GENERAL CLIENT AND CASE INFORMATION ENCLOSURES. We have enclosed the following documents in support of this demand:
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1 SETTLEMENT OFFER ER 408 Adjuster Geico Insurance RE: Our Client: Jane Doe Your Insured: John James Date of Loss: August 21, 2016 Claim Number: Dear : As you know, I represent Jane Doe with regard to injuries she sustained in the accident of August 21, 2016, caused by your insured, John James. Jane s condition has now stabilized to the point that I am now authorized to make a settlement demand to you with regard to this claim. Given the clear liability and intensity of her injuries, demand is hereby made for $. This letter and the enclosed documents are submitted for settlement purposes only. The Washington Rules of Evidence prohibit use of this letter and the enclosures as evidence in any legal proceeding without our express consent. If settlement fails for any reason, this letter and its enclosures are to be returned to me without retention of copies. Date of Birth: 07/09/1985 Gender: Female Medical Specials: $14, Date of First Treatment: 08/21/2016 GENERAL CLIENT AND CASE INFORMATION ENCLOSURES We have enclosed the following documents in support of this demand: 1. Medical Billing; 2. Medical Records from EvergreenHealth Medical Center; 3. Medical Records from Professional Chiropractic Services.
2 Page 2 FACTS OF ACCIDENT On the evening of August 21, 2016, Jane Doe was stopped at a red light at the intersection of 98 th Avenue NE and NE 116 th Street in Kirkland, Washington, when she was rear-ended by your insured, John James. INJURIES AND TREATMENT INJURIES ICD-10 CODE PROVIDER Acute right-sided low back pain M54.5 Abigail Gross, MD Neck pain on right side M54.2 Abigail Gross, MD Acute bilateral low back pain M54.5 Shakeitha Dillard, PA-C Neck strain S16.1XXD Shakeitha Dillard, PA-C Spine pain, multilevel M54.9 Jeffery Warner, DO SUMMARY OF MEDICAL TREATMENT APPOINTMENTS (SEE ATTACHED EXHIBITS): Provider No. of Treatments Treatment Dates EvergreenHealth Medical Center 1 08/21/16 Professional Chiropractic Services 64 08/23/16 09/20/17 TREATMENT 08/21/16: EvergreenHealth Medical Center Jane presented to the emergency room on the day of the accident with reports of a panic attack, chest pain, shortness of breath, bilateral arm tingling, neck pain, and right trapezius pain. Examination revealed a left neck abrasion from the seat belt and tenderness to her cervical spine. CT scans and x-rays were obtained and Jane was instructed to follow-up with her primary care physician. 08/23/16: Professional Chiropractic Services Follow-up care began on August 23, 2016, with notation of constant headaches, chest pain, shoulder pain, neck pain and stiffness, mid-back pain, sleeping problems, low back pain, shortness of breath, upper extremity numbness, cold hands, tension, nervousness, and severe reluctance to drive. Objective findings included tenderness, pain, and loss of cervical, thoracic, and lumbar motion and positive orthopedic and neurological testing results. Jane was instructed to remain off work through August 29, 2016, and return for treatment the next day. 08/24/16: Professional Chiropractic Services Pain unchanged and rated 6/7-10. Spinal adjustments and referral to massage therapy. Return three times per week. Home exercise instructions. 08/25/16 09/21/16: Professional Chiropractic Services Chiropractic adjustments and pressure point therapy. Work disability extended to September 6, Referral to mental health counselor for anxiety. Foot pain noted due to prolonged standing. 09/23/16: Professional Chiropractic Services Follow-up evaluation. Missed two weeks of work due to injuries. Work exacerbating symptoms with computer and headset use. Significant increase
