Mueller /
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NOTICE OF CLAIM FORM tc���ie� �i����Of Saint P��(�;I�inn�esota
Minnesota State Statute 466.05 states that " ...every person...who cl i damages any municipality...shall cause to be presenfed to the
governing body of the municipality within 180 days after the all���sJ�:c��tiw��l y��is discovered a notice stating the rime,place,and
circumstances thereof,and the amount of compensation or other relief demanded."
Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is
needed,attach additional sheets. Please note that you will not be contacted by telephone to clarify answers,so provide as
much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a
written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the
nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'.
SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK,
15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102
� �/y� //
First Name � / � �� Middle Initial � Last Name/ �( u � / G��-
—�
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VVilt�/0.11�' Vl JJUJ111VJJ 1\0.111V
�
Are You an Insurance Company? Yes No If Yes, Claim Number?
Street Address
City State Zip Code
Daytime Phone - Cell Phone ( ) - Evening Telephone(_� -
�a
Date of Accide Inj or Date Discovered � —� — �l � Time �`'� am�
Please state,in detail,what occurred(happened), and why you are submitting a claim.Please indi ate why or how yo� �
fe 1 the City of aint Paul or its employee are involved�or re onsible for yo ama e �����
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Plea�e check the box(es)that most close y represent the reason for completing this form:
❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow
❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow
❑ My vehicle was wrongfully towed and/or ticketed �I was injured on City property
❑ Other type of property damage–please specify
❑ Other type of injury–please specify
In order to process your claim you need to include copies of all applicable documents. 'I
For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of
your claim. Documents WILL NOT be returned and become the property of the City. You are encouragec3 to keep a
copy for yourself before submitting your claim form.
O Properiy damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/or receipts for the"repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt
O Other property damage claims:two repair estimates if the damage exceeds $500.00; or the actual bills
and/or receipts for the repairs; detailed list of damaged items
O Injury claims: medical bills,receipts
O Photographs are always welcome to document and support your claim but will not be returned.
Page 1 of 2–Please complete and return both pages of Claim Form
Failure to complete and return both pages will result in delay in the handling of your claim.
All Claims-please complete this section
Were there witnesses to the incident? Yes N ` Unlp�own/� (circle)�/�
Provide their names; addresses and telephone numbers: �/�����S 7`�c� /j �iC� �//� /���
Were the police or law enforcement called? Yes No Unknown (circle)
If yes,what deparhnent or agency? Case#or report#
Where did the accident or injury take place? Provide street address,cross street, intersection name of ark •facility
closest landmar etc. lease be as detail d as possible. If necessary, attach a diagram. �� �-7'�
�',(�OSS �- �°E' 7�-' �
Please indicate the amo t you are s kin in compensation or h you ould like th ty to do to reso ve this cl�i
to our satis action. ` ` . �� a-�- � r�°� � �ir�
,' �'/c ��' � ' � � .
_ � �—�-�-- � �-�-. ��.� e-�,� ,
Vehicle Claims-please complete this ecti ❑ check box if this section does not applv
Your Vehicle: Year Make Model
License Plate Number State Color
Registered Owner
Driver of Vehicle
Area Damaged
City Vehicle: Year Make Model
_ _
License Plate Number State Color
Driver of Vehicle(City Employee's Name)
Area Damaged
In'ur Claims- lease com lete this se tion ❑ check box if this sectio does not a 1
How were ou injured? d � p/f ` �'��
S ,� � � � ,� E i"n . �.
What part(s)of y ur b y w e inj ured? �� S �— /I U r(
S �
Have you sought medical treatment? Yes No Planning to Seek Treatment(circle)
When did you receive treatment� o� -(P - �D! �- (provide date(s))
Name of Medical Provider(s): S f� i �y9` GC/(J D
Address ��IJ /� �--� ;/� , elephone S��� /- �'O �
Did you miss work as a result of your injury? Yes o
;�'her�ct�3 yo��s�u:��?-- _---- -- ___ `_ (�,r�vide date�sl�_ --_---
Name of your Employer:
Address Telephone
❑ Check here if you are attaching more pages to this claim form. Number of additional pages
By signing this form,you are stating that all information you have provided is true atcd correct to the best
of your knowledge. Unsigned forms will not be processed.
