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Duffy W EINB �, ATT & GAYLORI) PLC ATTORNEYS SG COUNSELORS AT LAVV Suitc 3U0 Kellogg Syuare • s;;�r:',>;;•;:;%:� Alan W.Weinblalt 11l East lfeflagg Boulevard � � ��"�"�'�� KathieenA.Gaylord ,;,. , 5t.Paul,Minnesota�5101 Jay Benanav Telephone:(651)292-3770 Jane L.Prince Fas:(651)2?3-5282 Website:��v.��egla�v.com Katharina E.Liston Of Counscl J��2,zoi? �ECEI�� , ;,,,, �c;ir BY U.S.AND ELECTRONIC�IL C�r �4 Z��'� City Clerk Y C��K 15 West Kellogg Blvd. 310 City Hall Saint Paul,MN 55102 RE: NOTICE OF CLAIM F4RM FOR MICHAEL D. DUFFY Ms.Moore, - - Atiached please find the Notice of Claim Form for my client,�Michael D. DufCy,for injuries he suffered on iowa Avenue West in Saint Paul and Rice Street. Please do not hesitate to contact me if you require any additional information. Thanlc you for your consideration, � �' ,,,� �. c� J � � /L�iI�LE, � � JANE L.PRINCE FOR WEINBLATT& GAYLORD Cc: Michael D. Duffy � 4 �,-.;.-:;.-., NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota MinnesoJa SJate Statute 966.05 s7otes tltaJ"...every persan...tivho claims damages from mry mienicipatiry...s/iaU tause to be presenred to the goveming 6ody of t/�e mrenicipaliry ivi�hin 18Q days after rhe alleged loss or iajury is discavered a notice srating the time,ptace,and circumstances rhereof,and the amounr oJcompensation or orlier relief demanded." Please complete this form in its entirety by clearly tpping or printing your answer tn each qvestioa. lf more space is needed,attach additional sheets. Please note that you will not be contacted by telephone to ctarify answers,so provide as much informatioa as necessary to explain your claim,and the amount of compensation being reqnested. You vv�7t receive a writEen acknowledgement once your form is received. The process can take up to ten weeks or Tonger depending on the natuie of your claim. This form must be sigaed,and both pages completed. If soznething does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL,MN 55102 First Na�e �/1�c��,e ! Middle Initial,�Last Name �l�f�iTY Company or Business Nazne Are You an Insurance Company? Yes/No If Yes,Claim Number? Street Address �� { �47�t/O: �� uV , City ��' ._ �� S tate �� N Zip Code 5 s Daytime Phone (o( Sr )��Cell Phane f GS� )�-�5 Evening Telephane(lOSI )�C�t'�S Date of AccidenV Injury or Date Discovered 0 �•� � Z�G Time �l' � `t5 �/pm Please state,in detail,what occurred{happened), and why you are submitting a claim.Please indicate why or how you feel the City of Saint Paul or its employees are invoIved and/or responsible for your damages. , .�...,+rt.. :2�t�ti��-1 wr.�.'�' Please check the box(es)that most closely represent the reason for completing this form: O My vehicle was damaged in an accident ❑My vehicIe was damaged during a tow ❑My vehicle was damaged by a pothole or conrIition of the s[reet ❑My vehicle was dainaged by a plow ❑My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property O Other type of property damage—please specify ❑ Other type of injury—please specify In order to process your claim vou need to include copies of all apnIicable documents. For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your claim. Documents WII.L NOT be returned and become the property of the City. You aze encouraged to keeg a copy for yourself before submitting your claim form. O Property damage claims to a vehicle:two estimates for the regairs to your vehicle if the damage exceeds $500.00; or the actual bills and/or receipts for the repairs O Towing cIaims:legible copies of any tickeE issued and a copy of the impound lot receipt O Other groperty damage claims:two repair estimates if the damage exceeds$500.00;or the actuaI bitls und/or receipts for the repairs;detailed list of damaged items O Injury claims:medical biIIs,receipts O Photograghs are always weIcome to document and support your claim but will not be retumed. Page 2 of 2—Please complete and retarn both pages of Claim Form Failure to complete and return both pages will result in delay in the handiing of your claim. All Claims-ntease comulete this section Were there witnesses to the inrident? Yes o Unknown (circle) Provide their names,addresses and teiephone numbers: Were the police or Iaw enforcement ealFed? Yes No Unknown (circle) If yes,what department or agency? .�'e�`� CC�QC� Case#or report# Where did the accident or injury tmke place? Provide sireet address,cross street,intersection,aame of park or facility, closest I�n�ark,etc. Please be as det 'Ied as possible. If necessary,attaF h a diagram. � � 1 � [? 'tti 1�V '' � �P � . Please indicate the amount you are seeking in compensadon or what you would Iike ihe City to do to resolve this ciaim to your satisfaction. 2 7 G'3 �- , -�� VehicZe Claims-please comolete this section �check box if this secdon does not aoolv Your Vehicle: Year Make Model License Plate Nvmber State Color RegisEered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Madel License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged laims- lease om lete this section ❑check box if this se ti n does not a 1 How were you injured? `7� P�('�-- �� ' � � � � What part(s)of your body were injured? /"�, IIave you sought medical treatment? Yes No Planning to Seek Treatment(circle) When did you receive treatment? r � (provide date(s)} Name of Medical Provider{s): _ � .°�- ��.�� Address Telephone Did you miss work as a result of your inj ry? es No// ��fi�,,(� j�Q Gc�� When did you miss work? ' � •-t�� Q'.c. �• (provide date(s jS Name of your Employer. Address � Telephane Check here if you are attaching more pages to this claim form. Number of additionaI pages � , By signing tl:is form,you are stating tliat all iRfonnation yorc leave provided is true and correct to the best ', of your knowledge. Unsigned forms will not be processed Sub�nitting a false claim can result in prosecutivn. Date form was comgleted �� Q � ��2- Print the Name of the Person who Completed this Form: �/�N� L• ��►v � _ , r Signature of Person Making the Claim: ; Revised Febr�ary 2A1 i 64 Iowa Avenue West,Saint Paul,NIN-Google Maps ht#ps:!/maps.google.cordmaps?f=q&source=s_qBchl�n&geocode=... �� Address St PauE MN 5117 'marks site of Claimar�t's injury Claimar�t resides at 6A lowa Avenue West. �t �A�� rl xFC ,` ,�, ; - . `� ; f � s�..: �� ......:..�f��:: . ....-.. ._... :......... . _....:..: ..._. :.., .._.... � __....._ �.__¢.. _..::..__.. . .; _._.......__...._._....�_.. . . �__..... ... :> .. ;..�:�:: ._. _._._.. r_.. _ ....�._ ' -�-�"�°'�� I Gfihseioi�c Pl� -� �}-� �-- YY 1�V1a�odc`#'kIN!►.s`�""� � �' � ' �._ran ��...,,_ .�...___ .,._:.._ ! .__. 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' ' _ ' _ _'::_:_...""a' r_ ::::.........._................_._.......__._...�.__... . .... _....__..__:=C.�'��a:�:�:�=7�^;-.i;-.i.°�:�='i:1;:f.'�.�.�=::'=?�e��:,"�' , __..............'--........._.._._..._...._...-.._..... »._. ._ -" .,v,.