3 Page 3 in symptoms on returning to work on September 6, Anxiety still present. Recommend continued chiropractic and massage care twice per week for six weeks. 09/27/16 12/12/16: Professional Chiropractic Services Chiropractic adjustments, therapeutic exercises, and pressure point therapy. Work continues to increase pain. Frequent aggravations and exacerbations with activities of daily living and long work days. Additional concurrent massage therapy recommended. 09/23/16: Professional Chiropractic Services Follow-up evaluation. Slow progress made. Returned to work from vacation and symptoms escalated. Prior to accident, could work long shifts without any pain. Regressed in early December when not able to make appointments due to work schedule. Not yet fixed and stable. Recommend two visits per week for next four weeks then once per week. 12/29/16 02/08/17: Professional Chiropractic Services Chiropractic adjustments, therapeutic exercises, and pressure point therapy. Not able to return to the gym or yoga. Headaches, neck pain, right shoulder pain, and back pain remain persistent. 02/16/17: Professional Chiropractic Services Follow-up evaluation. Overall progress noted. Attempts to return to gym create symptomatic flare-ups. Headaches less frequent. Continued episodes of right sided neck pain and tingling in right arm especially with data entry at work. Feels 65% better. Recommend continued chiropractic care once a week for four weeks. 02/22/17 08/28/17: Professional Chiropractic Services Chiropractic adjustments, therapeutic exercises, and pressure point therapy. Right neck, shoulder, and back pain and headaches. Improvement noted. Referral to additional massage therapy. Continue aerobic and strength conditioning program combined with taper of chiropractic. Severe spasms after stressful days at work and helping family move. 09/20/17: Professional Chiropractic Services Final evaluation. Has returned to gym and handling flare-ups well. Has returned to pre-accident levels of function with aggravations in neck pain with driving and some activities of daily living. Pain present 25% of the time. Reached maximum medical improvement with no additional improvement expected. Flare-ups of accident related symptoms likely in the future. CURRENT MEDICAL SPECIALS SPECIAL DAMAGES Jane Doe has incurred medical expenses for treatment of the injuries sustained in her accident with your insured. The total incurred medical expenses are as follows: Provider Dates of Service No. of Visits Total Charges EvergreenHealth Medical Center 08/21/16 1 $8, Evergreen Emergency Services 08/21/16 1 $ Radia 08/21/16 1 $ Professional Chiropractic Services 08/23/16 09/20/17 64 $4, TOTAL: $14,989.60
4 Page 4 MILEAGE EXPENSES Jane Doe has incurred mileage expenses for treatment of the injuries sustained in her accident with your insured. The total incurred mileage expenses for medical treatment transportation is as follows: EvergreenHealth Medical Center 1 visit x 4.2 RT = 4.2 miles x.17 $.71 Professional Chiropractic Services 64 visits x 5.8 RT = miles x.17 $63.10 TOTAL: $63.81 SPECIAL DAMAGES SUMMARY Medical Specials $14, Mileage Expenses $63.81 TOTAL: $12, DUTIES UNDER DURESS & LOSS OF ENJOYMENT OF LIFE Jane continues to have good and bad days due to unexpected flare ups of pain. Such unexpected halting pain robs her of the enjoyment of life she had prior to August 21, Caring for her daily activities, many times can only be accomplished under duress. The once normal and commonplace activities before the August 21, 2016, accident are now attempted with concerns of exacerbating her injuries. The determination of Jane s functions in caring for her daily activities is the intensity and frequency of the painful flare ups. Having to go through life with constant awareness that anything she may do, would inflame this injury, deprives her of the pleasure of life she once enjoyed. To date, Jane Doe PRESENT CONDITION AND PROGNOSIS GENERAL DAMAGES Jane Doe is entitled to recover damages for all personal injuries caused by this accident, including damages for emotional distress and economic damages. The guiding principle of tort law is to make the injured party as whole as possible through pecuniary compensation. Aker Verdal, A/S v. Lampson, 65 Wn. App. 177 (1992). She is entitled to recover the reasonable value of necessary medical care, treatment and service rendered before trial. Jane may also recover the reasonable value of time, earnings, or salaries lost and the present value of reasonable future losses. WPI and Loss of earning capacity is a permanent diminution of ability to earn a living owing to disability as opposed to the temporary inability to continue in a prior occupation. Kubista v. Romaine, 14 Wn. App. 58, 62, 63, 538 P.2d 812 (1975);
