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NOTICE OF CLAIM FORM to��i�'���f Saint Paul, Minnesota
Minnesota State Statute 466.05 states that "...every person...who claims damages from any municipality...shall cause to be presented to the
governing body of the municipality within 180 days after the alleged loss or injury is discovered a notice stating the time,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 egplain 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
First Name ��� G� Middle Initial � Last Name �j ��-� ��
- - —�u�i c� .,� u ' .es��':ame --
Are You an Insurance Company? Yes�If Yes, Claim Number?
Street Address / �� V `�C/(J
City S T ���-�— State Yn �✓ Zip Code SJ a
Daytime Phone (�z�}�2,�-�Cell Phone( ) - Evening Tele.phone( S�)d�-2���(
Date of Accident/Injury or Date Discovered � �/�, /a— Time g: 3 � am pm
Please state,in detail,what occurred(happened),and why you are submitting a claim. Please indicate why or how you
feel the City of Saint Paul or its employees are involved and/or responsible for your dama.ges.�7A j j-;,�c, �-(arn�
�caM 5��� �c�c'; T' T,�, ��e..�S. a-n� -�-l.� S�d� ��) k c�.���r� ���e c�c.�
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Please check the box(es)that most closely 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.
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 encouraged to keep a
copy for yourself before submitting your claim form.
O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds
$500.00; or the actual bills and/ar receipts for the"repairs
O Towing claims: legible copies of any ticket issued and a copy of the impound lotxeceipt
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—nlease comnlete this section
Were there witnesses to the incident? Yes No Unl�o (circle)
Provide their names, addresses and telephone numbers:
Were the police or law enforcement called? Yes �� Unlmown (circle)
If yes,what department or agency? Case#or report#
Where did the accident or injury take place? Provide street address, cross street,intersection,name of park or facility,
closest landmark, etc. Please be as detailed as possible. If necessary, attach a diagram. (�I Ps.,�r -��
1��sec.�--���� a-� �� � Ev� a+�c�• J�fi�
Please indicate the amount you are seeking in compensation or what you would like the Ci to do to resolve this claim
your satisfaction. 0 �e.� t/�'� `c � � a..� rc �1� ��
�. i 1J� r G.°�J t
Vehicle Claims—please complete this section ❑ 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
Injurv Claims—please complete this section ❑ check box if this section does not applv
How were you injured? '"�r �, n�� o,� t1w e.�r e..� S �d 2..w���
What part(s)of your body were injured? ` � �[ ; e
Have you sought medical treatment? e No Planning to Seek Treatment(circle)
When did you receive treatment? (7 1 � (provide date(s))
Name of Medical Provider(s):_�p�;4.-e� �-�,o�fl;}�.- ��.ecc„Q c ba a�r�
Address Telephone
Did you miss work as a result of your injury? Yes
When di d you miss w�rk?_ ____ - {—��e�a�e�s j j
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 and correct to the best
of your knowledge. Unsigned forms will not be processed.
a�
Submitting a false claim can result in prosecution. Date form was completed �/�1 r Z1
Print the Name of the Person who Completed this Form: � �`C'�e�.�, I ��"���
Signature of Person Making the Claim: c�
Revised February 2011
; H&P Notes (continued}
-h/o hystrectomy sec to myoma, cervical dysplasia-out pt f/u.
Himanshu S Sharma, MD
H&P signed by Beckman,Luke C, MD at 06/15/12 1149
Aijthar: Beckman, Luke C, MD Service: (none) Authar Type: Physician
�il�d: 06/15/12 1149 Note Time: 06/15/12 1038
RESIDENT ADMISSION HISTORY AND PHYSICAL
Admission Date: 6/15/2012
Primary MD: Browning, Jimmie L, MD
Primary Clinic: United Family Practice Health Center
Info Source: Patient, Medical record.
CHIEF COMPLAINT: Finger fracture.
HISTORY OF PRESENT ILLNESS:
Janet L Barott is a 44 y.o. female with a history of painful ovarian cysts, hypertension, and an MRSA abscess
who presents to the emergency department with an open fracture of her finger.