•,.,..,,...�.:::r.:e::::::�.':c�:.=:r_.e:_.:::::.::�::�.e:.:��rce•:r_::��.r_::�-s=a:�rs�::c:c_c::.-..�:c�c:_::::::s_:s4:_::::::i::::::::::a:. p;�,��__.._�.r_'�b.:i»,:a:-� -- - - 42:Goo ..-•::--::::,::.-::::;::��..::�::,:-.:-::-:::;:��::::-:.:::::::�::::��.-:-��::=__-:_:_=_-.:_:.:::::-:::::::::::::�::::.�-_-.. .......:---::�:::>�:::--_=:rMa''.'d'eFa�1:�Go.6�e= I� NOTICE�F CLAIM FORM TO THE CITY OF SAINT PAUL,MINNESOTA ATTACHMENT Claimant: Michael D. Duffy 64 Iowa Ave.West Sa.int Paul, MN 55117 Date ofAccide��t Lzjury: June 28,2011,6:45 a.m. Please state, isz detail, N�hat occurred, a�zd wlty yot�are sztbnzitting a claim: Claimant walked from his home at 64 Iowa Avenue West to the Holiday store on the comer of Rice Street and Iowa(see Map attached)to purcliase coffee and a newspaper. There is no sidewalk on either side of Iowa(except on the Iowa side of the Holiday store}, so pedestrians wallc in the street. Claimant walked in a westerly direction to Holiday, on the south side of the street, facing oncoming traffic as a safety precaution. When he Ieft the Holiday store,he walked on the sidewalk adjacent to the Holiday store,until it ended. He then wallced into tlie street in an easterly directian,facing oncoming traffic on the north side of the street. With a car parked alang the north side of the street just east of the Holiday sidewalk, Claimant made his way east,facing oncoming traffic,noting children and school busses and past the parked caz. His foot went into a hoie in the street and twisted. As he Iast his balance he threw his left arm out to stop himself,hoping to reach the parked caz to stop his fa11. He fell to the ground. Upon investigating the hole in the street,he noted that it was about 13 inches in diameter, and about 3.5 to 4 inches deep. Inside the recessed hole,was a water utility metal cover. Believing that he was not seriously hurt,he picked himself up and walked home. By 11 a.m.he was in severe pain on his left side. He got a ride to Region's Hospital and was seen in the emergency roam. Emergency medical staff at Region's determined the Claimant had broken a rib on his left side. They exglained to him that there was no treatment for a broken or bruised rib. They asked him if he wanted an X-ray. He told them that if there was no treatrnent,that he did not see the value of having expensive X-rays to see something that was not treatable. They released him from Region's with a prescription for painkillers(Claimant recalls that it was Tylenol with cadeine). Claimant experienced severe pain on his left side, including his shoulder. He believed the shoulder pain was related to the broken rib. Claimant suffered severe pain for over a six-month perioc3. When reieased from the hospital the rib pain was a 10 on a I Q-goint scale,with 10 being the most severe pain. The pain at that time affected iiis sleeping and he lost consortium with his girlfriend over a period of manths. 1 After six months the pain was reduced to a 5-on a 1 Q-point scale. Complainant does not like to rely on pain medication, so he would take Ibuprofen to seek relief when the pain was bad.After eight or nine months,the rib pain was mostly gone. The Claimant also experienced severe shoulder pain,but could not necessarily distinguish whether the pain and limits to his range of motion in his shoulder were caused by the broken rib. Eazly on,the pain from Claimant's shoulder was about 8.5 on a 10-point scale. Several months later,the pain in