Muscle strength of the lower ex-tremities are 5/5 bilaterally including hip flexors, hamstrings, quadriceps, anterior tibialis, and extensor hallucis longus. Psychological: T'he patient is alert and oriented times three. Receut and remote memory aze intact. Patient concentrates well and is not easily d.istracted. Speech is smooth and clear. Aware of current e�%ents. Neurological: Bilateral superficial light touch and pain sensation is intac� Deep tendon reflexes in both upper and lower extremities are intact and normal. Sl�n: Examination of bilateral upper extremities and lower extremities reveal no rashes or tticers. Thoracic: Exam revealed spasms and pain to palpation in the thoracic paraspinal musculature. He also has point tenderness over T11-T12 with no paipable crepitus. Lumbar: Exam revealed spasms and pain to palpation of the lumbaz paraspinal musculatezre. ASSESSMENT: I do believe the below posttraumatic diagnoses are caasally related to the accident that occurred on 10/16/2013: 1. Posttraumatic thoracic pain. 2. Posttraumatic lumbar pain_ 3. Posttraumatic abdominai pain. 4. Posttraumatic muscle spasms. Received Time Apr, 18. 2014 3: 14PM No. 2184 Arcade Pain Center 651-3403549 p.5 � ---. -- I I . I TREATMENT PLAN, 1. The patient is proceeding well in therapy aad should continue under the direction of Dr. CoIe. I deem this to be medicaily necessary. 2. Urine toxicology is rnedicaIl3� necessary for new patienis and/or indicated follow-np visits secondar�cr to possibility of nazcotic andlor injection therapy this ��sit or future visits to rule out narcotic diversion�'compiiance or illicit substance usage. 3. Vlie �vill do an N1RI of the thoracic and lumbar spine. The risks and benefits of the procedure ��ere explained. 4. Prescription for Trarnadol 50 mg 1 po tid pm for pain, ,#30, no refills. A1so, Flexeri( 10 mg 1 po tid prn for spasm, #30, no refills. Risks and benefits of these medica2ions �vere explained to t�e patient. All questions were answered. The patient understands not to drive on these meaications. 5. The patient is going to follo�.v up in one week. DIC�'ATED BUT NOT PROOFREAD Susan Mnrray,PA Received Time Apr. 18. 2014 3: 14PM No. 2784 i Arcade Pain Center 651-3403549 p.6 i ��RC.ADE f'AIN CENTEr-- ' 65i ARC.ADE 5-CIZEET ST. PAUL, �ti-1N 5510G f'I lO�1E (6511"3=�0-35=�6 F:�X(651;��o-35=�9 Urine Toxicolog_y ' �� t� i Patient Name � Test Date CLLA Vi'aived Urine Toxicolosy Results Control �es ❑ No Control ��Yes ❑ No MDMA ��eg ❑ Pos BAR �e�eg ❑ Pos OPI �(Veg ❑ Pos BZO �Neg ❑ Pos AMP —�Neg ❑ Pos MTD ��Neg o Pos MET �Neg Q Pos TCA �e�Neg o Pos PCP ��Neg ❑ Pos OXY ��Neg ❑ Pos Tzchnician Physieian ! Y J �_. Received Time Apr. 18. 2014 3: 14PM No. 2784 Arcade Pain Center 651-3403549 p.2 Arcade Pain Center, P.L.�.C. 651 Arcade Street St. Pau I, MN 55106 Phone: (659)340-3546 Fax: (651) 340-3549 Itemized Statement S#atement Date: Friday, April 18,2014 For Activity: 03/01/2013 thru �4/18/2014 Ricky Vang Home: (651)202-1495 375 Farrington Street#F St. Paul, MIV 55103 .�� Ricky Vang 1664-P1 Date Code Description Uts Charge Pri Sec Pat Pat WOff DISC Misc Tax Unpaid Paid Paid Paid Owes CHG 12106/13 99204 Expanded Moderate 1 425.00 -425.00 0.00 0.00 Complex 12106/13 G0434 Urine tox 1 275.00 -275.00 0_00 p,Op 12/06/13 S9999 State Sales Tax 2% 1 14_00 -14.0� 0.00 0.00 Totaf Cha�ges $714.00 �� Total Pri Ins Payments (�714.00) Total Sec Ins Payments $0.00 Total Patient Payments $0.00 Total Write-Offs $p,pp Total Discounts $0.00 Total Misc Charges $p.pp Total Tax $0.00 Total PatieM Owes $0.00 Total Ensurance Owes ap_pp AccoerM Due $0.00 Printed: Friday,April 18,2014 10:19:24 AN Page i Of 1 Received Time Apr. 18. 2014 3: 14PM No. 2784 ��c. i?. 2u1� 1 ;2�� h�. 4711 ?. � � �Y11�� /�+�t�.1�c�.� �1'1'tc�. 11'l. 485 Ar�ar�dei st.'s�e: ZoZ st.Paui,Miv 5�103 P'�: 65�-797��85� �a��: �51�-207- 539� � a _ a Patient:k�GKY VANG< � a E�an�:T SPA� � v Y?ute of'�ervice:Dec i I,2013 +� Tiate nfBirth=Qct r4,1964 4 MRN: �694 � Referraug Physician:SUSA�T Zv1UI2,R1�.Y PA. � � a MF2� Q�TH�THE�RACIC SPINE " :�o �a HISTt7aY; Mfl#or-veh'icle accident: p �, T�CHNIQUE. MRi of#he thoracic spine was perfon»ed without�ontra�t. � C(IMPARISC?N: None. ° � m FlNDINGS: The nurnbering of ths`vertebrae i��ane from#he top down vvith th�,upper aspect af the � manu�eium assumed ko lie at the leve[of approximately T2-T3. Based on thi�methad'of rtum��ring, th� � cor�uS�nds at approximately t1. � There is a disc protrusion at the mid �r'vic;�1 spine`that is not weft visualized at appraximate[y C5-�fi. o Consider dedicated imagittg of fF�e�rvi�l.spine to further assess. � E 'There is acc�rttuation of thoracic spine kyphosls.Ttiere is`a brc�ad-bas�d centra�disc prc�trusion at T6 T7 a measuring a�iprbxim�te(y 2-3 mm witl�mild centr�al spina(canal st�i�t�sis, Di�C desicc�tion is seen in th� p ' uPRer thor�ci�s�ine.There is na sign�cant signaf aitera�on of th�thar�cic spinal card. No compressio� � � fracture�are$e��. �, �or th�purpose of this r�pc►rt, the term ""pr�frusi�n"and,�extrusion"are con$ider�d synanymous with' q � "�emiation." a u� � � a. r� IlVIl'RESSItJ►N� � ,N B�c�ad-bas�d central disc protrusion i�seen at the mid t�aor��ic spine measuring appr�ximately 2�»3 � r»m with miid�er�fral�pinal c�nal.�tenosi�. Q �' r 1 Th�nk you f�r t�te court�sy Qf this referral � Et�ctroni�lly sl�tted � Vikram F{atti. M.�. Qiplamate, A1'�B17C�t7 BD31'�Ctf R�tltOlfl�}/ - adt Uec 13,2Q131�:v7 Uee: l1 2�'� 1';29�'�' �1a. 4;'17 'F, 6 �dt n�� ,�07� �a:�� tdt i�eC 1�,2II1312:3� ttanscriber Lisa�taschur � � Ke �m es:2 : ft f� �` U m � � N 0: �l � m h 0 C1 T � � S}d � � � . . � �: � .. � . . . .. . .. .. � ... . .. '� . .. � ... - � �- �. �m; V Q Q � �ry Nt} Vt 1 Q '+: 0c>: LC f � � � f � C; .�f � N C 4 a r � Rf W' � � 6.; r� � a n n: �: r 0 �` A' r s< � r � 1 D�c. 11, 2413 1 :2�Pi� f�o:.4717 �'. � �.T�i�� Nl.et�i��,I �� i� 4$�Artxt��iel St.Sfie: �4Z St. �'aul,MN 55I03 �i: ��1-797�-3866` F'�ix. �5��207- 5395 � 4 � a Pat��nt:ItIC�Y VANG. � � Ezam:L SPAiE ,o �, Da#e"af Se�€wice:I�ec 11,20T3 ri a ' D�.�+�af�irthe Qct i9,19�9 ,� IvtRN:;i`593 � Referting Ph}�sician: St�S.AN MtJR�tA'Y'PA:. � r MRl UF THE LUMBAR SPINE m � HlSTE)RY' � m ,M T�CHNlQUE: MRI of the lumbarspine was'performed wi#F�out contrast. � , � GOMPARI�+Dt�:Nane_ � 0 �. FiNDINGS;There is mild matrt�w edema�t ttte an#eroinferic�r plate of L3, likely re�ctive ch�ng�s due to, � altered biomeehanics.There is straightening af tumbar spir�s lardosi�. Th�r� is rt�ild scoliosis of the lumbar � spine.l`here i�no evid�nce of spondytalist�esis. The canus'is normal in�ppe��$�ce 2�nd terrninafes at � approxirnatety L1. Fdr the purposes of this rept�rt,the [awest disc level is assumed ta be LS-S'I. L5 may o represerrt a trar+sitiona{verte�rae, Gonsid�rpiain film +correlati�n tt�futt��r assess, a � F[Ndf NC,S AT SPECIFIC LEVE�S: � � . ,� i.i-L2: No significant disc buiges or pro�rusions: No tteural fior�minal naerowing, cer�tra[spinai canal � stent�sis or facet arthra�athy. �, e I..�-L3: Mo s[gnific,�nt disc bulges:r�r prrrtrusions. No neural;f�raminal nar�owfng,ce�ral spinal cana( « stenosis or fa�e#arthropathy. � �. L3-L4; No significant diSC bulg�s or pro#rusions. No neural faramina! narrov+ring, cerrtrai'spin�i canai a stent�si�or facet art�r�p2�t�y. � L�-LS:t�o sign�fic�nt dis�bulges�r pratrusions, No neu�a{foraminal na�rowinc�, c�ntra!spinal canai � sten�sis or facet ar�hropaihy. � L5-S�: No signifi�ant disc bulg�s ar protrusions. Na neura{for minal na�rowing, central spinal canai � sfenc�sis ar facet arctsr.