Petition Approve Compromise of Claim

Cal. Super. - 6th Dist.June 19, 2020

Electronically Filed by Superior Court of CA, County of Santa Clara, on 3/5/2021 8:35 AM Reviewed By: T. Ngo Case #20CV367470 Envelope: 5970753 5/4/2021 7 9AM MC-350 ATTORNEY 0R PARTY VWTHOUT ATTORNEY STATE BAR NUMBER: 225305 FOR COURr USE ONLY NAME: Arash Nematollahi F'RM NAME Adamson Ahdoot LLP STREET ADDRESS: 1150 S.Robenson Btvd. CiTY: Los Ange'es STATE: CA ZIP CODE: 90035 TELEPHONE N0» (310) 888-0024 FAX N0: (888) 895-4665 EMAILADDRESS: arash@aa_uplcom ATTORNEY FORUM“): Plaintiff, Elllott Peter Gordon, a minor SUPERIOR COURT OF CALIFORNIA, COUNTY OF Santa Clara STREET ADDRESS? 191 North First Street MA'L'NG ADDRESS 191 North First Street r CITY AND ZIP CODE: San Jose, CA 951 13 BRANCH NAME: Downtown Superior Court CASE NAME; CASE NUMBER: Elliott Peter Gordon, a minor v‘ Sanh Cuong Lam, et al 20CV367470 HEARING DATE: PETITION FOR APPROVAL OF COMPROMlSE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF DEPTI: TIME: JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY NOTICE TO PETITIONER Except as noted below, you must use this form to request court approval of (1) the compromise of a minor's disputed claim, (2) the compromise or settlement of a pending action or proceeding to which a minor or a person with a disability (including a conservatee) is a party, or (3) the disposition of the proceeds of a judgment aWarded to a minor or a person with a disability. (See Code Civ. Proc., § 372; Prob. Code, §§ 3500, 3600-3613.) Both you and the minor or person with a disability must attend the hearing on this petition unless the court dlspenses with a personal appearance. The court may require the presence and testimony of witnesses, including the attending or examining physician, and the presentation of other evidence relating to the claim and the nature and extent of the injury, care, treatment, and hospitalization. The court has authority to consider a request for expedited approval without a hearing ofthe compromise of certain ctaims or actions or the disposition of the proceeds of certain judgments. To determine whether your claim, action, orjudgment quaHfies, see Cal. Rules of Court, rule 7.9505. If you want to request expedited consideration, you must use form MC-35OEX. 1. Petitioner (name or pseudonym*): Tracy Gordon is the (check al/boxes that apply): Parent Guardian ad |item* E] Guardian E ConservatorE Other (specify relationship): of the claimant identified in item 2. (*Petitioner may appear under a pseudonym only if appointed as guardian ad litem under that pseudonym. (See Code Civ. Prom, § 3725.)) 2. Claimant (name): Elliott Peter Gordon a. Address: 460 Franklin Street. Mountain View, CA 94041 b. Date of birth: 02/08/2005 c. Age: 15 d. Minor or E Person with a disability (If the claimant is an adult with a disability who (1) has capacity to consent to the order requested and (2) does not have a conservator of the estate, check e. and f. and ensure that the claimant personally reads and signs item 21, (Prob. Code, § 3613.)) e. E Has the capacity, within the meaning of Probate Code section 812, to consent to the requested order orjudgment. f. E Does not have a conservator of the estate. 3. Claim The claim of the minor or adult person with a disability (check one): a. E Is not the subject of a pending action or proceeding. (Complete items 4-23.) b. Is the subject of a pending action or proceeding that will be compromised or settled without a trial. (Complete items 4-23.) Name of court: Case no.: Trial date: c. [j Is the subject of an action or proceeding in which a judgment has been or will be entered for the claimant against the defendants named below in the amount (excluding Interest and costs) of (specify total): $ Defendants (names: E Additional defendants listed on Attachment 3.E The judgment was filed on (date): (Attach a copy of the (proposed) judgment as Attachment 30 and complete items 12-23.) Page 1 of 10 EZEEQ§13péZSJ°&é'f§;%aé'x“ MW” “5° PETITION FOR APPROVAL 0F COMPROMISE 0F CLAIM probisdsoz‘eflvg'§§88?