Submitting a false claim can result in prosecution. Date form was completed
Print the Name of the Person who Completed this Forms ��9� K� � � / � �u�// ��
F -�
Signature of Person Making the Claim: �, ��.��-�'
Revised February 20ll
'' Visif S�mr�ary(continu;e�} _
• Osteoporosis 733.00C
• Personal History of Colonic Polyps V12,72
• Pure Hypercholesterolemia 272.p
• Insomnia 780.52A
• Adjustment disorder with depressed mood 309.0
PMH: has a past medical history of Breast ca (1989); Smoker; Depression; Diverticulitis of colon (without
mention of hemorrhage); Adenocarcinoma lung (2000); Osteoporosis; Personal history of colonic polyps;and
Pure hypercholesterolemia.
PSH: has past surgical history that includes hysterectomy; appendectomy; and lobectomy (1/00).
OB HX; �.��ss����^!� �������
�r.?.F�i�, t�3`.�c�:;r,.;=�,,.. :
SOCIAL HX: reports that she has been smoking cigarettes. She has a 40 pack-year smoking history. She
has never used smokeless tobacco. She reports that she does not currently drink alcohol or use illicit drugs.
FAMILY HX: family history includes Cancer in her daughter; Cancer-breast in her daughter; Diabetes in her I
maternal aunt and maternal uncle; and Other in her mother and paternal grandfather. �
ALLERGIES:No Known Allergies ,
CIiRRENT �IiEdICATIONS:.Current outpatieni prescriptions:ASPIRIN 8i MG TAB, 1 tab daiiy, Disp: , Rfi: 0;
BONIVA 150 mg tablet, TAKE 1 TABLET BY MOUTH EVERY 4 WEEKS ON AN EMPTY STOMACH WITH A
FULL GLASS OF WATER. DO NOT LIE DOWN FOR 1 HOUR AFTER DOSE, Disp: 4 tablet, Rfl: 0; Ca�ium
carbonate (OYSTERSHELL CALCIUM} 500 mg tablet, Take 1 tablet by mouth once daily., Disp: , Rfl: 0
cholecalciferol(VITAMIN D)2,000 unit capsule, Take 1 capsule by mouth once daily., Disp: , Rfl: 0;
citabpram (CELEXA) 20 mg tablet, Take 1 tablet by mouth once daily., Disp: 30 tablet, Rfl: 3; omega-3 fatty
acids-vitamin E (FISH OIL) 1,000 mg Cap, Take by mouth., Disp: , Rfl: 0; simvastatin (ZOCOR}4d mg
tablet, Take 1 tablet by mouth once daily., Disp: 90 tablet, Rfl: 2
traZODone (DESYREL) 50 mg tablet, Take by mouth at bedtime. 1-2 tabs at hs pm sleep., Disp: 30 tablet, �
Rfl; 0 '
;
IMMUNIZATION HX: ��������a������t�i�:���s�:�..______ _ _ . �
':�,�ittia� t!-�.i :. . t t�<��� ��:i=iu`.i r:z r�
• Pneumococcal Poly,23-Valent(Pneumovax) 11/01/1998,,05/31/2007
• Tuberculin (PPD) 08/06/2008 '
ROS: 14 point review of symptoms was pertormed and is negative aside from the concems as mentioned
above.
OBJECTIVE:
ALLINA HOSPITALS 8 CL.INICS Report D�e: 3/16/12
MAPLEWOOD ASPEN
Patierrt: MUELLER,REGINA C DOB: 4/15/1942 MRN: 1 001 56756 1 HAR:
Adrrrt Date/Date of Service: 03/06/2012 Discharge Dade: AMB VISIT SUMMARY
*'`**�'`'`**'`**Redisclosure not permitted without the express written permission of the patient*'`**'`'`**'`**�
Rat�ent uNormauon
PatienE Niame Sex <:D(?B
_.