his shoulder was still at 5. In addition to the pain, his left shouIder is much weaker than his right, and he has a restricted range of motion in lus ieft shoulder.Because the pain was not abating,he contacted Summit Orthopedics to assess this shoulder injury. Summit Orthopedic's Dr. Jef&ey Furmanek's report from Claunant's diagnostic visit on December 20, 2011, is attached. Dr. Furmanek reports that Claimant has a left shoulder rotator cuff teaz which correlates to the accident in which Claimant"stepped in a pothole hyperextending his left shoulder.s1 Dr.Furmanek presented options for treatment to Claimant,which Claimant chose not to pursue. Claimant does not want to become reliant on pain medication, so rejected cortisone injections. Claimant prefers not tQ have surgery because he is awaze that this is difficult surgery and he knows others who have not had a positive result from rotator cuff surgery. Dr.Furmanek invited Claimant to call or come back with questions or concerns as needed in the interi.m if he decides to pursue further treatments. As of the date of tlus filing, Claimant continues to have a limited range of motion,pain at a level S, and weakness in his left shoulder. Claimant seeks payment from the City for the cost of his medical bills related to this accident,which were not covered by Medicare. Those bills are attached as follows: Date Provider invoices attached Cost 06/28/11 Re 'on's Hos ital $79S•88 12/20/11 Summit Ortho edic I08.51 TOTAL $90439 Claimant is retired and receives Social Security retirement income. As a retired electrician, Claimant continues to supplement his income doing handy-man work, and as a scrap metal recycler. For two months after his accident, Claimant was unable to work at all due to extreme pain(up to 8.5 to 10 on a 10 point scale as stated above). Claimant estimates that his lost income equaled about$2-304 per week,or about$1,800.00. Claimant's work continues to be effected by his injuries,but he is not seeking additional damages. Claimant's injuries stemming from this accident aze severe and ongoing. However,he is a modest man,who says,"I have to learn to live with it°' 1 Note that Dr.Furmanek's report refers to the accident occuiring in July 2011_This is due to the fact that Claimant incorrectly recalled the date of the accident. The date of the accident is firmly established by the date of Claimant's emergency room visit on dune 28,2011. 2 For that reason,he seeks minimal compensation from the Ciiy. From Swnmit Orthopedics,he was affered the options of additional treatment in the form of cortisone injections, ongoing care, and even surgery, aIl of which would have resulted in a mare extensive claim against tlze City. Please indicate wl�y or l�ow you feel the City of Saint Paiel or rts employees are irrvolved and/or r•esponsible for your damages. Claimant noted that the hole, into which he fell,was a recessed water utility pipe. �n a day shortly after the accident, Claimant saw a man in the Holiday store who was wearing a Saint Paul water utility shirt or uniform. He told the man how he had fallen into the hole created by the water utility and was injured. Within a short period of time, a few weeks or a month, Claunant noticed that the hole had been repaired;the water utility cover was raised to be flush with the road. Claimant believes that the City benefited from the information that the Claimant provided after Ius accident,by repairing the hole and protecting