�pa�thy. �y � Tl�e�ar�spir�al saft tissues are unremar�ablQ. � For th�purpose of th�s cepart,f�e#erm '°�roirusion"and "sxtrusio�"are con�id�r�d synonyma�s with' '"E�e�niatian." De�. i7'. 24�1'3 1 :29P�1 �0. 4117 P. 4 I�PRESSION: , '1. Na signific�artt t(isc buiges or pro#rusions are seen. � � 2. 1.5 may represent a transitianal vertebrae. Cansider plain�i�m+�orrelation to further assess. � u 3. Straighfsning af lumbar spine lordo�is. m n 0 4, Mild scoliosi� of:the lumbar spine. � m '� � � . Q n T�ank you f4r the courtesy o#tt�is r�ferral m Electrvnically si�n�d � � 0 Vil�ram Nat�. M.�. : _ � � �iplom�ta, Americarr 8oard af Ra�#iolagy ,�, adt Dec,13,�01� 12:31 p dd#Dec 12,20'!3 20:42 � td#DeC 13,2f�13 12:30 � transcriber Lisa Buschur Q a :o ' U �nw es:2 ` � 'a E h� a L � � � � t � L Q M R tl , � u 6 � ,f� C !�t .... . . _... ' ... :... ..:� '?� :� i e� � � :M r w t�l r {fl �'�c. l?. 2013 1�3�;Fh1 Ido. 4711 �, 1 � �� t c�� . � � �.T�ited �1�e�i��.l I�m�. �n _ 485 Arundt!Si.Suite 1Q2 Si.Peut,SSI03 A Ph:651-�47-386b Fa�x:651-207-539$ � � �' U � $c' ..descried why th:e darto�ord�red yvUr MI�t coday? 1�h�t type of symptams are you t,a�ing? � _ � ��- ' � ' _ .52 Y1 m �a ; � �.. 1 t� t� ��-a�'1 ��.�t (..c.3�'{,, !2 �,, � � �S S� - ��- 4 �i,�� Plr.�se mark on the figures fs) betow tlae � Location oTany pain yeu flre having. � ��ease m�rk on tl�e fignre{s}��ow#he location � ot'any implant or metal inside your�ody � � Q` . � �.� 0 �� 7 � . � r ,J i, -�. � � � - �.,� +a ro . �: L �i, c' Right : L�ft \le�t Ri�ht Right Leh Ce4t Right u 1. s � �, d Q � u • � a as � � �' � r� � a' � . ti Befare eneering chc 1vtk�I envir�snmerst or MRI roorn, yau rnust'rernove sIt metallic ab:�ects � inclu�ing c�cntures, hearing aicEs, partial plates, keys, gagers, ceil phones,eye�lasses, ha;r pins; � barrectes,jeweiry, all:pier�ings,jewctXy, wa�let,bank cards, cvins, pens,,pflcket knife, nail ciiPPers, �lothing w�th metalIic faster�ers and any ath��-metallic iterns. oEC��ec, 1i. 2�133 1:30F�3 ro.ss��rs��o. 47�1 P. 93:i�� .�� 485,Axundtl Stc+ttt � l02 S��'aul�Iv�T 55103 �'hoz�e:b51-797.38b6 Fa�651-201-5395 0 �a�rt� ��.��..,..�1.4� I�1 I 1 °!�v � Dace oE B' Actd�sa: ��'J �dl.�'P"f f.L� ��`�'j C,a1: - �� GcP St��,.,— U z:�pt "��} phoue�; t �OT r1'�p�D�� f� 1� Tiansporatiair Yes No `0 � ' Tnat�11Vo �rt.rpceter I,xngwa�e needed ;� � � M 723.t Cervicalalgia T244 I�pr�ndi�jnis 719.41 Sho�lderp�ift h 723.4 �'xtvicstl Radicce(ips 7i9.4S F�!t�U�gG/pelvic pa,ix� �14.59 Ites�ci�ced n�or.'� N 1 7haracic Pair� T19.46 Kn�e/loper Jeg joiat r 4.2 LwnbarPam 719.47 An1deJ foot,paiu m R/t�Disc or Nerve Iry�ry $taeus�osc �'tVA, Worl�man�o�.k� � F� � � ' � v r� RVICAL S SQ�T'�SSUE NEC3� L a�e a L ose a. a QC Sfi�E CIiE�ST s�b�t �,oR x K1VEB L OR R a AR$� A�UO�N ELBOW L OR B ANiSI.E L Alt& 4 �RARrt PELVIS WR1ST L ait�e POOT � olt x p 0'I��R5CAi� � I . 0 0 Ci�cl�aacc Acci r I Wact�ss�oa►gcnsatioa ;��;�,ty I O t3�Q� + �(D � � . � r�„t,��- a�e;�2'2?�00 '�7__nz��' + � �,�.�,�. �r�� ,'.�..��.n ��: l°�s�l,r� -- �`p - ` � a � � �n�r�,��. �'-,�ts� 1�� o�r: fr�s51 � - `� o ��s�� :��1� 3'�0` 35 � }��'� � t�'°ic 1V�,c a \.�5.V•t�' � " - C � � � N p�y�cc€�oc AppoirnisuntTiu� ----- � m Scbad�tkd aw �Y�� a � Rcc�uestfor. 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NUCC 1nsW ct'ron Manual available ar,vw+w.nucc.otQ PLEASE PR/NT OR TYPE APPRQVED OMB-0B38-0999 FORM CMS-1500(b8-05} rdm.�r►ae0oa�Ms P+e�s� «1ne w1oLY 61��i<5�nlm�tl}ot Itat a6;aeN.-a9eq G1 a�arsa��-6m0.RS3�74 L�Ulll-�Yl�/1`dCAli� �Il`LCZ�lZSC -- �..--.�__..!'l-1 '11 HjJl� Gt/1Y� 1lJ:LO:�LO [i17--17'Ot...: :. � . . . .. .... ., �F'ddb'C GC�UI�.._, .,, I Mobile Rehab, LLC i 2915 Wayzata Blvd Physicat Therapy ' I Minneapolis, MN 55405 Initial ' Phone:(612)310-8844 I Fax: (763)559 1660 Examination _. . -. . . .... ....:_ _ � i Patient Name: Vang, Ricky Date of Initlal Examinatlon: 02/20/2014 ', Date of Blrlh: 10/19/1969 Injury/OnseUChange of Status Date: 10/16/2013 Referring Phystclan(s): Davison,William DC Diagnosls: 847.0: Sprain of neck, 847.1:Sprain of thoracic, 847.2:Sprain of lumbar, 846.0:Sprain of lumbosacral (joint) (ligament) ' Vislt No.: 1 Treatment Diagnosis: 847.0:Sprain of neck, 847.1:Sprain of thoracic, 847_2:Sprain of lumbar, 846.0:Sprain of lumbosacral (joint) (ligament) , �41t3��t1V� , ,. ` History of Present Condltlon/Mechanism of Injury. Pl was in a MVA Primary Concern/Chief Complalnt: Pt states he has minimal neck pain anymore, but does have headaches and right shoulder to elbow pain. He has mid to low back pain as well. Prior Level of Function: Changing &Malntalning Body Posftion: Moblliry:Walking & Moving Around: Carrying,Moving &Handling Objects: , Current Functional Limitations: Setf Care: Sleep:Disturbed Sleep Changing &Malntaintng Body Posltion: Maintaining a Body Position: Remaining Seated, Remaining Standing,Squatting Carrying,Moving &Handling Objects: IADLs:Shopping, Housekeeping, Laundry ! Pain Locallon: mid to low back � Paln Scale:Worst:7 Best: 4 Current:5 Aggravating Factors: Bending � Home Health Caze: No ; Medlcal History: No Known Significant PMH To Affect Treatment Mental StatuslCognitive Funcdon Appears Impaired? Na �.....:,:�;:�.; :: ::,�'�li�£►�` . .. :.:.... . .:� . .. :' .. .:..:. . : ,.... . ::: . . . . . . . . . . .. - . . . . ,...,:.: �. �:.;.:.�. . .. � ... .:.. . :•:�:::::.::....: �: ;�:�:::.:•.;::...�.. Inspection.... ....... ............ ....:.........:.:..............: ..:..:.:.............:..........: :............:........: ............: .._ ......:........ ...... . . .. ... . ... . . . ... . ... . . . Patlent Consent PatienUParenUGuardian Consent Yes Observation ...:. ... . . . . . . . . .... .. .. . . . . . Posture Forward Head, Rounded Shoulders, Decreased Lumbar Lordosis Range.of Motion .. ...:........ .. ..... ........._.... .... ...:... _.. ....... ... Cervical AROM Forward Bending 2 Fingers From Chest Backward Bending WNL Right Side Bending 60% Left Side Bending 70% i Lumbar AROM Forward Bending Hand Reach to Mid-Shins Backward Bending 30% Strength.. ............._.. .. ....... - ...... -.. .. ......-.............. .. ............;....... .. .._............__.. .. ................... .. ................_. .. Gross Muscle Tests Trunk ' Core Stabiliza6on Poor Rlpht Left Received Time Apr. 11. 2014 12:27PM'No, 2583 . y y ; . ��.r:-��]T"' . . _ ::�_ __ .-.. I 1�Ulil� II�/1dP All� C.11LGZ.�i.�15G� - -� � - I'i-1� 11 HjJi�- G V 1�� 1 V:G�O:��GO Hl7 17�7-1 � --.............��-------'-F'iL�C�.�.GJ...OI .. ,.; �. Mobile Rehab, LLC Patlent Name:Vang, Ricky 2915 Wayzata Blvd Physicai Therapy Date of Birth: 10/19/1969 Minneapolis, MN 55405 Initial Document Date:02/20/2014 Phone: (612)310-8844 Fax: (763)559-1660 Examination � Special Tests..... .. .. ...... Sacral Passlve Mobility Decreased right SI motion Right Left SI Compression Positive Not Tested AS�eS�i'��[t# , ; . _ AssessmenVDiagnosis: Whiplash Syndrome Rehab Potentlal: Good Contraindications to Therapy: None Patlent Problems: - Headaches - Decreased Cervical ROM - Decreased Lumbar ROM - Decreased tolerance to sif/stand - Disturbed sleep Short Term Goals: 1:(6 Weeks) � 0%� Eliminate headaches 2:(6 Weeks) � 0%� Improve cervical ROm to WNL 3:(6 Weeks) � 09'0� Improve lumbar ROM to WNL ! 4:(6 Weeks) �0%� Improve siUstand tolerance to 45-60' ' 5:(6 Weeks) �0% � Improve Undisturbed sleep time ta 4 hours �.