_ __, ,,.< : ,.:.
.. ...;
Mueller, ReginaC (1001567561) Female 4/15/1942
Corrtact IMormation
C1ate�7'le�+� Itirovlder< 'Efepertrtm� '�cc�ter� ; �` Center ''
3/612012 9:40 AM Deanne Printon,NP Ampw Internal Med Amb 138141874 MAPLEWOOD
_._ ___ _ _ -__ _ _._ _ _ _ _ _ _ _ __ _ _ _ _._ _. . __ _._ _..._ _._ __. _ ___ _ _._ ___
_ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ . _ _ _ __
- _......_ . .. __ ..... . . __ .. _ _.__... _. ..__ . . . .._ ..... _ . ..._ _._.. ... _ ___ __ ... _
_ _ ! '�f18It�Ul�1'11�1`�t `. _
Dlamoses
Knee pam,bilateral,�719 46AP� Pnmary. . . ._
, _ ..... _:._.. „ ...,,...... ..: ., ..,: ..:,. .. ..:.....:.:.,:: _ ...:... ..:....:...........:......
Persanal history of fall [V15.88J
Rea9on for Vislt
Fal1 bialteral knee injury
Cllnic Staft Notes
ANN SCHAFF Tue Mar 6, 2a12 9:50 AM
Pt Was walking outside on Friday and fell the side walk was uneven. Both her knee's are bruised and left is swollen.ANN
` SCHAFF LPN 3/6/2012
Vitals-Last Recorded
' BP ` <#�lse i Tem�rc� ;; �lesp ; 5� ' � Sp
' ; > ;; .
i .: , ::> ;: ;:.. > .: >: . >
. :::. . :!:: .. .::: �:
100i62 88 97.6 °F(36.4 °C� (Oral) 20 60.328 kg (133 Ib) 99
%
? ��1���
..:.-.- _.--.�.. ......-:___::.
..._., .:,:. .__
...-., ._.. . .._,.�. ...._: .:.,. .__ _..
, -:.. ... .._..::,. ...._..,. .
No
Proqress Notes
Deanne Printon, NP 3/6/12 10:39 AM Signed
SUBJECTIVE; Regina C Mueller is a 69 y.o. female who presents for followup on bilateral knee pain and
swelling after tripping on a curb as she was stepping up over it and fell forward onto her hands and knees 4
days ago. Did not hit her head. Sustained some abrasions on the left knee associated with swelling and pain.
Able to walk right away. The right knee has just been mildly swollen, painful and bruised. Has been applying
antibiotic salve on the abrasions. No signs of infection there. Hands and arms have been fine. The rest of her
legs have been fine.
CURRENT PROBLEM LIST;���i�����:#��r�� €��•s��at�� �.���#
_ _.._ _ __ _ _ __ - _ __. _ _._ _._ ___ _ _ _ _ _._ __. _ _.._ _._ __ _ _ - _ __
i,=,�i3�1�'�a,='•� r��`F`�
• Health Maintenance Examination V70.9L �
• Breast Ca 174.9M
• Smoker 305.1 AM
• Depression 311 F
• Diverticulitis of Colon (without Mention of Hemorrhage} 562.11
• Adenocarcinoma lunq 199.1 DW
ALLINA HOSPfTALS 8 CLINICS Repart D�e: 3J16/12
MAPLEWOOD ASPEN
Patierrt: MUELLER,REGINA C DOB: 4/15/1942 MRN: 1001567561 HAR:
Adrrit DatelDate of Service: 03/06/2012 Discharge Date: AMB VISIT SUMMARY
*'`****'`�****Redisdosure not permitted without the express written permission of the patient'`***'`*'*'`'`*�
� e
Rest�1#S[tmFnary fo�XR K�iIEE 31/1EtA�S!�EFT'{corrtinu�d�; _
Result Impress�on
No acute diagnostic abnormality. Negative for fracture.
Lab and CollecUon
XR KNEE 3 VIEWS LEFT on 3/6/2012
Result F#storv
XR KNEE 3 VIEWS LEFT on 3/6/12.