§23%_%EZ§§ ca o o ' a a. eso ou, 95.1 , fiflugg'55ngclflarjtgfl‘fnz‘oml OR ACTION OR DISPOSITION OF PROCEEDS OF C ' RU' fg‘wfilg‘l'ggqu‘z JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY WWW’Couflslca-QOV MC-350 CASE NAME: Elliott Peter Gordon, a mlnor v. Sanh Cuong Lam, et al CASE NUMBER: 20CV367470 . Incident or accident The incident oraccidentoccurred as follows: a. Date: 09/13/2019 Time: 3:50 p.m. b. Place: On Franklin Street, city of Mountain View, Cafifornia. c. Persons involved (names): See Attachment 4. Continued on Attachment 4. Nature of incident or accident The facts, events, and circumstances of the incident or accident are (describe what happened): On 09/13/2019 at approximately 3:50 p.m., Plaintiff Elliott Peter Gordon was ridiing his bicycle on Franklin Street, city of Mountain View, CaHfomia. when a vehicle driven by Defendant Sanh Cuong Lam (during the course of his employment) struck EIUott Peter Gordon with his vehicle causing injury to Plaintiff. E Continued on Attachment 5. . Injuries The following injuries were sustained by the claimant as a result of the incident or accident (describe): Abrassions to Plaintiffs face, shoulder, elbow. arm and knee. E Continued on Attachment 6. . Treatment The claimant received the following care and treatment for the injuries described in item 6 (describe): Plaintiff Elliott Peter Gordon has received medical treatment and evakuation. E Contlnued on Attachment 7. . Extent of injuries and recovery (An original or a photocopy of any doctor's repon‘ containing a diagnosis of the claimant’s injuries or a prognosis for the claimant's recovery, and a report of the claimant's current condition, must be attached to this petition as Attachment 8. A new repon‘ is not necessary if a previous report accurately describes the claimant's current condition.) a. The claimant has recovered completely from the effects ofthe injuries described in item 6, and there are no permanent Injuries. b. [j The claimant has not recovered completely from the effects of the injuries described in item 6. and the following injuries from which the claimant has not recovered are temporary (describe the remaining injuries and symptoms): [::] Continued on Attachment 8b. c. E] The claimant has not recovered completely from the effects of the Injuries described in item 6, and the following injuries from which the claimant has not recovered are permanent (describe the permanent injuries and symptoms): [:j Continued on Attachment 8c. MC-350 (Rev, January 1, 2021] Page 2 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION 0F PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 CASE NAME: Elllott Peter Gordon, a minor v. Sanh Cuong Lam, et al CASE NUMBER: 200V36747O 9. Petitloner has made a careful and diligent inquiry and investigation into the facts and circumstances of the incident or accident in which the claimant was injured; the responsibility for the incident or accident; and the nature, extent, and seriousness of the claimant's Injuries. Petitioner understands that If the compromise proposed in this petition is approved by the court and consummated, the claimant will never be able to recover any more compensation from the settling defendants named below even if the claimant's injuries turn out to be more serious than they now appear. 10. Amount and terms of settlement To settle the claim in 3a or 3b, the defendants named below have offered to pay the following amounts to the claimant: a. The total amount offered by all defendants named below is (specify): $ 200,000.00 b. The defendants and amounts offered by each are as follows (specify): Soph, |nc., dba Papa John's Pizza, a corporaiton Defendants (names) Amounts 200,000.00 @wwm D Defendants and amounts offered continued on Attachment 10b. c. The terms of settlement are as follows. (/f the settlement is to be paid in installments, both the total amount and the present value of the settlement must be included.) See Attachment 100 (Settlement Agreement). Continued on Attachment 100. 11. Settlement payments to others a. No defendant named in item 10b has offered to pay money to any person or persons other than the claimant to settle claims arising out of the same incident or accident that resulted in the claimant's injury. b. E To setfle claims arising out ofthe same incident or accident that resulted in the claimant's injury, one or more defendants (1) (2) (3) (4) (5) (6) named in item 10b have also offered to pay money to a person or persons other than ciaimant. The total amount offered by all defendants to others is (specify): $ 0.00 Petitioner does not have E] has a claim against the recovery of the claimant (other than for reimbursement offees or expenses paid by petitioner and listed under item 14). (/fyou answered "has, " explain in Attachment 1 1b(2) the circumstances and the effect your claim has on the proposed compromise of the claim described in this petition.) Petitioner is not E is a plaintiff in the same action with the claimant. (/fyou answered "/‘s, ” explain in Attachment 1 1b(3) the circumstances and the effect your claim and its disposition has on the proposed compromise of the claim or action described in this petition) D Petitioner would receive money under the proposed settlement. The settlement payments are to be