� . . .. . . . . ... .. . .. . . ... .. �'d�i ,..,_...:..:...........-.- .. .... . . :: .. . . ........... .. Frequency: 2 times a week Duratlon: 6 weeks Plan: Begin Plan as Outlined Treatment to be provided: ,Procedures........... . ..:.......:..................:....................:....�......:...........:...,.......:.................:.......: _.... ....:.....:... ..........:_.. .. .... Therapeutic Exercises(ROM, Strength,Stability),Therapeutic Activity{ADL Specific), Neuromuscular Rehabilitation (Balance/ Proprioce ption Training, Muscle Re-Education, IiN�, Manual Therapy(Manual Traction, Muscle Energy Techni9ues, Manual Resistive Exercise), Patient Education (Home Exerc�se Program, Postural Training, Ergonomics, Lifting Mechanics,Activity Modification) ! 4 .. s �I +'� �,+j�f }��--�` 1C Tammy Saphir, RPT License#6097 Cmm�lnhad hv T�mmv$nnhi� I7PT pn Fs+M��?ni��` P M4 N oF�d nm Received Time Apr. 11. 2014 12:27 2583 _ ._,.;;,,-;;�;_ ��='=�':�PT� � �Z Ulll 17�JIldI'E1lti�-�I1l.CI�l 15C-� � - I'1�1 --11� -t�})I GV1Y -iV:GO: G0-��Hl'i��l'1�71��--�� - -�-� ��-- � Y0.SG-�G�Y VS-- � - _ � Mobile Rehab, LLC 2915 Wayzata Blvd Minneapolis, MN 55405 Daily Note / Phone:(612)310-8844 Fax: (763)559-1660 Billing Sheet ;�;_ Patient Name: Vang, Ricky Date of Daily Note: 02/20/2014 Date of Birth: 10/19/1969 Injury/OnseUChange of Status Date: 10/16/2013 Referring Physician(s): Davison,William DC Dlagnosis: 847.0:Sprain of neck, 847.1:Sprain of thoracic, 847.2: Sprain of lumbar, 846.0:Sprain of lumbosacrai (joint) (ligament) Date of Original Eval: 02/20/2014 Vislt No.: 1 Treatment Diagnosls: 847.0:Sprain of neck,847.1:Sprain of Insurance Name: Natiornnride Insurance thoracic,847.2:Sprain of lumbar, 846.0:Sprain of lumbosacral (joint) (ligament) $L[t1j�Ct1Y@ ` ' -:;. `: . °: . : ,. ,: ... Current Complalnts/Gains. Pt states he has minimal neck pain anymore, but does have headaches and right shoulder to elbow pain. He has mid to low back pain as well. Prior Level of Function: Changing �Maintalning Body Posltlon: Mobtlity:Walking & Moving Around: Carrying,Moving&Handling ObJects: Current Functlonal Umitations: Self Care: Sleep: Disturbed Sleep Changing &Malntaining Body Posltion: Maintaining a Body Position: Remaining Seated, Remaining Standing, Squatting Carrying,Moving &Handling Objects: IADLs:Shopping, Housekeeping, Laundry Pain Locatlon: mid to low back i Paln Scale:Worst:7 Best: 4 Current:5 Aggravating Factors: Bending Home H�Ith Care: No �` Medical History: No Known Significant PMH To Affect Treatment � Nlental Status/Cognitive Functlon Appears Impaired? No . _.... .. : ...:... . .. .... .;,:: >f3l7}E£flv�:° ...:. ' : ' .. . _ . . . . . .. .... . . Its ; �,......::�... :: ,... � .: .�:...... . `- ;.:..:;.;c::;:..,r.:._:; . _ : ::.. :..,..:, �: . :. . ... . ..:... :... ...... , , 2 . CP'i'�Code DlreCt Tlmed Codes UO � g711 p Therapeutic Exercise � Core stability with transverse abdominal activation CPT�Code Untimed Codes unns j 97001 PT Examination � ' CPT eapyr(ghf 2013 Nnciran Medlcal Associallon.A1 rlyMS msened. .. ..::.. .... . .. . .. .:�...:..�::.......:�y.:...:. . .: . - ..:-•:... .:��.��w.��pi�1•� .:� . .. .:: '��`.. . .. . .. . � . � . .. ... .. . . . .. .. � . ... ... .. � .. .. . . ..... �� . . . - � . ... . ..... . .....• ... .. , ..:........:....::........:................._--..:.. . ...:. . . AssessmenUDlagnosls: Whiplash Syndrome Rehab Potenttal: Good Patient Problems: - Headaches i - Decreased Cervical ROM - Decreased Lumbar ROM - Decreased tolerance to sit/stand ' - Disturbed sleep Short Term Goals: ' 1:(6 Weeks) �O�o� Eliminate headaches� � 2:(6 Weeks) �0%� Improve cervical ROm to WNL� � 3:(6 Weeks) �0%� Improve lumbar ROM to WNL� 4:(6 Weeks) �0%� Improve siUstand tolerance to 45-60' � 5:(6 Weeks) �09'0 � Improve Undisturbed sleep time to 4 hours � Received Time Apr. 11. 2014 12:21PM No. 2583 =�r',�-� i ' . . . . � . .3�:.7_ �yz4+.*` i:��'• i I rc�iu nylar�►n cnLeiprzs�_._, rri 11 Aj�Jl �cvr�-,.tv:..c�:GO_'�7-.1.��1 , -ragc c:o 'vz : Mobile Rehab, LLC Patient Name:Vang, Ricky 2915 Wayzata Blvd Date of Birth: 10/19/1969 � Minneapolis, MN 55405 Dail Note / Document Date:02/20/2014 Phone:(612)310-8844 y Fax: (763)559-1660 Billing Sheet , , _:. �!f�i3'_ _: `:; - <;. ,:: , _ „ ,,. . _ Instructions: Progressing Patient Next Visit i N 'S „ T �/ �'��f T" �L�� J � Tammy Saphir, RPT License#6097 L"nmi+lntorl hv Tnmmv$ni+hir RPT pn FaFv�/pni 9t 'J/114�I r.�/ld nm . Received Time Apr. 11. 2014 12:27PM No. 2583 , �pl-�• r.:.;;... _ .;�;�r ' . . . � �� ::[:'i:�.{�_ 4. a�.. '. i �ltJ(ll--Cly1dl'"Li2►�-C11I.C1'�Z��1bG_; . . _ . lll�� I�l� H�I"—LVlY.� .1V.::.Gb:�.:.Lt3---t11'(..ClD1... .. .: �_. _._ ..-. ..�_ . -Yii.�C '�GU�..UZ...... ._� Mobile Rehab, LLC 2915 Wayzata Blvd = Minneapolis, MN 55405 Daily Note / Phone:(612)310-8844 Fax: (763)559-1660 Billin Sheet _ _ 9 .. _. Patient Name: Vang, Ricky Date of Daily Note: 02/24/2014 Date of Birth: 10/19/1969 Injury/OnseUChange of Status Date: 10/16/2013 Referring Physlctan(s): Davison,William DC Dlagnosis: 847.0: Sprain of neck, 847.1:Sprain of thoracic, 847.2:Sprain of lumbar,846.0:Sprain of lumbosacral Qoint) (ligament) Date of Original Eval: 02/20/2014 Vislt No.: 2 Treatment Dlagnosis: 847.0: Sprain of neck,847.1: Sprain of Insurance Name: Natiornvide Insurance thoracic,847.2: Sprain of lumbar, 846.0:Sprain of lumbosacral (joint) (ligament) Sub��ve ; ;: :; ` _. Current Complaints/Gains: Pt states he his mid to low back pain is moderate today Prlor Level of Functlon: Changing & Maintaining Body Position: Moblllty:Walking & AAoving Around: Carrying,Moving & Handling Objects: Current Functional Llmltations: Self Care: Sleep: Disturbed Sleep Changing & Maintalning Body Position: Maintaining a Body Position:Remaining Seated, Remaining Standing,Squatting Carrying,Moving &Handling ObJects: IADLs:Shopping, Housekeeping, Laundry Pain Location: mid to low back Pain Scale:Worst: 7 Best: 4 Current:5 'P�evious Andfrgs as of 02/"10/2014-Worst:7 Best:4 Current:5 ; Aggravating Factors: Bending ' Home Health Care: No Medlcal Hlstory: No Known Significant PMH To Affect Treatment Mental Status/Cognitive Function Appears Impaired? No ,......:�.; :..::,.-:,.... �.: ,:::.:.:_ :- .;.:..-.:�.::�°;:: ...:......:.:.;...:..:.<... �... .. .:.. ::�..�..:: , .,:.:;.;:::: ;;::�: �:::::; E�br�Ctt�e.'.,.... ::�::'":;::::::.. . .: ., ... .:..::: . .. _... �. :..;..::. . .:... .. . . : .. _. . .. ... . CPT�Code Direct Timed Codes unns I g7110 Therapeutic Exercise 2 Core stability with transverse abdominal activation and spinal intrinsic � strengthening g7112 Neuromuscular Re-Education � Posture training. - CPT capyrqht 2�l3 M�er(ran Medlwl Assiodat(an•AI AgMS rrsene�d. Objective Findings Poor core stability,weak spinal intrinsics. Poor posture with forward head, rounded shoulders,and decreased lumbar lordosis. . :.::.. ..:.: .. .::.. ,. :.:. . ..: .. ..: .:;... . ... �. . . .::........ ......... R# ..:.:.::;: . . :�$S�SS11'�@ '.• . _ : .;:. ;:r:.::: � .. .. .. . . : .. . . . Patlent Educatton: Posture correction Rehab Potentlal:Good PatieM Problems: - Headaches - Decreased Cervical ROM - Decreased Lumbar ROM - Decreased tolerance to siUstand - Disturbed sleep Shon Term Goals: 1:(6 Weeks) �0%� Eliminate headaches� 2:(6 Weeks) �0%� Improve cervical ROm to WNL� 3: (6 Weeks) �09�0 � Improve lumbar ROM to WNL� 4:(6 Weeks) � 09'0 � Improve siUstand tolerance to 45-60' � 5:(6 Weeks) � O�o� Improve Undisturbed sleep time to 4 hours� Received Time Apr. 11. 