other unsuspecting pedestrians from his fate. Pursuant to Minn. Stat. 466.Q5,the Claimant became aware of the full extent of his injury when, after suffering chronic pain in his left side and shoulder from the date of the accident,lune 28, 2011,he sought a thorough exam at Summit Orthopedics on December 20, 2011. This submission falls within the 180 days"after the alleged loss or injury is discavered." Pre azed by: � ' � � � ane . Prince,Attorney inblatt& Gaylord PLC 111 East Kellogg Boulevard Saint Paul,MN 551�1 3 +� �u��rr �� aRTHmP�Di�S . SUMMIT ORTHOPEDICS Doctor's Professional Buiiding 280 N. Smith Avenue, Suite # 500 St. Paul, MN 55102 (651) 968-5420 Patient ID: 105b5fi8 MRC: NEW PA'f"IENT Patient Name: MICNAEL D DUFFY �ate of Birth: 04/�4/1942 Gender: M Provider: JEFFREY A FURMANEK D.O. Provider's NPI: 1508873860 Date af Service: 12/20/2fl11 CHIEF COMPLAINT: Left shoulder pain and wealcness. HISTORY OF PRESENT iLLNESS: Michael Is a 69-year-old gentleman retired electrician who states that in July of this year he stepped in a pothofe hyperextenc�ing his left shoulder. Since the he has had pain and weakness. He states his left shouIder prior to this was the better of his 2 shoulders. He states he did have an ernergency department vlsit at that time. Since then he continues tQ have paln and weakness and pain at night. Denies neck pain, numbness, or tingling. No history of previaus injury. Here today for orthopedic evaluatian as a new patient. Patient's allergies, medications, past medicai, surgicalr 5ocial, and family histories as well as a compiete review of systems on the intake form in the chart reviewed. X-RAYS: Four views of the left shoulder AP, Grashey, scapular, Y and axiIlary views do show evidence of a well-healed old mid diaphyseal humeral fracture. There is evidence of some narrowing of the acrorniai humeral space. Mild degenerative changes af the AC joint. There is a type 2 acromion with anterior and inferior spurring and some cystic changes at the greater tuberosity. PHYSICAL EXAMINATION: Pleasant male appears stated age. No acute distress. Normal affect and pleasant. Attentian to the bi[ateral upper extremities shows limited forward elevation externa( rotation af the left campared to the right. He is passively able to forward elevate to near 150. He has weakness on external rotation at grades about 3+/5 and he does have a positive empty can sign. Distal CMS grossly intact. Cervical motion normal without pain. Negative Spurling. IMPRESSION: Left shoulder rotator cuff tear. PLAN: Today we discussed his diagnosis options at this point. His symptoms seem to correlate with his injury in ]uly. At this p�int he is not really interested in much treatment. He is hoping that he will be able to get the city to pay for his medical bills, currently in that process. Deferred corttsone injection and/ar further workup wlth MRI at thls point. We did prav9de home exercise program with instrucCion. Encouraged ice and antiinflammatories. He will call or come back wifih questions or concerns as needed in the interim and if he decides to pursue any further treatments. �«.