She was walking this morning, something got caught on her her shoe, she lost balance and landed on her
outstretched right hand. She had immediate pain and bleeding in her hand. She could see bone in the
proximal middle finger on her right hand. She did not pass out, and she did not hit her head. She scraped her
knees. She was not feeling lightheaded before, but did feel slightly lightheaded and nauseous when she
arrived in the emergency department.
In the emergency department the fracture was reduced after a finger block. Xray showed an oblique open
fracture.
Pas# Medical Histary
Diagnosis Date '
• Allergy, unspecified not elsewhere classified
Allergy
• Calculus of kidney
Kidney stones
• Endometriosis, site unspecified
• Other and unspecified ovarian cyst
• Polycystic ovaries '
• Dysplasia of cervix, unspecified �,
• Back pain '
• HTN (hypertension)
• Pain in joint, lower leg 11/11/2010 '
• Abscess of female pelvis 11/19/2009
after hysterectomy, MRSA
0mmunization History
ALLINA HOSPITALS&CLINICS Report Date: 8/1/12
UNITED HOSPITAL
Patient: BAROTT,JANET L DOB: 6l12/1968 MRN: 1004429238 HAR: 8042322
Admit Date/Date of Service: 06l15/2012 Discharge Date: 6/15/2012 IP MINIMUM NECESSARY
**"`**"'**'`*''*Redisclosure not permitted without the express written permission of the patient'`*******�***
Discharge Summary Nates(continuedj
Physician(s) in addition to primary physician who should receive a copy:
eCi: Browning, Jimmie L, MD
CC2: Dr. Mark Holm, MD
'; Emergency C�ep�rtrnerrt
VisiUED Diagnoses
Fracture of finger,proximal phalanx, right,open
. _ _._ _.. _ _
HTN(hypertension)
.. _. . _. _ _ . . _,
Dysplasia of cervix, unspecified
PCOS(polycystic ovarian syndrome) _ _
ED Provider Nofes '
ED Provider Note signed by Olsen,Jeremy D, MD at 06/17/12 2000
�uthor: Olsen,Jeremy D, MD Service: (none) Author Type: Physician
i=i(ed: 06/1 7/1 2 2000 Note Time: 06/15/12 0851
Chief Complaint:
Hand Pain/problem
History of Present Illness:
HPI Comments: I, Adam Forry, am serving as a scribe to document services personally performed by Jeremy
Olsen, MD based on my observation and the provider's statements to me.
Janet L Barott is a 44 y.o. female with no significant medical history, who presents to the ED for evaluation of
obvious hand fracture.
At 0800 this morning, the patient was ambulating and tripped on a protrusion of the sidewalk. She fell to the
ground, bracing herself with her right hand, and landing without striking her head or losing consciousness. She
experienced the immediate onset of continuous right hand pain, which has since persisted. The pain is
primarily located in the proximal 3rd digit (where there is an obvious open fracture), does not radiate, and is
rated at 10/10 in severity. This is described as aching and sharp in quality, is exacerbated by movement of the
joints, and she notes no palliating factors. Associated with the pain, she also complains of nausea, and denies
other symptoms presently. She notes that her last tetanus shot was within the past 5 years.
SHx: Smoker, 0.5ppd for 5 years. EtOH use
I, Jeremy Olsen, MD attest that Adam Forry is acting in a scribe capacity, has observed my performance of
the services and has documented them in accordance with my direction.
ALLINA HOSPITALS&CLINICS Report Date: 8/1/12
UNITED HOSPITAL
Patient: BAROTT,JANET L DOB: 6/12/1968 MRN: 1004429238 HAR: 8042322
Admit Date/Date of Service: 06/15/2012 Discharge Date: 6/15/2012 IP MINIMUM NECESSARY
************Redisclosure not permitted without the express written permission of the patient********"`***
'Pr+acedure Na►tes(continuedj
JILLIAN CUNNINGHAM, PA-C
PREOPERATIVE DIAGNOSIS
Open fracture of proximal phalanx, right middle finger.