2014 12:27PM No. 2583 � _ ' N��ns'>•�o ' . . . . ., ,".!S:�a. 'i'�4�i's.c .�. 1 L�VIII 11yldi'H/1 �I1�GZ�j)i1.7G.. .. ..C.YS ..11...!'Y�JZ� L.V1��"`1l!':�G.O :�GO �-t11'1`-l'15.1 `... .� .. .... �.� , .`"-."`"EYU.SG Z..1 `Vi .... Mobile Rehab, LLC Patient Name:Vang, Ricky 2915 Wayzata Blvd Date of Birth: 10/19/1969 � Minneapolis, MN 55405 Daily Note / Document Date: 02/24/2014 Phone:(612)310-8844 Fax: (763)559-1660 Billing Sheet pl�t�.: ; - Instructions: Progressing Patient Next Ysit � - � I � � ,� .t _ � ,1,Y � �� 1i//��f-��//}�'�Lr �- 1' T.- + Tammy Saphir, RPT Licer�se#6097 (�`mm�laforlhv T�mmv S�nhii APT pn Fohr�iv'7F 7/11,4 ni�.410 nm Received Time Apr. 11. 2014 12:27PM No. 2583 y _ .5�;��<pl'° . . ..::;�«�-. _ :f�..<,. . _. : L � , . .. ; i .. . _ _ ' .. -_ _ � .-.. _�__ - .. � .�. .�... -.i ' ' . . __ 1011l ..IY�110.CHA �G11C�Z�jJT1,5C -- .�..�� C21 �11 HjJl - GVI�"�1V:GO:�GO lil'l C101 �:. ..... _..`�".. _- ..,� Y'6Sc �tc�- V1 �- •- Mobile Rehab, LLC 2915 Wayzata Blvd - Minneapolis, MN 55405 Daily Note / Phone:(612)310-8844 Bj��l�1 Sheet Fax: (7fi3)559-1660 _.. .. g . _. .. _. . . Patient Name: Vang, Ricky Daie of Daily Note: 02/26/2014 Date of Birth: 10/19/1969 InJury/OnseUChange of Status Date: 10/16/2013 Referring Physician(s): Davison, William DC Diagnosis: 847.0:Sprain of neck, 847.1:Sprain of thoracic, 847.2:Sprain of lumbar, 846.0:Sprain of lumbosacral (joint) (ligament) Date of Origlnal Eval: 02/20/2014 Visit No.: 3 Treatment Diagnosis: 847.0: Sprain of neck,847_1: Sprain of Insurance Name: Nationwide Insurance thoracic,847.2: Sprain of lumbar, 846.0:Sprain of lumbosacral (joint) (ligament) SUb]�BCfFVe ; ;; ; , Current Complaints/Galns. Pt states he his mid io low back pain is moderate again today. Prlor Level of Function: Changing &Malntalning Body Positlon: Mobility:Walking & Moving Around: Carrying,Moving &Handling Objects: Current Functlonal Limltatlons: Self Care: Sleep:Disturbed Sleep Changing &Mafntaining Body Posftlon: Maintaining a Body Position:Remaining Seated, Remaining Standing,Squatting Carrying,Moving &Handling Objects: IADLs:Shopping, Housekeeping, Laundry PaU Locatlon: mid to low back Pain Scale:Worst: 7 Best: 4 Current:4 'Pievious Findings as o/02124/20 1 4-Worst:7 Bese4 Current:5 Aggravating Factors: Bending � � Home He�alth Care: No Medlcal Hlstory: No Known Significant PMH To Affect Treatment Mental SiatusJCognitive Function Appears Impaired? No :.;::,..::�. :...:,,......:<::...:, _ . t�btJ�tt�e_ ; :;_. : . _. . . .�=_ .. . . _ . ... . .. . . .. . �S . . ..... ..,.. :., 2 .. . . . , . .. Un .. . . .... . CPT�Code Direct Tlmed�Codes ' 971�p Therapeutic Exercise ' Core stability with transverse abdominal activation and spinal intrinsic ; strengthening g7112 Neuromuscular Re-Education � Posture and body mechanics training. � CPT caPNlgM 2013 Amariran A4edkal Arsnciatian.Af rfpMa resened. � Objective Findings shoulde s,and decreased umbar�lo dosis P�r posture with forward head, rounded .....:. . . ...:...� : . . .. . ... ....... .. ...::.. .. . � � .... . . - . , , :.: _ . _ . . . . .: . . .. :1�$.Sl;SSIi'iG�13#`.`::.::: : . ., ...- :� _. . . . . . ..:.:,,::•.:::;....... ...:... ..;.:.•.�: :: .. :: .. : ... ,....... Patlent Educat(on: Posture and body mechanics training. � Rehab Poiential:Good � Patlent Problems: � - Headaches - Decreased Cervical ROM - Decreased Lumbar ROM - Decreased tolerance to siUstand - Disturbed sleep Short Term Goals: ' 1:(6 Weeks) � 20%� Eliminate headaches � ' 2:(6 Weeks) � 20% � Improve cervical ROm to WNL� 3:(6 Weeks) � 15% � Improve lumbar ROM to WNL� 4:(6 Weeks) � 15% � Improve sif/stand tolerance to 45-60' � 5:(6 Weeks) � 15�e � Improve Undisturbed sleep time to 4 hours � Received Time Apr. 11. 2014 12:27PM No. 2583 , , .:_ ��;:�:� _ �:�:�::�� ._ -�PT.. � z'v�n'nylarrin cri�Ci�iYSC . rii ii' r�pi z�l� i'v:2.O�:G� HI•r: rrdr ';--,_ _ , �rn�c i�' v= ,I Mobile Rehab, LLC Patlent Name:Vang, Ricky ;� 2915 Wayzata Bivd Date of Birth: 10/19/1969 Minneapolis, MN 55405 Daily Note / Document Date:02/26/2014 Phone: (612)310-8844 Fax: (763)559 1660 BI��I11g $heet PFa�°: . Instructions: Progressing Patient Next Vsit � I i H � � 7 f � A ��,,. ��:�'�` J ' Tammy Saphir, RPT License#6097 CnmrJala`l hv T�mmv Sanbir RPT pn Fahry/ani 97 9M¢�I 1194 n� . Received Time Apr. 11. 2414 12:21PM No. 2583 - y _ s ��-��f�" i:s-":- , Y:� :[:Ef:.l�'_. '. ''k� i�Um nyiare�►x criz�i�I_15� rl-1 i1-t��ii: _zvi� lv:zo':co ru•i ri�i _ � � _ _ ra�c lo vi ;:_ Mobile Rehab, LLC - 2915 Wayzata Blvd Minneapolis, MN 55405 Dail Note / Phone:(612)310-8844 y Fax: (763)559-1660 Billing Sheet Patlent Name: Vang, Ricky Date of Daily Note: 03/05/2014 Date of Birth: 10/19/1969 InJury/Onset/Change of Status Date: 10/16/2013 Referring Physician(s): Davison, William DC Diagnosls: ICD9:847.0:Sprain of neck, 847.1:Sprain of thoracic, 847.2:Sprain of lumbar, 846.0:Sprain of lumbosacral (joint)(ligament) Date of Origlnal Eval: 02/20/2014 Visit No.: 4 Treatment Diagnosis: ICD9:847.0:Sprain of neck,847.1: Insurance Name: Nationwide Insurance Sprain of thoracic, 847.2: Sprain of lumbar, 846.0: Sprain of lumbosacral (joint) (ligament) Subj�ctwe < ' ;: `:: _ . Current Complaints/Gains: Pt states he is about the same. Prior Level of Functlon: Changing &Maintaining Body Position: Mobility:Walking & Moving Around: Carrying,Moving &Handling Objects: Current Functional Limitations: Self Care: Sleep: Disturbed Sleep Changing &Maintalning Body Position: Maintaining a Body Position: Remaining Seated, Remaining Standing, Squatting Carrying,Moving & Handling Objects: IADLs:Shopping, Housekeeping, Laundry Pain Location:mid to low back Paln Scale:WOfSt:7 B2St: 4 Current:6 'Previous Fndings as o/112f2&2014-Worst:7 Best:4 Cur�ent:4 Aggravating Factors: Bending � Home Health Care: No '' Medtcal History: No Known Significant PMH To Affect Treatment ' Mental Status/Cognitive Functbn App�rs Impalred? No ;: ;�::::,.; .:.., -,.::::.;:.' ,.. :.: .. C�br �ftrre: :. . . . . . . .. .. _ . .. _. � :; .: 1�....- . . ..-.. : . . � . .�. : . .. ... .. : .. :....:.: ..:.. . CPT�'Code Direct Tlmed Codes un►rs 97110 Therapeutic Exercise 2 Core stability with transverse abdominal activation and spinal intrinsic i strengthening 97112 Neuromuscular Re-Education � Posture and body mechanics training. Lifiing mechanics. CPT capyrlgM 2013 Mixlran Abdfcal Aseodatla�.AI Aghfs re�verved. ; Objective Findings Poor core stability,weak spinal intrinsics. Poor posture with forward head, rounded ' shoulders,and decreased lumbar lordosis. ..:.: :.....::: ...::.:.. ;1�s`sessr�en# .::.: . ` _... .. .:°. . : ` ,.... . . Patlent Education: LiRing mechanics Rehab Potentlal: Good Patient Problems: - Headaches ' - Decreased Cervical ROM - Decreased Lumbar ROM - Decreased tolerance to sit/stand - Disturbed sleep ' Short Term Goals: 1:(6 Weeks) � 25�0 � Eliminate headaches � ; 2:(6 Weeks) �25% � Improve cervical ROm to WNL� 3:(6 Weeks) �259�0 � Improve lumbar ROM to WNL� 4:(6 Weeks) � 25% � Improve siUstand lolerance to 45-60' � 5:(6 Weeks) �25% � Improve Undisturbed sleep time to 4 hours� Received Time Apr, 11. 2014 12:27PM No, 2583 . ;::�,t,,�: y-;��:��QPl-�• I-UItI 11�71'dt' !l �L'I1LSI"�T1�C`.' � i,i l 1i HjlY� Gvl� 1v:Lo:`GO tiri rlui -- _ � - rasc--i"i vt . ; Mobile Rehab, LLC Patient Name:Vang, Ricky _ 2915 Wayzata Blvd Date of Birth: 10/19/1969 - Minneapolis, MN 55405 Daily Note / Document Date:03/05/2014 Phone:(612)310-8844 Billin Sheet Fax: (763)559-1660 , , 9 _. . p��Yt; _ . _ . Instructions: Progressing Patient Next Visit � i ; I'� f; .4 � i j� � ��1--��G,.