* Re-disdosure not permitLed without the express written permission of the patient*'��" +� su�w�rr �� ORTHOPEDi� SUMMIT ORTHOPEDICS Doctor's P�ofessional Building 280 N.Smith Avenue, Suite # 500 St. Paul, MN 55102 (651) 968-5420 Patfent ID: 1056568 MRC: NEW PATIENT Patient Name: MICHAEL D DUFFY Date of Birth: 04/04/i942 Gender: M Provider: )EFFRE`(A FURMANEK D.O. Pravider's TtPI: 1508873860 Date of Service: 12/20/2011 Electronically signed by ]effrey A. �urmanek, D.O. on 12/22/2011 4:03:00 PM CST/ Onlivia RI340 D: 12/20/2011 T: J.2/21/2011 �x:* I� Re-disctosure not permitted withou#tfie express written permission of the patient•x#' � SUMMIT Duffy, Michael D �` ORTHOPEDICS Pa�ient Na DOB:04ro4142 Patient ID#1056568 Date of E �urmanek DO, Jeffr�y A DR#118 Plaasc use blaCk ink. 12/2012011 Dr's Pro$!dg Clinic MEDICAL �BISTORY FOltM Appoinhnent Dafie: �� `��- ��nrith Dr. Daminant Hand ❑ R� L Email Address: pge:��Sex: �F QY�! Heigt� ' p L// Weeght:�_____ Did you bring X-rays? C}Y L�N R�ercing Physicians Name: Part of the body being seen for today: � R�� r rm #- ��, L�e�- Have you hatl a probfem like tbis before? ❑Y 0'I lr Onset Date: In tlils section,check the box which best descn'bes how your problem stattEd.Please answer tfie qt►estions related to the b�x you checked. ❑ NO IN7URY Was the anset � Gradual O Sudden Comments: ❑ INlURY �Aaddent �Sport !.�a� �l�+ h � , pate:��Please spec3fy where and how it happened. ,�Yn T- 7<<e., �s f- 6 '�S A/}� What spo�t7 Schoof? �• � � -�- � IN3URY AT WORK Date: � s O � LiPt �Twist ❑ Fall ❑ 8end D Pul) ❑Reach � RepeGtive o h,� e - O AUTO ACCIDENT Date: How was your car hit? �►-Q r a � a r f ¢ O DESCRIPTION: ' Lk'�- • ,� L G. Were you seen in fhe E.R.for this problem? 1�Y C7 N Which E,R.? What test scans have yeu had for this probl/e�.? ❑ X rays ❑MRT ❑ CAT Sc�n O Bone Scan �'Werve Test(EMGjNC1/} Where? On a s�ale of�-10(10 is the wotsE}how severe is your pain?(circle) 0 1 2 3 4� 6 7 8 9. 10 Wf�at is tha quarity of the pain? I�Sharp ❑ DuIE �Srabbi�g �'`Throbbfng �"Aching �Buming The pain is: ❑Constar►t 4d int�rmittent(comes&goes) Does the paia wake you from ynor sieep? L�Y � N I experlence: ❑Swelling CI Brvising ❑ Numbness O Tingling L�Weakness O Loss of control of bowe!or bladder ❑ Lodcing/Catching O Giving way O�Pain 9�(Stiffiess ❑ Other Since my problem started,it is: C,d�Getting better ❑ Getting warse ❑ Unchanged Wtwt makes your symptoms worse? 0 Standing ❑WaUdng Pfl.ifting ❑Twisting Ci Bending D Stairs �Exe�e �Squatting O Kneeling D Sittlng CI Coughing O Sneeiing �Lying in bed Which malce your symptoms better? ❑ RPSt 0 Elevation �Ice ❑ Heat O �ther: PAST MEDICAI.HISTORY � List all previous haspibfizations and/or surgeries: D NONE Y R t r^ L.ist any med�cadons 1►eu are taking en a regular basis�mdudmg hormanai repYaePment tl�apy or bittf�aantron: [�NONE Medicat�on Reason Aro you taki�y,or have you ever taken,blaod thinners2 ❑Y N If yes.which one? -Page oae- soza-1(o�lii) II �� SUMMIT Duffy, Michaef b �` ORTHOPEDICS p��e��a �8��9�04/42 Patient 1D#1456558 Furmanek DO, Jeffrey A DR i�1'I 8 D�te O#L' �y�0I2011 PAST j�►IEDICAL HISTORY D►'s Pro Bldg Clinic Are you�tlerglc to any medicatians? ❑Y B�N If yes,please list below: Medi+cation Reactiari Other Allergies? 0 Y ❑N If yes,what are they? l.atez allergy? �Y ❑ !V Do you have a peesonai history of a�y of the following? ❑ NONE I�Excessive or Pralonge�Bleecling �Rheumatic Fever O HIV/AIDS �Stroke ❑Blood Gots Diabetes O Grcufabory Problems �Asthma ❑Reaction to Anesthesia ❑Type: ❑Heart Oisease/Defect �Cancer Type: ❑Stomach Ulcers O Chemotherapy/Radiation �Birtl� Defects ❑Hepatitis �FracturesjJoir►t�islocations ❑Continuous Se¢ures ❑Arthr�is Type: ❑Problems with Waunds Healing ❑Epitepsy ❑Bane or]ofnt Infectlons ❑Tubercutosis ❑Lung Disease O Abn�rmal Blood Pressure 0 Chemical Dependenry 