POSTOPERATIVE DIAGNOSIS
Open fracture of proximal phalanx, right middle finger.
PROCEDURE
Open reduction internal fixation, proximal phalanx fracture, right middle
finger.
INDICATIONS
This 44-year-old female tripped and fell earlier this morning and jammed her
right middle finger. She sustained an open fracture of the proximal phalanx
with a 2 cm laceration on the flexor surface of the middle finger. X-rays
revealed a split in the articular surface of the distal end of the proximal
phalanx that went down to the middle of the proximal phalanx. She was brought
to the operating room for open reduction internal fixation of this fracture.
SUMMARY
The patient was placed in supine position on the operative table after an
axillary block was administered to the right upper extremity. She had
received IV antibiotics preoperatively. An axillary block was administered.
The right arm was prepped Hibiclens and alcohol. The arm was exsanguinated
and the tourniquet inflated to 250 mmHg.
The C-arm was brought into place which confirmed the displaced fracture. A
longitudinal incision was made on the extensor surface of the right middle
finger with a 15 blade between the PIP joint and the metatarsal phalangeal
joint. Skin flaps were retracted. The extensor tendon mechanism was intact.
It was split longitudinally and retracted exposing the fracture. The fracture
hematoma was washed out. The wound was cleaned. The fracture was reduced and
2 transverse K wires measuring 0.035 inches in diameter were inserted. The
C-arm was brought back into place and confirmed the reduction. The wounds
were washed out again with saline. The extensor tendon was closed with 4-0
Vicryl. The skin was closed with 5-0 nylon suture. Inspection of the wound,
on the flexor surface of the finger revealed that the flexor tendons were
visible and were intact. That wound was closed with 5-0 nylon as well. A
bulky dressing was applied and the plaster splint secured with an Ace
bandage. The tourniquet was released. The patient was taken to recovery room
in good condition and discharged home with a prescription for Percocet, '
Vistaril, and Keflex. She will be seen in the office in 2 weeks for a cast i
change. '
MARK E. HOLM, MD
MEH/rg
D: 06/15/2012 20:40:59
T: 06/17/2012 13:03:21
ALLINA HOSPITALS&CLINICS Report Date: 8/1/12
UNITED HOSPITAL
Patient: BAROTT,JANET L DOB: 6/12/1968 MRN: 1004429238 HAR: 8042322
Admit Date/Date of Service: 06/15/2012 Discharge Date: 6/15/2012 IP MINIMUM NECESSARY
'`**********"Redisclosure not permitted without the express written permission of the patient"*"*"*******
� � , . ., , : ,
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Allina Hospitals&Clinics CARD NUMBER EXP.DATE
ALLI NA. 2s2s cn��go A�en�e
Hospitals&Clinics Minneapolis, MN 55407-1321
SIGNATURE AMOUNT PAID
Billing Questions?
Please call us at 612-262-9000 or 1-800-859-5077, STATEMENT DATE ACCOUNT NUMBER P�EASE PAY THIS AMOUNT
� Monday-Thursday 8am-4:30pm 07/03/2012 8042322 s16,138.04
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� Page 1 of 1 ' '
N ALLINA HOSPITALS&CLINICS
`g JANET L BAROTT PO BOX 9125
0 416 VIEW ST MINNEAPOLIS MN 55480-9125
� SAINT PAUL MN 55102
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U000000008042322001613b0403 02
HOSPITAL STATEMENT
ACCOUNT NUMBER PATIENT NAME HOSPITAL NAME
8042322 JANET L BAROTT United Hospital
Date ' Description Charges/Paymerrts
SERVICES FROM 06/15/2012 to 06/15/2012 at
If you require an itemization of charges,please call(612)262-9000 or(800)859-5077.