�'� Tammy Saphir, RPT License#6097 (�`mm�faFOi'/hv Tammv S'�nhlr FiPT pn�/7m,(�4 'J11 id nI]''Jd nm Received Time Apr. 11. 2014 12:27PM No. 2583 , ",.;:, .=��-r,.��Pr" rvui 'riyla:rA�► `�trz�i�r�iSC ' ri Y li K�,i '��i� �v:co:�o`r,��,...�,��t' . rasc �Y 'v= : Mobile Rehab, LLC 2915 Wayzata Blvd Minneapolis, MN 55405 Dail Note / Phone:(612)310-8844 y Fax: (763)559-1660 Billing Sheet Patlent Name: Vang, Ricky Daie of Daily Note: 03/12/2014 Date of Birth: 10/19/1969 InJury/OnseUChange of Status Date: 10/16/2013 Referring Physician(s): Davison,William DC Diagnosis: ICD9:847.0:Sprain of neck, 847.1:Sprain of thoracic, 847.2:Sprain of lumbar, 846.0: Sprain of lumbosacral (joint) (ligament) Date of Original Eval: 02/20/2014 Vlsit No.: 5 Treatment Diagnosis: ICD9:847.0:Sprain of neck,847.1: Insurance Name: Nationwide Insurance Sprain of thoracic, 847.2: Sprain of lumbar, 846.0:Sprain of lumbosacral (joirit) (ligament) SUb�$Cfl�@ :° , , Current Complaints/Galns: Pt states he feels slightly better today. More mobile he thinks. Prlor Level of Functlon: Changing &Mainta(ning Body Posltion: Mobtltry:Walking & Moving Around: Carryfng,Mov(ng &Handling Objects: Current Functlonal Llmltations: Self Care: Sleep: Disturbed Sleep Changing &Maintalning Body Positlon: Maintaining a Body Positian: Remaining Seated, Remaining Standing,Squatting Carrying,Moving &Handling Objects: IADLs:Shopping, Housekeeping, Laundry Aggravating Factors: Bending Home Health Care: No Medlcal History: No Known Significant PMH To Affect Treatment i Mental Status/Cognitive Functlon Appears Impaired? No ! .. ........ -:: ��::.::: ::....:: .. ; . ;: ::.. : , :Q��t..Q., , ' i .::::.:::�:..:,. :. . : ..��::.:�... . .:.....::_.. .... . .. . .. . CP'i'�Code Direct Tlmed Codes unns ; 97110 Therapeutic Exercise 2 Core stabiliry with transverse abdominal activation and sp+nal intrinsic strengthening 97112 Neuromuscular Re-Education � Posture and body mechanics training. Lifting mechanics.ADL modifications � cvrcapy,gmaof3a,�rrcantifadicaiassodanw�.�u�rsre�,�e. I Objeciive Findings Poor core stability,weak spinal intrinsics. Poor posture wilh forvvard head, rounded shoulders,and decreased lumbar lordosis. :. .: .. .... . >:... . ... . .. . ;1�S8�5111�h� ..:.:. . .. . ..... . . . . ... . . : .. :........ ..... . ....... .... Patient Educatlon: ADL Modifications Rehab Potential: Good Patient Problems: - Headaches - Decreased Cervical ROM � - Decreased Lumbar ROM - Decreased tolerance to sit/stand - Disturbed sleep i Short Term Goals: 1:(6 Weeks) �40%� Eliminate headaches � 2:(6 Weeks) �35% � Improve cervical ROm to WNL� 3:(6 Weeks) �35% � Improve lumbar ROM to WNL� 4:(6 Weeks) �40% � (mprove sit/stand tolerance to 45-60'� 5:(6 Weeks) � 40% � Improve Undisturbed sleep time to 4 hours� Received Time Apr. 11. 2014 12:27PM No. 2583 _ � ' , ,.r.. ..:�� -'��pT-" ; . . - �.-�.- S�Ulll��Ily1dCH7l�-r.i1G�Ci��I�ISC -. ...- - IZ� 11 �H�l- _.LVI1t-�1CJ�:��-GD-:-GO Hl•1 -19.71-_. . . . . . .� � .F,d�'C_ 1�...02 .: � Mobile Rehab, LLC PDate oNB rth: 10/19/�1969 2915 Wayzata Blvd Minneapolis, MN 55405 Daily Note / Document Date: 03/12/2014 Phone:(612)310-8844 Fax: (763)559-1660 Billing Sheet , ; ; ,. Pfar�, Instructlons: Progressing Patient Next Ysit I ' M ,;c _ r ! :�?'1' �l��!'/ 1�,'�` ,�f � r Tammy Saphir, RPT License#6097 Cmm�laixl hv Tammv$�nhir F7PT pn�I�m,h 1 R 9/Nd n Q•/IR�m Received Time Apr. 11. 2014 12:27PMtNo. 2583 . .., . ;,� _ �F�•=��..�-��T" :-:.. I'U1D Yly L�dP AJi Ci1LCl"pT15�C C 2 Y 11 H'jJl Z.111Y 1L[Lo: GO t�i•1 i7i7'i "ragc l[."vi � Mobile Rehab, LLC 2915 Wayzata Blvd Minneapolis, MN 55405 Daily Note / Phone:(612)310-8844 Fax: (763)559-1660 BIIIIng Sheet..... _ Patient Name: Vang, Ricky Date of Daily Note: 03/21/2014 Date of Birth: 10/19/1969 injury/Onset/Change of Status Date: 10/16/2013 Referring Physician(s): Davison, William DC Dlagnosis: ICD9:847.0:Sprain of neck, 847.1:Sprain of thoracic, 847.2:Sprain of lumbar,846.0:Sprain of lumbosacral (joint) (ligament) Date of Orlgtna! Eval: 02/20/2014 Visit No.: 6 Treatment Diagnosts: ICD9:847.0:Sprain of neck,847.1: Insurance Name: Nationwide Insurance Sprain of thoracic, 847.2: Sprain of lumbar, 846.0:Sprain of lumbosacral Qoint) (ligament) $tl�j�Ctl� ` _ -; .; _ : _ Current Complaints/Gains: Pt states he feels about the same. Prior Level of Function: Changing & Maintaining Body Posftion: Mobility:Walktng & Moving Around: Carrying,Moving &Handling Objects: Current Functional Limltations: Self Care: Sleep: Disturbed Sleep Changing &Maintalning Body Position: Maintaining a Body Position: Remaining Seated, Remaining Standing,Squatting Carrying,Moving &Handling Objects: IADLs:Shopping, Housekeeping, Laundry Pain Locatlon: mid to low back Pain Scale:�IVO�St:7 Best: 4 Current:4 'Previous Findings as ol Q3/OS2014-Wast:7 Best:4 Currenl:6 Aggravating Factors: Bending i Home Health Care: No I Medtcal History: Na Known Significant PMH To Affect Treatment Mental StatusJCognitive Function Appears Impaired? No .... ..-- . .. . .. . ..... ........:. .... ........:...,.-.:. ....::... . . . .. . . . ....................... .......:......:............. ..........:...... _..:..:::,,;:::..::_, :.._....,.:,..:.::::: ::::::_:�:::;.:; .:�::�:;::::�..:;,,. ... :;::..... . :. , .. ....; ::�::::.;::;:... ;:. .:.. ,:....:..:�:... :......:. , :: . ...:::....::. . .. . :.,..:: .:..�,.:.:;':.�."': .C�.btJ�GtiVe. - :. _: .. ::. .. . .. . ns. ..... ... .. .. . . .;. . ... .... . . . .... . �:_ . .. _ . CPT�Code DlreCt Timed Codes 2" � 97110 Therapeutic Exercise Core stability with transverse abdominal activation and spinal intrinsic sirengthening g7112 Neuromuscular Re-Education � Posture and body mechanics training. Lifting mechanics.ADL ; modifications CPT eappk�M 2013 Ameriran Medleal Asaodation.AI rigMa ressrved. j I Objective Findings Poor core stability,weak spinal intrinsics. Poor posture wiih forward head, rounded shoulders,and decreased lurnbar lordosis. ,: .�:;.::.�:..;.�..:-::.::.::.:.. . .. .:..;..:.. . ; ;..: .. ::: _..:.... .: . . ...::.. ..:.:::.. ..: ..:.: ..:...: . . , .. :..:. . .........:.. �:: �..:: .. . :::;:::::..:::: .::.... :As5�sm44�t...:::: . . .. .. . . . ; Rehab Potential: Good Patient Problems: � - Headaches i - Decreased Cervical ROM - Decreased Lumbar ROM - Decreased toterance to sit/stand - Disturbed sleep I Short Term Goals: . 1:(6 Weeks) ( SO�o � Eliminate headaches( 2:(6 Weeks) � 45% � Improve cervical ROm to WNL� 3:(6 Weeks) � 45%� Improve lumbar ROM to WNL� 4:(6 Weeks) � 45% � Improve siUstand tolerance to 45-60' � 5:(6 Weeks) � 45% � Improve Undisturbed sleep time to 4 hours � Received Time Apr. 11. 2014 12 27PM No. 2563 � r:� w{r'�_��,P]-� � !U[il i'1J�ldi'All L.S7ZCl�1ZSC' , _ Cl l: 11. A�l_ GV1Y tV:GO C�G� HPI l'1�1 _ _ _ . ;':- ' Yd,��1�, VI ,: Mobile Rehab, LLC Patient Name:Vang, Ricky 2915 Wayzata Blvd Date of Birth: 10/19/1969 Minneapolis, MN 55405 Daily Note / Document Date:03/21/2014 Phane:(612)310-8844 Fax: (763)559-1660 BI��It1 Sheet :.. 9 P1an : _ . ; _ . Instructions: Progressing Patient Next�sit � I I i i , .� ' r• „ r ! �'� ('�'.�f��.,-J��:� . Tammy Saphir, RPT License#6097 � Cmm�lAMr�hv T�mmv$niJ+ir RPT pn Illam,(7 9 f 7/11d n 7•AR n^/mrn^x^{ y Received Time Apr. 11. 2014 12:27PM`�No. [J�IJ ' �j�.n"F�,pj-� xiy�,:�'SE . . " � .,a::�i'�i.