0 Sleep Apnea CPAP ❑Yes No �Psydiiatric Care ❑Emphyserna ❑Pacemaker R��w o�svsrEMs Have you ever had as�y of these symptams?If no,mark NONE. NONE YEAR Details/Camments i)GI ❑Heartbum,Ulcers � fVausea,Vomtting 0 Blood in Staol ❑ 2)ENDO ❑Thyroid Disease C{ Heat or C41d Intaferance � 3)C4N 0 Weight t,�ss ❑ Loss of Appetite D Fabgue ❑ 4)EYE ❑Blurred Vfsion ❑ Dauble Vlsian ❑Ysion Loss ❑ 5)ENT ❑Hearing Loss ❑ Hoarseness ❑Trouble SwaAowing � � 6)CV ❑Chest Pafn ❑ Palpltations ❑ 7)RS O Chronit Cough ❑ Pneumonia ❑Shartness of Breath O 8)GU O Painful Urination O Blaod in ilrine ❑Kidney ProbEems ❑ 9)SK O Frequent Rashes O Skin Ulcers 0 Lumps ❑ Psoriasis ❑ 10)NEU ❑Headaches ❑ Q'�zziness ❑Seitures ❑ Numbness ❑ 11)PSY ❑Depression/Anxiety ❑ Drug/Alcohol Addiction ❑Sleep Diso�er 0 12)HEM 0 E�y Bleeding ❑ asy Btvising �Anemia �_,� 13)Are you HN Posithre7 ❑Y �N Have yoa ever had Hepatitis A,B,or C? ❑Y �N If yes what type? 14)Are you pregnant? ❑Y �'N � / 15)Are yau daustrophobic? ❑Y 19 N FAMILY HISTORY Have any direct retaWes t�ad any of the following disorders'�If so,list yaur relative. O Dfabetes €7 High Blood Pressure ❑ Rheumatoid Artltn'tis ❑ Dlffccu(ty with ancsthesia �Bleeding Problems None known SOCIAL HLST4RY Do yau us�bobacco? I1�Y ❑ N If yes, packs per day_� ❑ Quit Informed of Smoking.R�skt O Y C7 fV Akoh�use? ❑Y �N ❑Quit Msrital History: ❑ Marriecf ❑ Singie Riyorced O Widawed Are you currently worlangT 0 Y N L►'J Retired �Disabied if no,when did you{ast woric? Are you currer�y on any work restric#ions? 0 Y �N If yes,what are tiiey? Ocwpstlon: r� t m� 1=f� aC-Fr�c. a�, �Employer: ❑ Student pLEASE SI :The tn bn�n 's form is accurate to the best of my knowledge. �- '� �- g��q�� Date �OR OFFICE USE ONLY: Compteted Date Revlew#1 by MD Date: lteview#2 by MD Dat,e: -Page Two- sam•x(Qryis) ••+•.•"•� ��+�+��+••� '��'��. 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"`M�z �y a �sr^��`��` �.� �F R s�� 'F .�'t �e,�L�i{F. �; o � � `t��.., n�y • . .• .� _ �� ,ti�- ,. .,.� t [�'Sc�ca yti G. ti, � �1 xw, . g T q. ry ��... , »Ki��..� �+.i�f'�._. `Tr}S,y'� 1�'�''��'at��" '` A, .�[- . .i ai b� : '�' , �"� .r "`: '�.L��. 'u"'��' -�� !�I` ��+r� �-t�r, � �i � y_ � � q 'i �}k.f�N:F�ti�.�'��`:C{' f ��A3.. '' ' '� .0 r'�.��-� _ - �,{�kr�. Y� i,�p�� +�� th� a..,� � 6�1� r�L'��,- vY_� �.�c ��. ,��a•s �a fi�` _ � � ' EXPL.Ai�ATiON OF PATIENT RESPONSlBiL[TY � Regions Hospital filss�}nsurance cfaims for patients as a courtesy with the understanding that the.patientlguarantor has full'responsibility for payment of the biil. If you are uninsured or under-insured, our �inancial Gounselors will . assist you to apply for pr�grams that may be available to help with payment of your bil[s. : Payment is due at this time unless you�have macle other arrangements with Regions Hospital.�However, we wou�d : not want the cas#ta prevent you from receiving the care yau need. To discuss payment options or to make payment . � arrangements within hospita!guidel€nes, please contact our Patient Accounting Customer Service Staff. If you do � . .no#make arrangements or if your account is nbt paid within hospital policy guidelines, it is subject to review for placement with aur collection agency Qr for further legal actian. . ON-LINE BILL i'AY lS�AVAiLABLE.YOU MAY ENROLL OF{ MAKE A PAYMENT VIA OUR WEBSITE: WWW.REGIONSHfJSPITAL.COM UNDER THE"FOR PATIENTS"LIRtK, OR CALL�UR OFFICE AT (fi5�) 254-4791 TO PAY ELECTRONICALLY. ' � . • . . - . .� .