5 Page 5 affirmed, 87 Wn.2d 62, 549 P.2d 491 (1986). WPI Travel expenses reasonably necessary to secure proper treatment are compensable. Shipman v. Foisy, 49 Wn.2d 406, 302 P.2d 480 (1956). Recovery for pain and suffering compensates for the physical and mental discomfort caused by the injury. Kirk v. WSU. The amount is determined by the discretion of the jury. Collins v. Doe, 112 Wn. 71, 191 P. 819 (1920). Lay witness testimony of purely subjective symptoms still existing at trial allows for a jury instruction and consideration of future damages for all categories of general damages. Bitzan v. Parisi, 88 Wn.2d 116, 558 P.2d 775 (1977). Negligently inflicted mental distress is compensable. Hunsley v. Giard, 87 Wn.2d 424, 553 P.2d 1096 (1976). So is distress about the fear of the future consequences of an injury. Elliott v. Aerosmith, 149 Wn. 631, 272 P. 32 (1928). Loss of ability to enjoy life is a proper element of damages, and if there are special artistic or athletic skills, separate or added distress compensation is appropriate. Kirk v. WSU, at The injured person's anxiety and worry are compensable. Freeman v. Intalco Aluminum Corp., 15 Wn. App. 677, 552 P.2d 214 (1976). CONCLUSION In light of the clear liability in this case and the injuries clearly proximately caused, as well as the damages documented herein, we make a reasonable and fair demand in the total amount of $ in full and final settlement of this claim. If your insured s policy limits are lower than our stated demand, please consider this our request for policy limits. Hopefully, we can settle this claim quickly and in a cordial negotiation. We make this request pursuant to Washington Administrative Code, Section (3), which states in relevant part: (3) An appropriate reply shall be made within ten working days on all other pertinent communications from a claimant which reasonably suggest that a response is expected. Thank you and I look forward to hearing from you. Yours truly, John Doe Attorney at Law JD/tlm Encl. cc: client w/o encl.
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NEW PRACTICE MEMBER APPLICATION Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
PATIENT APPLICATION FORM
PATIENT APPLICATION FORM WELCOME and THANK YOU for applying as a patient in our clinic. We are a very unique team specializing in researched-based spinal and postural rehabilitation. These methods have
Name Date / / Age Male/ Female Address City State Zip
T 1 2 3 : Name _ Date / / Age Male/ Female Address City State Zip Phone: Home Cell Cell Phone Provider Email Address Date of Birth / / Occupation Employer Single / Married / Divorced / Widowed Spouse s
Sports and Spine Physical Therapy
Sports and Spine Physical Therapy PATIENT MEDICAL HISTORY Name: Referring Physician: How did you hear about Sports & Spine Physical Therapy? First date of pain: Have you had surgery for this injury? Yes
New Practice Member Application
New Practice Member Application Name Date of Birth / / Age Male/Female Address City State Zip Phone: Cell Home Social Security #: Email: Occupation Employer s Name Status: Single / Married / Divorced /
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 346/14
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 346/14 BEFORE: J.E. Smith: Vice-Chair HEARING: February 25, 2014 at Toronto Written DATE OF DECISION: March 13, 2014 NEUTRAL CITATION: 2014
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 2010/06 BEFORE: A.V.G. Silipo: Vice-Chair HEARING: October 17, 2006 at Toronto Oral DATE OF DECISION: October 20, 2006 NEUTRAL CITATION: 2006
Welcome to Manna Family Chiropractic!