[— .... a. 1 V(I! T1y1dtAll �IILCI"�I�15C CI�1 tl �A�1' LV1't� 1V:GO:GO HtR 19�1 � Yd�G .Lll t7i ; Mobile Rehab, LLC 2915 Wayzata Blvd Minneapolis, MN 55405 Daily Note / Phone:(612)310-8844 Fax: (763)559-1660 Billing Sheet Patient Name: Vang, Ricky Date of Daily Note: 03/24/2014 Date of Birth: 10/19/1969 Injury/Onset/Change of Status Date: 10/16/2013 Referring Physlcian(s): Davison,William DC Diagnosis: ICD9:847.0:Sprain of neck, 847.1:Sprain of thoracic, 847.2:Sprain of lumbar, 846.0:Sprain of lumbosacral (joint) (ligament) Date of Origlnal Eval: 02/20/2014 Vislt No.: 7 Treatment Diagnosis: ICD9:847.0:Sprain of neck,847.1: Insurance Name: Nationwide Insurance Sprain of thoracic, 847.2: Sprain of lumbar, 846.0:Sprain of lumbosacral (joint) (ligament) S1�lyj�1C��Yfi' > ..- .. .. ... . . Current Complaints/Gains: Pt states he feels about the same. His right shoulder is a little sore. Prior Level of Functlon: Changing &Malntalning Body Position: Mobility:Walking & Moving Around: Carrying,Moving & Handling Objeds: Currenl Functional Limitations: Self Care: Sleep: Disturbed Sleep Changing &Malntalning Body Position: Maintaining a Body Position: Remaining Seated, Remaining Standing,Squatting Carrying,Movtng &Handling ObJects: IADLs:Shopping, Housekeeping, Laundry Pain Locatlon:mid to low back Pain Scale:Worst:7 Best: 4 Current:5 'Previous Fndfngs as of 03/'21/`1014-Worst:7 Best4 Current:4 Aggravating Factors: Bending Home Health Care: No Medlcal History: No Known Significant PMH To Affect Treatment ; Mental Status/Cognftive Functlon Appears Impatred? No .��:.:�;:_;:"..:��:::::::::;;:;:� :�:.�':�`:';::;:.::�; _.:..:<:.. : ,.::...:;: : ......:... C��eC#lVe.; . . ... . . . ... . . _ ...:.:..:. ::.:....:..: �::::::. .::.....:.... ,.. : ... .- _... .. .. . . . ..... ... .. .. .. ... . ... . _. . _ -. .. CPT�Code Dlrect Tlmed Codes unns ': 97110 Therapeutic Exercise 2 Core stability with transverse abdominal activation and spinal intrinsic � strengthening ' 97112 Neuromuscular Re-Education � ' Posture and body mechanics training. Lifting mechanics.ADL � modifications CPT copyrlyht 20/3.M�erkan Madtal Aesodatlon.A/dgMs reaen�ed. Objective Findings Improving core stability and spinal intrinsics. Poor posture with forward head, ' rounded shoulders, and decreased lumbar lordosis. .::..::.> ,. , _ , ,, Assesstt�er�t ,. < . .: . . . ... ... .... . . . ... Patient Educatlon: Home exercises Rehab PotentlaJ: Good ' Patlent Problems: - Headaches - Decreased Cervical ROM - Decreased Lumbar ROM - Decreased folerance to siUstand - Disturbed sleep Short Term Goals: 1:(6 Weeks) � 65% � Eliminate headaches� 2:(6 Weeks) � 55% � Improve cervical ROm tu WNL� 3:(6 Weeks) �55% � Improve lumbar ROM to WNL� 4:(6 Weeks) �55% � Improve sit/stand tolerance to 45-60' � 5:(6 Weeks) �45% � Improve Undisturbed sleep time to 4 hours� ,:,P1` - _ - . -. _. ... ...... -. . ... ... .. .. . . .. .. .. .. . . ... .. . .. . . .. .. .. .. . . .. .: �17':'::::<=::::::�:�`:`:::.��::::::::::;';;:.'°::.:::°;:::°:�>;�::�:::':::::::::.`:=`::=::�:� . � ...:..:...:....:.:. .......:...:.�......r. . . Received Time Ap . 11. 2014 12 27PM No. 2583 _ =t ��- , ._,.,,.,.�r �;�:'*�_� I't�ur`nylat'[ix r.IltiCr-�r15� ,-- _. ..r_t 1,.:.il; Hpr<_:c'vl� ' lo: �'o:zo Eu•i:ri�t ' ' - .__:. . ---ra�� 1:1_v= :t Mobile Rehab, LLC Patient Name: Vang, Ricky 2915 Wayzata Blvd Date of Birth: 10/19/1969 Minneapolis, MN 55405 Daily Note / Document Date: 03/24/2014 Phone: (612)310-8844 Fax: (763)559-1660 Billing Sheet Instructions: Progressing Patient Next Vsit y� f'f .. � �,��fr�.f��r--G�,�` Tammy Saphir, RPT License#6097 Cmm�latarf hv Tammv$nnhli APT pn lllnm/�9d 9Als a(R•d�.nm , Received Time Apr. 11. 2014" 12:21PM No. 2583 .. ,,..f�,��:s�pT-�• . _;�:c'?fi� G .:,.-.+ i-VI11�Ily�d.CAli r.I1LCI"�3�1`.S� t`Z'l ll A�I- :LV14 lt):GO:LO E1P1 1•l�l' - , - _ t,d�yC 0 V= �- Mobile Rehab, LLC 2915 Wayzata Blvd � Minneapolis, MN 55405 Daily Note / Phone:(612)310-8844 Fax: (763)559-1660 Billing Sheet Patlent Name: Vang, Ricky Date of Daily Note: 03/26/2014 Date of Birth: 10/19/1969 Injury/OnseUChange of Status Date: 10/16/2013 Referring Physician(s): Davison,William DC Dlagnosis: ICD9:847.0:Sprain of neck, 847.1:Sprain of ihoracic, 8472:Sprain of lumbar, 846.0: Sprain of lumbosacral (joint)(ligament) Date of Orlglnal Eval: 02/20/2014 Visit No.: 8 Treatment Diagnosis: ICD9: 847.0:Sprain of neck,847.1: Insurance Name: Natiornvide Insurance Sprain of thoracic,847.2:Sprain of lumbar, 846.0:Sprain of lumbosacral (joint) (ligament) Si1�j�GflY@ ` ' _ Current Complaints/Galns: Pt states he is a bit stiff and sore, but exercise helps. Prior Level of Function: Changing 8�Malntaining Body Posltion: Mobility:Walking & Moving Around: Carrying,Moving & Handling Objeets: Current Functfonal Limitations: Self Care: S(eep: Disturbed Sleep Changing &Malntalning Body Position: Maintaining a Body Position: Remaining Seated, Remaining Standing,Squatting Carrying,Moving & Handling Objeds: IADLs:Shopping, Housekeeping, Laundry Pain Locatlon:mid to low back Paln Scale:�1IO�St:7 Best: 4 Current:4 'P�evious Findings as of 03/24/"1D14-Worst:7 Best4 Current:5 Aggravating Factors: Bending i Home Health Care: No Medical History: No Known Significant PMH To Affect Treatment Mental Status/Cognitive Functlon Appears Impaired? No i .V.. . . ..... .. .. _ � � ":alr .. .. � e..�: . . . � �.. .::::: �..;�::: ..... ....::.....::::::.::.�. :.::.... ;�::.-:�:..:..:.. ... . . .:: :. :.. ....�:... . . ... .::::.. ��.;::. . . .::. ....:: .... .... .. . . . ... .. .:._.. .. .. . .....::�.> .. .2- . . CPT'�Code Direct Timed Codes unirs 97110 Therapeutic Exercise � Core stability with transverse abdominal activation and spinal intrinsic strengthening 97112 Neuromuscular Re-Education � Posture and body mechanics training. Lifting mechanics.ADL modifications ' CPT capyr(�M 2013 Amerlran Medkal Aasodatian.A1 AgMa res�vcd. � Objective Findings Improving core stability and spinal intririsics. Improved posture with decreased forward head, rounded shoulders,and decreased lumbar lordosis. � : . . .. . .... .. .. .. . .. .. .. . . ::..:>:::.:.::.:::....: ,... :...:...:.. ,,..,:.. .. .:.-:::.:..,:.. � . .. . ..:. : .. :; �...: �::. .:.: �. . .>.: . .. :. ........... . . _: _ ;�:::.;�:�::.::..:,;:.._..�:;;::,;::r ,;::.>.:.�::: .:.,..:.:_.:,.°... . ....:....... :.: : : ... ;.,..._.. �5�.�,�.$i�@�l ........ ' :':. : �,._... . < ..,: �.. :::_:;.. Patient Education: Hep Rehab Potential: Good Patlent Problems: - Headaches - Decreased Cervical ROM - Decreased Lumbar ROM - Decreased tolerance to siUstand - Disturbed sleep Short Term Goals: 1:(6 Weeks) � 75�0 � Eliminate headaches( 2:(6 Weeks) �65%� Improve cervical ROm to WNL� 3:(6 Weeks) � 65% � Improve lumbar ROM to WNL� 4:(6 Weeks) � 65% � Improve siUstand tolerance to 45-60' � 5:(6 Weeks) �60% � Improve Undisturbed sleep time to 4 hours � >P�`��`n:;::::�.:::::::��::;.::::::::.:::::°�:;�:::::_.°:;�.:-::=:=°��:::=�-��`� �' -. . . ... . - ..... ... :. ... . . ... ..�.: .. . . ... .. .. .. .- . .. .: .. .. - . ... .. .. .-. . ... .. .. ........:.....:..:.:...::.:..:............ . ...... ....... ........:. ;.. :.. . ...�:........:...;:.�:::::::�:::�:�:::�:. ��:�::.,::,: -: ... . .._ . .....;:;.:..:::: ...,:�.:....:;. ..... . . .... ......�...:.. . ....: ....:.::::.:::.::.: �::.:: .::.: :.:-�.:::.,.............: ::.. .. . ........._..:�..: :�:::::.:;- . .g :..:... ... . ...:..:..:....... . ..... .. .... : . .. :.::......:.. -.:: ... :..:.:. :.: Received Time Apr, 11. 