....................................... ..............................................................._........................ ..............................._......................_..........................................---.._.....
Encbunter Status
Ciosed by Eligibility Batch on 3/7/12 at 2:02 AM
..........................................................................................................................................................._.................................................. .............................. .......
Aesu�S�ntr�airy 3�`�XR�4N�E�Vf€V�i�;L��T<
Result Informatlon _ _ _ _ __ ,_ - _ _
,' StaWs = ;::: Pr�nrider�tatus >
,... . ....... ,_.:: . , , . ,.
_ ... ,:> ;;.
, ,.. . -. ,:. ,:.
Normal Final result(3/6/2012 1:56 PM) Reviewed
Entrv Date
3/6/2012
Result Narrative
LEFT KNEE 3 VIEWS
CLINICAL HISTORY: History of fall. Knee pain.
FINDINGS: Knee joint compartment spaces are maintair.ed. There is subtle
medial slippaye of the patella with patellotemoial joint space maintained.
Joint effusion is trace if any. No fracture is ider.tified.
Result Impresslan
No acute diagnostic abnormality. Negative for fracture.
Lab and Collectlan I
XR KNEE 3 VIEWS LEFT on 3/6/2012
Res�Nt FNst
XR KNEE 3 VIEWS LEFT on 3/6l12.
ALLINA HOSPITALS 8 CLINICS Report Date: 3/16/12
MAPLEWOOD ASPEN
Patierr[: MUELLER,REGINA C DOB: M15/1942 MRN: 1001567561 HAR:
Admit Date/Dffie of Service: 03/06/2012 Discharge Dade: AMB VISIT SUMMARY
*'`**'�''�"***Redisclosure not permitted without the express written permission of the patient**�*****'`***
Patient Mformation
F►a�lenE Narfle �',yex >Cyf�B
_
,
_ _ ,
_ _ , >
Mueller, ReginaC (1001567561) Female 4/15/1942
Cattact Mormation
L?8f��i Tl�fe � � Prahrtdet<:; ;t�pe�rtnt�l�t � ';i ;i E1�+cc�t�� '; !C�Eer'! _
3/6/2012 10:10 AM Maplewood Aspen Med Ampw Med Imaging 138158566 MAPLEWOOD
Imaging Amb
_... _. . ._. .. ... _.. . __.. . .. . . . .. _ . .. . .... ... .... ...._ ...... ..._ _.. . ._.... .. .
_ ... .._. .. . .. . ._ _... . _.. . _.. .._. ._... . _ _.. ._ . . _.. __. . . . _._ .... _ ..... _...
'V€s1t;5urnmat'y
Dla�oses
Persa��,rrstoryof_fa��..fVt,5,ss1................................. ..
.. ................................................................................................................................................
Knee pain,bilateral [719.46AP]
Reason for Vislt
Imaging
Vftals-Lsst Recorded
Br�asEiee�ng�
No
>' <', i; > >: i: �1�#�..4Q1Y�C�ia� .!:: !' >; >
Referrinn Provider
Dearne Printon, NP
i ; �� �II�rQ1+��;
Alleraies
(No Known Allergies) .�w._. ..�. ��;::d3/06l12 -_ _ _ _ __ _ __. _ _ . _.. _
; _ _ ,.:.., _ __ -:: _._
� QCCi�:".
_
_ _ _ _ - __ , _ _ _ __ __ _ _ -
IOrders
XR KNEE 3 VIEWS LEFT[73562 CPT(R)]
i�
��.�ie���.��t�r�ary#c�':XF�i�N��3�EVVS L�T::;
ResWt Ir�formatlon
i ' StaUts : ' ', ;: Provjd�'Siatus . ` ;'
__.: _... _
Normal Final result(3/6/2012 1:56 PM) Reviewed
EntrY Date
3/6/2012
Result Narrative
LEFT RNEE 3 VIEWS
CLINICAL HISTORY: History of fall. Knee pain.
FINDINGS: Knee joint compartment spaces are maintained. There is subtle
medial slippage of the patella with patellofemural joint space maintained.