Welcome to Manna Family Chiropractic! Today s date Who should we thank for referring you here? Is your visit today regarding you, or your whole family? Family Just Me Your name Date of Birth Street Address
SUMMARY DECISION NO. 1505/00. Chronic pain. DECIDED BY: Marafioti DATE: 21/03/2001 NUMBER OF PAGES: 6 pages ACT: WCA
SUMMARY DECISION NO. 1505/00 Chronic pain. DECIDED BY: Marafioti DATE: 21/03/2001 NUMBER OF PAGES: 6 pages ACT: WCA 2001 ONWSIAT 869 WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 1505/00
RAINIER VALLEY CHIROPRACTIC P.S th Avenue S. Seattle, WA 98118
Patient Health History Full Name Date Street Address City & State Zip Phone Number Gender Date of Birth Age SSN How did you hear about our office? Marital Status # of Children? Currently Pregnant? / How
History of Present Condition
Name: Date: Address: City: Province: Postal Code: Home Phone: Cell Phone: Work Phone: Email: Marital Status: Name Of Family Physician (MD): Age: Occupation: Employer: Extended Health Care Company: Policy
2. Ms. Gilbertson applied for accident benefits August 6, 2013 and received seven physiotherapy treatments.
2 OVERVIEW 1. The applicant, Michele Gilbertson, was injured in a motor vehicle accident on July 14, 2013, and sought benefits pursuant to the Statutory Accident Benefit Schedule, Effective September 1,
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 652/16
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 652/16 BEFORE: J. Goldman : Vice-Chair M. Christie : Member Representative of Employers A. Signoroni : Member Representative of Workers HEARING:
A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS AWARD OF DISPUTE RESOLUTION PROFESSIONAL
CASE NO. 18 Z 600 04628 2 2 A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS In the Matter of the Arbitration between (Claimant) AAA CASE NO.: 18 Z 600 04628 2 v. INS.
Please fill out the following form in as much detail as possible. Please Print. Name. Address. City State Zip. Home Phone Office Phone.
CASE NO. Please fill out the following form in as much detail as possible. Please Print Date Name Address City State Zip Home Phone Office Phone E-mail Address Age Date of Birth Occupation Sex (M) (F)
PATIENT FEE SCHEDULE As of January 1, 2017
TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is
BEFORE THE ARKANSAS WORKERS COMPENSATION COMMISSION CLAIM NO. F OPINION FILED MAY 2, 2008
BEFORE THE ARKANSAS WORKERS COMPENSATION COMMISSION CLAIM NO. F609262 DAVINE PARKER, EMPLOYEE CLAIMANT STANT MANUFACTURING, EMPLOYER RESPONDENT #1 AIG CLAIM SERVICES, CARRIER RESPONDENT #1 SECOND INJURY
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 2389/14
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 2389/14 BEFORE: A.G. Baker: Vice-Chair HEARING: December 22, 2014, at Toronto Written DATE OF DECISION: March 30, 2015 NEUTRAL CITATION: 2015
BEFORE THE ARKANSAS WORKERS' COMPENSATION COMMISSION CLAIM NO. F & F CAROLYN SANCHEZ, EMPLOYEE OPINION FILED MARCH 30, 2010
BEFORE THE ARKANSAS WORKERS' COMPENSATION COMMISSION CLAIM NO. F709437 & F502600 CAROLYN SANCHEZ, EMPLOYEE TYSON POULTRY, INC., SELF INSURED EMPLOYER CLAIMANT RESPONDENT OPINION FILED MARCH 30, 2010 Hearing
PATIENT INFORMATION FORM
PATIENT INFORMATION FORM First Name MI Last Preferred Name Date of Birth / / Age Gender Patient/Guarantor SS# - - Email Address Martial Status Single Married Other Street Address City State Zip Code Profession
NPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone:
NPM INTAKE FORM INFORMATION: Name: Chosen Name (What would you like to be called?): Address: Date: Age: City/State/Zip: Home Phone No.: Work Phone No.: Cell Phone: Email Address: Date of Birth: Occupation:
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy
Van Wyk Chiropractic Center Terms of Acceptance and Privacy Policy Terms of Acceptance When a patient seeks health care in our office and we accept a patient for such care, it is essential the patient
Name Age Date. Please list All your current health complaints, including the reason that brought you to our office:
Name Age Date Please list All your current health complaints, including the reason that brought you to our office: List any other doctors see for current problems and list treatment received and results:
FD: ACN=2115 ACC=R FD: DT:D DN: 840 STY: PANEL: McIntosh-Janis; Heard; Jago DDATE: ACT: 1(1)(a) KEYW: Continuity (of symptoms); Continuity (of
FD: ACN=2115 ACC=R FD: DT:D DN: 840 STY: PANEL: McIntosh-Janis; Heard; Jago DDATE: 200187 ACT: 1(1)(a) KEYW: Continuity (of symptoms); Continuity (of complaint). SUM: The worker appealed a decision of
Vinson, Dedra v. Dillard's, Inc.