2014 12 27PM No. 2583 . '�.�p]-° . ._:...is-::� �� rvur nylahtjn_ �nzerpt-i5C' rz i_ 11 Apr �vi� _iv:zo:Lb 'ri[•r ri�i __ _ _ ra.�c � u= r ,_: Mobfle Rehab, LLC Patient Name:Vang, Ricky 2915 Wayzata Blvd Date of Birth: 10/19/1969 Minneapolis, MN 55405 Daily Note / Document Date: 03/26/2014 Phone:(612)310-8844 Fax: (763)559-1660 BIIIIng Sheet Instructions: Progressing Patient Next Vsi1 � I � i ,- .x _ : �` �1�ff!!/-��;rL� 1�� .. Tammy Saphir, RPT ' License#6097 (�`mm�lokul hv Tammv$�nhir FiPT pn IU�m,h 97 9M t Q 1R grp Received Time Apr. 11. 2014 12:27�1� No. 1�63 , ,.w.4 ,,�t::_.-;��:;;�.��vf'" Z Ullf tl)/ld'CF1)l CI1LC!'�l'15C - I'i'1 11 E'ij�! LCI1� 1V:GCS :Gb Al'1 1RDL" ; ' Yd�'C b` Y3Y L� „ Mobile Rehab, LLC 2915 Wayzata Bivd ' Minneapolis, MN 55405 Daily Note / Phone:(612)310-8844 Fax: (763)559-1660 Billing Sheet Patient Name: Vang, Ricky Date of Daily Note: 04/02/2014 Date of Birth: 10/19/1969 InjurylOnseUChange of Status Date: 10/16/2013 Referring Physician(s): Davison,William DC Diagnosls: ICD9:847.0:Sprain of neck, 847_1:Sprain of thoracic, 847.2:Sprain of lumbar, 846.0: Sprain of lumbosacral Qoint) (ligament) Date of Original Eval: 02/20/2014 Visit No.: 9 Treatment Diagnosis: ICD9: 847.0:Sprain of neck,847.1: Insurance Name: Natiornvide Insurance Sprain of thoracic,847.2:Sprain of lumbar, 846.0:Sprain of lumbosacral Qoint)(ligament) , .: _ SiI�1j84�IY@ .. ..: .- , > . ` Current Complaints/Gains: Pt states he is about the same. Prior Level of Functlon: Changing &Malntaining Body Position: Mobility:Walking & Moving Around: Carrying,Moving & Handltng Objects: Current Functlonal Llmltations: Self Care: Sleep: Disturbed Sleep Changing &Malntalning Body Posltlon: Maintaining a 8ody Position: Remaining Seated, Remaining Standing,Squatting Carrying,Moving & Handling Objects: IADLs:Shopping, Housekeeping, Laundry Pain Location: mid to low back Pain Scale:Worst: 7 B@St: 4 Current:4 'Previous Rndings as ol U3/26l2014-Worst:7 Best4 Gurent:4 Aggravating Factors: Bending Home Health Care: No ! Medical History: No Known Significant PMH To Affect Treatment � � Mental Status/Cognitive Functlon Appears Impaired? No ;: .:.:.. .. :.::::::. :::.,:.:.:..:.,:.:..: ._:.':,;,.,<r.: . ...�......,:.:..;�. .:.: :-:°-;�.� _ t�1F .. .. ..: . .... . .. . . .. „. ... ... . .. ....:. . . ...;;�:....:.:.. :.. :. _ ;:Qbr�ec .::e .........:._�... .:.. .. :... .: _:. .. ... .. .. . _.. . � -��.... ...: . .... .. . NS .::.:.. .:.:.. ... .. ... .. . .. ...:.:. . ....,:..: .. , .... :.:.. .... ...... ... . ........ ... ....... . ..... ...... CPT�Code Dlrect Timed Codes un 97110 Therapeutic Exercise 2 Core stability with transverse abdominal activation and spinal intrinsic strengthening 97112 Neuromuscular Re-Education � Posture and body mechanics training. Lifting mechanics.ADL � modifications ! CPT capyrlgM 20 f3 M�er/can Medkal Assodatlon.AI dgf2s nsserved. . Objective Findings Improving core stability and spinal intrinsics. Improved posture with decreased forward head, rounded shoulders,and decreased lumbar lordosis. . ..... .. - - ... :...�:..::.�:::. :: ...:,:�.:. ::�:::.:..�..:.�:�.::�:...� .: ��::.�.:�:::�:: ; .......:..::..::::;. .. �: . .� _'.:::.::> :::_�;:;...: :..:.::....:..:•�.,:.,.. ;.: . . :� .:. .. .. ::... :...... .:..::..: ..:.. ::::::.-.::::::� :�:..:..::.. . . . ' , .:::::.:::�:� ;:::. ..,:. : .... ,. _.:::::. :: :.. ; ::.: SS£S$1'1�@�...:::°,>.: , :.:::.:; . ,;.. :::`:;:::::, . ..:::.. :::� .. .... . . .. . .;..... . .. ... . . Rehab Potential: Good Patlent Problems: - Headaches - Decreased Cervical ROM �I - Decreased Lumbar ROM - Decreased tolerance to siVstand - Disturbed sleep Short Term Goals: 1:(6 Weeks) �75% � Eliminate headaches � 2:(6 Weeks) � 75% � Improve cervical ROm to WNL� 3:(6 Weeks) �75% � Improve lumbar ROM to WNL� � 4:(6 Weeks) � 70% � Improve sit/stand tolerance to 45-60' � 5:(6 Weeks) � 70% � Improve Undisturbed sleep time to 4 hours� Received Time Apr. 11. 2014 12:27PM No. 2583 _ .:i;{.�_ cY;n��J-" l_�� . . . . : - � , ...,� ..�.�_ . .. _ � . lil Ry1dt'-Hd r.IIL��-�i-�15� �-'--- -l_1..1� 11.- P1�I-. GVl'f� IV:�GtS:Lt7�_.At7� I'1.'7'1'. . _-��-°-. .r,��r�-..,�._ V=. � �,-... Mobile Rehab, LLC Patient Name:Vang, Ricky 2915 Wayzata Blvd Date of Birth: 10/19/1969 Minneapolis, MN 55405 Daily Note / Document Date:04/02/2014 Phone:(612)310-8844 Fax: (763)559-1660 Billing Sheet �fdfl ; _ _ , - . Instructlons: Progressing Patient Next�sit i : ;: � ,I � � i n' * _ i `,_.' p�(�f-J��x�f �(� . Tammy Saphir, RPT License#6097 Cmm�foixlh T�mmvSanhir f7DTpndrrilQ �ni��PM'No.n .: Received Time Apr. 11. 2414 12:27 2583 . . ._y.,.r,�_^,;,��y:��. L �._. , : , . I Vl11 nylar'P,a C[1LCl�1ZbC�- -�� --C-i-1 11�--E'f�l Gl/l'f 1 V: Gb�:LO�--IiPI 1•1�1 - -�� Yd�G Y -VI� L =-' Mobile Rehab, LLC 2915 Wayzata Blvd Minneapolis, MN 55405 Daily Note / Phone:(612)310-8844 Fax: (763)559-1660 Bl��ltlg $heet _ _ .. .. _ Pafient Name: Vang, Ricky Date of Daily Note: 04/07/2014 Date of Birth: 10/19/1969 Injury/Onset/Change of Status Date: 10/16/2013 Referring Phys(cian(s): Davison,William DC Diagnosis: ICD9:847.0:Sprain of neck, 847.1:Sprain of thoracic, 847.2:Sprain of lumbar, 846.0:Sprain of lumbosacral (joint) (ligament) Date of Original Eval: 02/20/2014 Vlsit No.: 10 Treatment Dfagnosis: ICD9:847.0:Sprain of neck,847.1: lnsurance Name: Nationwide Insurance Sprain of thoracic, 847.2:Sprain of lumbar, 846.0: Sprain of lumbosacral (joint) (ligament) , Si[tl��'C�11f�' �: ` Current Complaints/Gains: Pt states his neck and low back are in moderate pain. Prior Level of Function: Changing &Maintaining Body Position: Mobility:Walking & Moving Around: Carrying, Moving & Handling Objects: Current Functional Llmitattons: Self Care: Sleep: Disturbed Sleep Changing &AAalntalning Body Position: Maintaining a Body Position: Remaining Seated, Remaining Standing,Squatting Carrying,Moving & Handling ObJects: IADLs:Shopping, Housekeeping, Laundry Pain Location:mid to low back ' Pain Scale:Worst:7 Best: 4 Current:5 'P2vious Frndings as of 04102l2014-Worst:7 BesL-4 Current:4 Aggravating Factors: Bending Home Health Care: No Med(cal History: No Known Significant PMH To Affect Treatment Mental Status/Cognitive Functlon Appears Impaired? No .,:. �:....,..:.: ..... : ... . ,::��..: .:- ::.: ,.,:. : ::�;: 0 ive .:.:.. _ .. - ... .... . , _... ; ...fxl!� . :::. : ...::.. _ .: � � ::. ..:. . ,. . . .. . .. . .:. . . . .....:. ... CPT�`Code Dlrect Timed Codes un s , 97110 Therapeutic Exercise 2 Core stability with transverse abdominal activation and spinal intrinsic strengthening 97112 Neuromuscular Re-Education � Posture and body mechanics training. Lifting mechanics.ADL modifications CPT capyrlqM 2013 Mnerkan MedYal AssodaHan.AI dghta reserued_ Objective Findings Improving core stability and spinal intrinsics. Improved posture with decreased forvvard head, rounded shoulders,and decreased lumbar lordosis. .: :.: :: ...:...:..::_:.,.�:..:..:_. c:�. ..: : ,:.:: :.:.. .; _ ..... ... �S$:�, $�i@r1� :: � :::�.'r:�r�: � . .. . .. .. . .. .. ... _ _.... . . Patient Educatlon: Home exercises Rehab Potentlal: Good Patlent Problems: - Headaches - Decreased Cervical ROM - Decreased Lumbar ROM - Decreased tolerance to siUstand - Disturbed sleep Short Term Goals: 1:(6 Weeks) �75% � Eliminate headaches � 2:(6 Weeks) � 75% � Improve cervical ROm to WNL� _ 3:(6 Weeks) � 75% � Improve lumbar ROM to WNL� 4:(6 Weeks) � 70% � Improve sit/stand tolerance to 45-60' � 5:(6 Weeks) �70�0� Improve Undsturbed sleep time to 4 hours � ::P1��: : _ _. . - . .. .. .. .. . . .. . .. . . . .. .. :. " . .