Joint effusion is trace if any. No fracture is iden*_ified.
ALLINA HOSPITALS&CLINICS Report Date: 3716/12
MAPLEWOOD ASPEN
Patierrt: MUELLER,REGINA C DOB: 4/15/1942 MRN: 1�1567561 HAR:
Admit Date/Date of Service: 03/06/2012 Discharge D�e: lUAB VISIT SUMMARY
*'`*"'`*'`*****Redisclosure not permitted without the express written peRnission of the patient*'`***'''`*****
�
> ; , , ,
;; Qu�sfionr�ire�contm�redj _
PH(�-9 DEPRESSION SCREENING(coMlnued)
>: �d'�. <:' 'iAr1s1�V�` ';::
........... ... ..... _ _ _
in some way...:.........
.. . ,., .....,.,. ........ ....
Depression Severity Level 0 none
..... . _. . .... ......_ .... ..... . .... ..... ..... ,.,,,,.. .:,_ .. ...... .,..,,,. ,__,:,.. ..... ,... .,,,_ .... _ __
.... ......
If any answers were positive, how difficult have these problems not dlfficWt at all
made it for you to do your work,take care of things at home,or
getaton�with other.P�P�e...._._.............. _..._..................... ................................................................._
__ _ . .. ..... . . __ _ _ .... _ .. _ . . .. __ . .. __ _ _ __.. _ ... __. . _ . . ._.. _ .. ... ....__. . __ _...
__ ._ _. .._ . . . - . ._ _. ...... _ . . _ ..... __ . . ._ __ .. ..__.. . . ..... . .. .. ......._ ._...
_ _ A11�rgies
Al�ery�es
__ _ __ ._. . __ _ _ __ __ _ . __ . _ _ ._ _ .... __ . _ .. ...... _........ _ .
_ _ __ ._. . _ . . __._ ..... ..._ .. __.. ... __. _ _ ... __ . .. _ . _..... .. .._ . . ... . . ..
__ __ _ _ _ _ __ __ _ __ ___ _.. __.. ___ _.. _ _ _ _ . ... ..__ _ .
(No Known Allergies) '?at�+�;E.�i���+t#:03I06/12
___. _ _ __ _ __._._. ,._._ ,.,__ ,, _ ..._ ...._ .. .. .. .._ ,._._ ...... .. __ _ __ __ __ _ _____ _. __ __.__ , ___.__.. ... _ _. .. _ ___.___
_ _ __ ____ __ _ _ __ __ __ _ _ __ __ _ _ _ _ _ _ _ _
Q��@CS :_::
OrderS
�>. F�W'�i��del's !Exp�d By ;' Dtplrlg
XR KNEE 3 VIEYVS LEFT[73562 CPT(R)] _ _ ,, _ _ 6/4/12 _ , , _ _
>: . . >.. : ». `: . r::. . > ��.ft�:�/1.�fGi`r�liHlB ,:;. .. , .... . ., . . . ..... . ,
Orders Placed Thls Encounter
XR KNEE 3 VIEWS LEFT
Advil, heat, rest. Follow up failure to improve.
l.evel of SeMce
PR OFFICE OUTPT ESTAB LEVEL 4[99214.0]
Encounter Status
Closed by Deanne Printon, NP on 3/6/12 at 10:39 AM
ALLINA HOSPITALS 8 CLINICS Report D�e: 3116/12
MAPLEWOOD ASPEN
Patient: MUELLER,REGINA C DOB: 4/15/1942 MRN: 1001567561 HAR:
/idmit Date1Dffie of Service: 03/06/2012 Discharge D�: AMB VISIT SUMMARY
*'`"***'`**'`'Redisclosure not permitted without the express written permission of the patient'`'`**'`'`***'`'``
Vi�S�mmary(conti�tue� ;
BP 100/62 � Pulse 88 � Temp{Src)97.6 °F{36.4 °C)(Oral)� Resp 20 � Wt 60.328 kg(133 Ib) � Sp02 99°�6 �
Breastfeeding? No.There Is no helght on file to calculate BMi..