06/15/12 Room and Board $2,980.00
06/15/12 Pharmacy $1,986.85
06/15/12 Medical/Surgical Supplies $515.49
06/15/12 Laboratory General $646.30
06/15/12 Radiology-XR $1,238.20
06/15/12 Operating Room $6,544.40
06/15/12 Emergency Room $2,007.10 ,
06/15/12 EKG/ECG $219J0
__- -- - _ _�@�,"�t-^n-"�°�-� -
__ --- $'l�,�38.@4- --
07/02/12 Insurance Payment $0.00 �
BALANCE: $16,138.04
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PLEASE NOTE:If you have requested this itemized statement,the balance listed as patient responsibility may still be pending witF�your insurance company.
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� � $16,138.04
� � � � �� � � � � FOR BILLING INQUIRIES: 612-262-9000 or 1-800-859-5077(if you
. . . .. ,. .
are outside the Twin Cities area). ti
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Allina Hospitals&Clinics:2925 Chicago Ave�Minneapolis,MN 55407
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37369 �SIGNATURE EXP.DATE
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Y�� TEMP-RETURN SERVICE REQUESTED ' --- - --- -��� — --- � � ` -�-�—�- � � j
� STATEMENT DATE PAYTHIS AMOUNT � ACCT.# I
I 07/24/2012 $1894.00 i 365615
PAYMENT DUE UPON RECEIPT �
006966 0101 L.------—------�
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653437
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JANET L BAROTT SUMMIT ORTHOPEDICS LTD
416 VIEW STREET PO BOX 86 SDS 12 2901
ST PAUL, MN 55102-3428 MINNEAPOLIS, MN 55486-0096
37369*TK20GQF7 M000057
�Please check box if address is incorrect or insurance STATEMENT pLEASE DETACH AND RETURN TOP PORTION WITH YOUR PAYMEP(T
information has changed,and indicate change(s)on reverse side.
�
DATE CPT DESCRIPTION FEE TOTAL INSURANCE PATIENT
Janet L arott 83239 Mark E Holm IrID United Hospital
06/15/2012 26735 Open treatment of phalangeal shaft fracture, 1894.00 1894.00 0.00
07/21/2012 Payment from Blue Cross Minnesota 0.00 0.00 0.00
O7/23/2012 Transfer from Insurance 0.00 -1894.00 1894.00
Additional information has been requested
from your insurance carrier.
0.00 1894.00
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CURRENT 31-60 DAYS 61-90 DAYS 91-120 DAYS OVER 120 DAYS ACCOUNT BALANCE INSURANCE BALANCE
$1894.00 $.00 $.00 $.00 $.00 $2244.00 $350.00
Summit Orthopedics would like to offer patients the opportunity to complete our online patient �—
satisfaction survey. If you are interested, please go to www.summitortho.coMonline_services.html. � DUE FROM PATIENT
�� ►►►► $1894.00 I�
PAY YOUR BILL ONLINE WITH A CREDIT CARD OR DEBIT CARD OR AN ELECTRONIC PAYMENT �`
FROM YOUR CHECKING OR SAVINGS ACCOUNT. VISIT US AT www.summitortho.com.
Thank you for your prompt payment. Balance is due upon receipt. Summit Orthopedics would like to offer patients the
opportunity to complete our online patient satisfaction survey. If you are
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PLEASE ENTER CORRECTED NAME OR ADDRESS BELOW DUESTIONS:
NAME For questions regarding insurance benefits and payments,
STREET APT.NUMBER please contact your insurance company by calling the phone
number listed on the back of your insurance card.
CITY STATE ZIP
HOMEPHONE WORKPHONE
INSURANCE UPDATE CONTACT US:
INSURANCE EFF. To contact b hone, call Customer Service at 651-968-5050,
CO.NAME DATE Y P
INSURANCE Monday- Friday, 8:00 a.m.to 4:30 p.m.
co.a�oRESS To contact us by mail, please include the following information
and mail to:
CITY STATE ZIP
710 Commerce Drive, Suite 200 Patient Name
SUBSCRIBER EMPLOYER Attn:Customer Service Account Number
Woodbury, MN 55125 Dispute Amount
i�# GROUP# Description of the Dispute
COVERED INDIVIDUALS
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