- . . .. . :. .::.. ..... ..:... .. . ..;:....:.:.::... ... ....>::. ::. an.;��"'��::� . . . .. . Received Time Apr. 11. 2414 12:27PM No. 2583 ;,�,r��" � ....r.:<f::.i- � wr..s, rom nyiar tix�--�nterpri5e rri il' :�pz'' zvi4 1�:c�':Ld_ Ari`M�•i____ � ..,. _ r�age � o= _� . ,_,. Mobile Rehab, LLC Pat(ent Name:Vang, Ricky 2915 Wayzata Blvd Date of B1rth: 10/19/1969 Minneapolis, MN 55405 Daily Note / Document Date:04/07/2014 Phone:(612)310-8844 Fax: (763)559-1660 Billing Sheet : Instructions: Progressing Patient Next Visit � � �II i i t,' ! q „ �.�'r'r ��j�� =� � �� Tammy Saphir, RPT License#6097 CjAT/IIPIPlIIIV Tammv$anhir FiPT pn Anril J 9/11d af R•Q1 nm . Received Time Apr. 11. 2014 12:27PM No. 25S3 , y :�:-�a � ,_ ti:,.:.� �-. �,�x.�:4PT,. Y��n nyi-ari�x 'r:�itier-pri5� � rri 11 ri�r c�14 lv:ca:co '�►ri ri��l <, , , ., -ra�� z tir , �. _ Mobile Rehab, LLC 2915 Wayzata Blvd Minneapolis, MN 55405 Daily Note / Phone:(612)310-8844 Fax: (763)559-1660 Billing Sheet Patient Name: Vang, Ricky Date of aaily Note: 04/09/2014 Date of Birth: 10/19/1969 Injury/OnseUChange of Status Date: 10/16/2013 Referring Physician(s): Davison,William DC Diagnosis: ICD9:847.0:Sprain of neck, 847.1:Sprain of thoracic, 847.2:Sprain of lumbar, 846.0:Sprain of lumbosacral (joint) (ligament) Date of Orlginal Eval: 02/20/2014 Visit No.: 11 Treatment Diagnosis: ICD9:847.0:Sprain of neck,847.1: Insurance Name: Nationwide Insurance Sprain ot thoracic,847.2:Sprain of lumbar, 846.0:Sprain of lumbosacral(joint) (ligament) Si��Jj��f�V� ; ` ; ° , ° Current Complaints/Galns. Pt states his neck and low back are in moderate pain, but better than earlier in the week. Prior Level of Function: Changing &Malntaining Body Position: Mobillty:Walking & Moving Around: Carrying, Moving &Handling ObJeds: Current Functlonal Limitations: Self Care: Sleep:Disturbed S(eep Changing &Maintaining Body Positlon: Maintaining a Body Position: Remaining Seated, Remaining Standing,Squatting Carrying,Moving &Handling Objects: IADLs:Shopping, Housekeeping, Laundry Paln Locatlon: mid to low back Patn Scale:Worst: 7 Best: 4 Current:4 'Previous Findings as of 04/07/2014-Worst:7 Best-4 Current:5 � Aggravating Factors: Bending � Home H�Ith Care: No ' Medical History: No Known Significant PMH To Affect Treatment ; Mental StatuslCognitive Function Appears Impaired? No ' .....:....:.....:.....::.:.:�..:..� .:� -..: ..... . ..:....,...._. ,. .. :. . :. ..... .. .. .. . ...:.......:...:..�:::::::.:::.:..:�:;::.:.,:.;.:::.:.,.::.:,:::-;::,�::.::;: .:::,;..:::....:::��:_:,.:<:-:.:;::<�:�.::;�...,::;..::;::::;::::::.::.:;:>;:;:.�:::::s;.:._-.;::�.::.:::;;::;�:.:::<�>.;-:=::::.:::,:;:. .. .. .. ,.....: ;{�f}jBCtiVB: .:.:. ? :. . .: . ` .. .. . . - . . .. :. >.. ... ,..: �. .:. , .. .. . � . . _ . _ . .... . . . . CP7�Code Direct Timed Codes UnNs i 97110 Therapeutic Exercise 2 ' Core stability with transverse abdominal activation and spinal intrinsic ; strengthening 97112 Neuromuscular Re-Education � Posture and body mechanics training. Lifting mechanics.ADL modifications ! CPT capyrlght 2a 13 Muriran Medlcal Assodattan.AI rlgfXs reserveC. Objective Findings Improving core stability and spinal intrinsics. Improved posture with decreased forward head, rounded shoulders,and decreased lumbar lordosis. ... . .....:. .:.....:.::: :;�:.:.:�.e'`=::::.:.;ht . ..::�::: �.:.:;.::...:.:;::.:,.. . ... . . . . .. ;.. ..:. . . .. �:.::::....:: .. .. .: .:. .. .. .. ...: ::::�.:;.:....: ..: . ..: : ::..:�..:.:..;.. . .... .... .:...:.: �.: .:.�As.s ssme... ... .... . .. :. :.: Patient Demonstrates Compliance wlth Prescrtbed HEP Rehab Potentlal: Good . Patlent Problems: - Headaches - Decreased Cervical ROM - Decreased Lumbar ROM - Decreased tolerance to siUstand - Disturbed sleep ' Short Term Goals: ' 1:(6 Weeks) � 85% � Eliminate headaches � ' 2:(6 Weeks) � 85% � Improve cervical ROm to WNL� 3:(6 Weeks) � 85% � Improve lumbar ROM to WNL� 4:(6 Weeks) � 85% � Improve sit/stand tolerance to 45-60' � ' 5:(6 Weeks) � 85% � Improve Undisturbed sleep time to 4 hours � �P�ara�`�' . . .. ..- . .. �. .... .. :. . ... .. .. .. . ... . . . . .. . .. . . ... . .. . . . .....:..... .... . .:. . . :,. . .. .. .... .:. . . ..: .:. .. , . . .. . Received Time Apr. 11, 2014 12:27PM No. 2583 . ��:��: .:��, < _,..:,:�{�. ;_�:pT,. i�ni.:.nyrarA� r.Yit�i`�SriS�` __ rZ_'1 .11 HpI_,. �vi� �lu :ccs:cc� �rr rtS�1. __.._ � t,a`�� _3 v*_ � Mobile Rehab, LLC Patient Name:Vang, Ricky 2915 Wayzata Blvd Date of Birth: 10/19/1969 Minneapolis, MN 55405 Dail Note / Document Date: 04/09/2014 Phone:(612)310-8844 y Fax: (763)559-1660 gl��lllg $heet Instructions: Progressing Patient Next Visit � j� � > .. �l--��'� ��'�"' �� ''' .� � Tammy Saphir, RPT License#6097 (�'nmrJufnrlhv.T�mmv Snnhi� qPT pn drvil j/1 9/l!E f -r+Q am Received Time Apr. 11. 2014 12:21�N1��No. 2583 -�,n�,�p�._ . '..,.,..,�y_ ��.K�:-"�;� Mobile Rehab, LLT Patient Day Sheet Show all data where the Chart Number is between VANRIOOO,VANRI000 Entry Date POS Description Provider Code Check# Amount VANRI000 Vang, Ricky 78406 02/20/2014 11 p.t.evaluation TLB 97001 160.00 78407 02/20/2014 11 Therapeutic Exercise TLB 97110 133.64 78408 02/24/2014 ll Therapeutic Exercise TLB 97110 133.64 78409 02/24/2014 ll Neummuscular Re-education TLB 97112 61.68 78583 02/26/2014 11 Therapeutic Exercise TLB 97110 133.64 78584 02/26/2014 11 Neuromuscular Re-education TT.B 97112 61.68 78585 03/OS/2014 11 Therapeutic Exercise TLB 97110 133.64 78586 03/OS/2014 11 Neuromuscular Re-education TLB 97112 61.68 78847 03/24/2014 11 Therapeutic Exercise TLB 97110 133.64 78848 03/24/2014 11 Neuromuscular Re-education TT.B 97ll2 61.68 78862 03/12/2014 ll Therapeutic Exercise TLB 97ll0 133.64 78863 03/12/2014 ll Neuromuscular Re-education TLB 97112 61.68 78864 03/21/2014 11 Therapeutic Exercise TLB 97110 133.64 78865 03/21/2014 11 Neuromuscular Re-education TLB 97112 61.68 78932 03/26/2014 ll Therapeutic Exercise TLB 97110 133.64 78933 03/26/2014 I 1 Neuromuscular Re-education TLB 97112 61.68 78934 04/02/2014 11 Therapeutic Exercise TLB 97110 133.64 78935 04/02/2014 11 Neuromuscular Re-education TLB 97112 61.68 Patient Charges Patient Receipts Adjustments Patient Balance $1,85620 $0.00 $0.00 $1,856.20 Printed on04/11/2014 1:51 pm Page 1 This program is registered to: Beacon Accounts Management Mobile Rehab, LLT Patient Day Sheet Show all data where the Chart Number is between VANRIOOO,VANRI000 Entry Date POS Description Provider Code Check# Amount Total#Patients 1 Total#Procedures 18 Total Procedure Charges $1,856.20 Total Product Charges $0.00 Total Inside Lab Charges $0.00 Total Outside Lab Charges $0.00 Total Billing Charges $0.00 Total Charges $1,856.20 Total Insurance Payments $0.00 Total Cash Copayments $0.00 Total Check Copayments $0.00 Total Credit Card Copayments $0.00 Total Patient Cash Payments $0.00 Total Patient Check Payments $0.00 Total Credit Card Payments $0.00 Total Receipts $0.00 Total Credit Adjustments $0.00 Total Debit Adjustments $0.00 Total Insurance Debit Adjustments $0.00 Total Insurance Credit Adjustments $0.00 Total Insurance Withholds $0.00 Total Adjustments $�•� Net Effect on Accounts Receivable $1,856.20 Printed on04/11/2014 1:51 pm Page 2 This program is registered to: Beacon Accounts Management