University of Tennessee, Knoxville Trace: Tennessee Research and Creative Exchange Tennessee Court of Workers' Compensation Claims and Workers' Compensation Appeals Board Law 3-5-2015 Vinson, Dedra v.
NOVA SCOTIA WORKERS COMPENSATION APPEALS TRIBUNAL
NOVA SCOTIA WORKERS COMPENSATION APPEALS TRIBUNAL Appellant: [X] (Worker) Participants entitled to respond to this appeal: [X] (Employer) and The Workers Compensation Board of Nova Scotia (Board) APPEAL
Personal Information. Reason for Seeking Care. What is your reason for seeking care at Strive Chiropractic?
Adult Intake Form Date: Personal Information First Name: M.I.: Last Name: Preferred Name: Social Security Number: Address: City / State / Zip: Cell Phone: ( ) Alternate Phone: ( ) Text Reminders: Y N Before
Physical Evidence Chiropractic 7035 Beracasa Way Suite 103 Boca Raton FL, Phone# (561) Fax# (561)
7035 Beracasa Way Suite 103 Boca Raton FL, 33433 Phone# (561)361-4888 Fax# (561)361-4999 Date File # PERSONAL HISTORY Last Name First Name Address City State Zip Date of Birth Age Social Security # Circle
SUMMARY DECISION NO. 2182/99. Chronic pain. DECIDED BY: Marafioti DATE: 27/02/2001 NUMBER OF PAGES: 6 pages ACT: WCA
SUMMARY DECISION NO. 2182/99 Chronic pain. DECIDED BY: Marafioti DATE: 27/02/2001 NUMBER OF PAGES: 6 pages ACT: WCA 2001 ONWSIAT 549 WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 2182/99
A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS AWARD OF DISPUTE RESOLUTION PROFESSIONAL
CASE NO. 18 Z 600 17181 01 2 A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS In the Matter of the Arbitration between (Claimant) AAA CASE NO.: 18 Z 600 17181 01 v.
SUMMARY DECISION NO. 984/98. Delay (onset of symptoms). DECIDED BY: Sandomirsky; Rao; Howes DATE: 31/01/2001 NUMBER OF PAGES: 6 pages ACT: WCA
SUMMARY DECISION NO. 984/98 Delay (onset of symptoms). DECIDED BY: Sandomirsky; Rao; Howes DATE: 31/01/2001 NUMBER OF PAGES: 6 pages ACT: WCA 2001 ONWSIAT 247 WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL
Patient Health Record
PERSONAL INFORMATION: Patient Health Record River Falls Chiropractic Name: Age: Date: Address: City/State/ Zip: Home Phone #: ( ) - Work Phone #: ( ) - Cell Phone #: ( ) - Email Address: Male Female: DOB:
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 738/16
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 738/16 BEFORE: S. Netten: Vice-Chair HEARING: March 16, 2016 at Toronto Written DATE OF DECISION: March 31, 2016 NEUTRAL CITATION: 2016 ONWSIAT
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 497/10
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 497/10 BEFORE: V. Marafioti: Vice-Chair HEARING: March 12, 2010 at Toronto Oral DATE OF DECISION: May 7, 2010 NEUTRAL CITATION: 2010 ONWSIAT
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 111/07
WORKPLACE SAFETY AND INSURANCE APPEALS TRIBUNAL DECISION NO. 111/07 BEFORE: S. Ryan: Vice-Chair HEARING: January 15, 2007 at Toronto Written DATE OF DECISION: January 17, 2007 NEUTRAL CITATION: 2007 ONWSIAT