GENERAL; She appears well, in no apparent distress. Alert and oriented times three, pleasant and
cooperative. Vital signs are as noted by the nurse..
MUSCULOSKELETAL2 clean abrasions over the left patella. No infection. Effusion left knee with tender
joint line. Range of motion of the left knee is normal. Ligaments stable. Bruise over the right knee with mild
medial effusion. Normal range of mo6on right knee and ligaments stable. Some crepitus under the patella.
Nbves arms and legs normally. No weakness or atrophy. Neck and spine normal. Peripheral pulses normal.
NEUROLOGIC: Cranial nerves 2-12 intact. Cerebellar exam normal. DTRs in the upper and bwer
extremities are normal. Strength in extremities is normal and equal. Gait and balance are noRnal. Cognition
intad.
XRAYS: negative for fractures.
ASSESSMENT:
1. Knee pain, bilateral{719.46AP)
2. Personal history of fall (V15.88)
PLAN:
Orders Placed Thls Encounter
XR KNEE 3 VIEWS LEFT
Advil, heat, rest. Follow up failure to improve.
Deanne Printon CNP ................3/6/2012 10:07 AM
_ _ ;' �res#lonriair+� !
__ __, ___ _ __ _ _< <
PHQ-9 DEPRESSION SCREENING
QLIe31�i#'t ., ,:' A1#3�VY91' ;
, <
. . ; < , ; ;:
, < ;
. . ;, ,
. ..:; .: ; : ..
Date of PH09 exam 3/6/2012
........ ...... ....... ......_.......... .._...._......_.............. ..........._...__... ........ _..... ..... _.._.... ............................... ..............._......._....._......._._...
Over the last 2 weeks, how oiten have you been bothered by the 0-no answer requlred here
following Problems
... .................................................�..,.........,.....................,..............,......,...........,...,.........................,.....,.
Little�nterest or pleasure in doing things 0—nd at all
_-,. ,,,.. ,..::,: :: .....:.: . ..... :. . .:.::
.,..: .,:,.:.
Feel,ing down,depressed,or hopeless. ....,. .,..,.. ,,..,, 0,=nat:at,all
Trouble fallin�or sta in aslee " "'" `� "�"" "'""'
,. _ ..... , .
Y 9 . .. R or sleeping too much.. . . 0=not at all _
............... ....... ...... ........................... .._ .... _......
Feeling tired or havmg bttle energy:_,.: . . ,:. ,. : ,...0_not at ell
...:_..:,: ,...,
.. ..:,. .:
.:.. .::_. ...
Poor appetde or overeatin � ���
, ......., , ....,.. .. 9..,... . ...,..,. ,.,..,... .,...... . 0 not at all
.. _,:.., ,,.... ,.,... „ ,...,.. . ........_ ,.,........,...:.
.,.,.....
Feeling bad about yourself-or that you are a failure or have let 0=not at all
yourself or.your familX down ,
,...,..., _ .,.... . _...,,,. . . .,,,.... ,...:.. ...,....
,,,.,, ,.,..:.. .................
Trouble concentrating on things,such as reading the newspaper 0=not at�all
or watching,television
.,.. ,,:,. . _ . ,..:... ._
,.,_ ,..,,. ... ..... .....,.. _..._... . .,,,.:.,.:,,,..
Moving or speaking so slowly that�other people could have 0=not at all
noticed.Or the opposite-being so fidgety or restless that you
have been movin�around a lot more than usual
.............................. .... .. ....................................................................,.....................................................................................................................
Thoughts that you would be better off dead,or of hurting yourself 0=nd at�1
ALLINA HOSPffALS 8 CLINICS Report Date: 3/16/12
MAPLEWOOD ASPEN
Patient: MUELLER,REGINA C DOB: 4/15/1942 MRN: 1 001 56756 1 HAR:
Admit DatelDate of Service: 03/06/2012 Discharge Date: AMB VISIT SUMMARY
'`'``*"`""'`*"Redisclosure not permitted without the express written permission of the patient**"'`******"*
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