� • � : . �. . _ � QUESTIONS ASOUT TH1S'STATEMENT : . � � . . � �Our Customer Service stafif�will assist you with questions aoncerning this statemen#:Our office haurs are Monday . through Friday 8:OOAM to 4:30PM.Voicemail is availabie outside regu(ar business hours. � . For heip with billing questions;call (651) 254-4797 or toll free 1-877-9743640 or email us at� regionsbilling�heafthpartners.com, . . � . . • . . . : . . � � : - �.� . Kev pab txog tej fus nug nuj nqi, liu rau (65l} 254-�791:. � . . � _ � : � � � � . � � - . Hadii aad u baahantahey in lagaa caawiyo su'aalah aad ka'qabtid�biilka, soo wac(651) 254-4797;.,• ' • � � � Para hacer pregunta,� acerca de[ estado de su�cuenta, Ilame al te[e#ono(651} 254-479'1.. : � . : � . � � Neu qujr vi cb cau ho i gi v�v�n cte h�a ddn, xin goi so (B51)2544791.�. � . _ . ' �. • � . You havethe option ta�address any�concerns with#he Minneso#a Attorney General's Office,which�.'•. � can be reached at(651}�296-3353.or 1-800-657-3787: � � �� . � • • � � �� . . . . � . . �, - � �: � - � : ASSOCIATEb EXPENSES�.�- .� �' : .. . . � � '. . . • � . . � � � You may receive additional biils from specific physicians who assisted with your care v►rhile��at�Regions. �-" � . Hospital.�Please contact them directly if you have questians regarding their bills.Tt�e telsphane number for. the Health Partners Medical Grbup is (651) 265-1999. � . � . � , � - �. Account � � ` 03172�0'S92 > ' Account' Balance ; 5795,88 � ,,Gtiiarantor ARiount, Due $795..88 � ; ;'; - - - � Th'ank y�u ror usirig Regions ifacili.taes: for yout healtlic�r� rieeds > If `you : ; , , '` cannot:.pay in full �iiediate3y, please''c�ll ;vs, to. make`paymen� ariangeinents: We' abcept most arec�.i.t` cards `; For _assistance:with :any x�ies�it5ns reg��ding yoiir hosgital; bill;, you''rnay eall u's at ,the telephone L� nurnber: below: � t ' : ..:: . , .; ,h ; •. :.. , ; : , , . . ; ;.;; > :; Ua: tsa�ig uas;, ko� sa.v cha+� klio moh, Regions qYiov chaw ua�hau7?lwm :l'os pab kYia koj, kev mob nkeeg � Yoq,`.tias ko� 'tliem tsis tau tag;=nrho,:tus n.qi hoo maura tam sim_,no, .'thov.hu tua� rau' peb es qhia seb ko� ;yuav tnem :tau 1i'. � cas Peb txais yuav luag txhua,txhua daim ,cxedit, card: Yog xav tau lcev� ' �Qab dabtsi 1`os yog muaj lus-:'nu j dabtsi';txog..'ntawm ko� daim nqi h�.o maum, ,;e= 'ko� hu:.:tau tua� ;rau peb ntawm tu.:xov ,top� hauv qab no : � ' � Waad ku� mahadsan, tahay-,inaac� goobaha Regians u is.tzcma�ashay,�daryeelka . c�afirnaadkaaga Haddii aana'd si,bunxda kharashka, zskaga bixin karin isla - �taxkiiba; fadlan �na so.o Wac,:sa looga �hesh"izyo habka iska bixinta:;: ; - , + ktiarashka i Waxa�annu;'qaadariaa kaadhadhka ;daymaha {creda.t �ard) intood'a ' badan Si,lag�aga gargaazo•:wixii ah su'aalo ku saa�san biilka 3ma ' kh'arashka ciabita�.lka, `waxa .aad naga soo wica. karta Iainbarka teleefonka ' ee hoos. ku.' oran :: ?� q. Gracias por 'atenderse en el Hospital Regions Si es qiie Ud . no puede � � pagar t'oda la cuenta en este momento, ' por favor llamenos para h8cer un: � `arreglo sobie su;`pago :: Aceptamos; la ,inayoria de. Tas,tar�etas' de `credito � Si: tisne alguna' siuda'r.especto a:su• c�ienta nos puede Tlamar,al; siguiente _ . ''teletoiia � - - ;< Sincerely, � ..: . .. .. . . . ... : : .. � Regions� Hospital` Customsi Serv�:ce _ .' 65.1-254'=4'791 or:.5-877-974��360a '_ ::Nionday , 'F"riday;� .8 OOain 4:3flpin �� - :. MI�/GA': � _ � - . . . . .:. . , ,. .. . sosse-irri�«TeeoJauRSaaooa2 � IIt�IIfi��l{��U91��11�1�1�1�I�i�l9