apportioned and distributed as follows: Other plaintiffs or claimants (names) Amounts 0.00 0.00 0.00 0.00 wwww E] Additional plaintiffs or claimants and amounts are listed on Attachment 11b(5)‘ Reasons for the apportionment of the settlement payments between the claimant and each other plaintiff or claimant named above are specified in Attachment 11b(6). M0350 [Rev. January 1, 2021] Page 3 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 CASE NAME: Elliott Peter Gordon, a mlnor v. Sanh Cuong Lam. et al CASE NUMBER: ZOCV367470 12. The claimant's medical expenses-Including medical expenses paid by petltioner, Medicare, Medi-Cal, and private insurers-to be paid or reimbursed from proceeds of settlement orjudgment a. Totals (1) Total medical expenses before any reductions: $ 26,939.40 (2) Total medical expenses paid (include payments by private insurance, Medi-Cal, or Medicare): ($ 0.00) (3) Total of negotiated, contractual, or statutory reductions. if any: ($ 47,778.30) (4) Total medicaI expenses to be paid or reimbursed from the proceeds: $ 9,161 .10 (5) Total amount ofstatutory or contractual liens, if any: $ 0‘00 b. Medical expenses were paid and are to be reimbursed from the proceeds as follows: 1) E Paid by petitioner in the amount of: $ 0.00 ) (E3 Paid by private heafth insurance or a self-funded plan under: )E] An Employee Retirement Income Security Act (ERISA) insured plan. () E An ERISA self-funded plan. (c) E A Non-ERISA insured plan. (d) E A Non-ERISA self-funded plan. (e) Amount paid by plan: $ 0.00 (f) Amount of reimbursement to the plan from the proceeds of the settlement or judgment: (i) [j No reimbursement is requested by the plan. (ii) [j Reimbursement is to be made to the plan, and: A) E There is a contractual reduction of: ($ 0.00). (B) [:3 There is a negotiated reduction of: ($ 0.00), (C) E] No reduction has been agreed to, for a total reimbursement to the plan, in full satisfaction of its lien rights, in the amount of: $ 0.00 (3) E Paid by Medicare in the amount of: $ 0.00 less the statutory reduction in the amount of: ($ 0.00) for a total reimbursement to Medicare in the amount of: $ 0.00 (Attach a copy of the final Medicare demand letter or letter agreement as Attachment 1 2b(3).) (4) [j Paid by Medi-Cal in the amount of: $ 0.00 a) [:j Notice ofthis claim or action has been given to the Director of Health Care Services. (Weh‘. & Inst. Code, § 14124. 73. ) A copy ofthe notice and proof of delivery:D is attached [:3 was filed in this case on (date): b): Notice of this claim or action has not been given to the Director of Health Care Services (Explain Why notice has not been given in Attachment 12b(4)(b).) ) E In full satisfaction of its Hen rights, Medi-Cal has agreed to accept reimbursement in the amount of: $ 0.00 (Attach a copy of the final Medi-Cal demand letter or letter agreement as Attachment 12b(4)(c).) ) [:3 Petitioner is entitled to a reduction ofthe Medi-Cal lien under Welfare and Institutions Code section 14124.76 and (check one): ) D ls filing a motion seeking a reduction ofthe lien concurrently with this petition. (ii)D Requests that the court reservejurisdiction over this issue. The amount of the lien in dispute is: $0.00 (5) (a) (i) E There are no statutory or contractual liens for payment of claimant‘s medical expenses. (Ii) There are one or more statutory or contractual liens of medical service providers for payment of c|aimant's medical expenses. The total amount clalmed under these liens is: $26,939.40 In full satisfaction of their lien claims, the Ilenholders have agreed to accept the sum of: $ 9,161 ‘10 (Provide requested information for each lienho/der and other specified medical service providers on next page.) M04350 [Rev, January 1, 2021] PETITION FOR APPROVAL 0F COMPROMISE 0F CLAIM WM” 0R ACTION 0R DISPOSITION 0F PROCEEDS 0F JUDGMENT FOR MINOR 0R PERSON WITH A DISABILITY MC-350 CASE NAME: Elllott Peter Gordon. a minor v. Sanh Cuong Lam, et al CASE NUMBER: 200V367470 12. Claimant's medical expenses (continued) b. (5) (b) The name of each medica! Service provider that furnished care and treatment to claimant and (1) has a lien for all or any part of the charges or (2) was paid (or wiil be paid from the proceeds) by petitioner, for which payment petitioner requests reimbursement; the amounts charged and paid; the amount of negotiated reductions of charges, if any; and the amount to be paid from the proceeds of the settlement orjudgment to each provider are as follows: (i) (A) (B) EV .n Vv (ii) AA AAAA m vv 35953 (m) AA AAAA W) vv O ) D) E) ( ( ( (F) Provider (name): Mind and Body Pain Clinic Address: 2516 Samaritan Dr., Suite M, SanJose, CA 95124 Amount charged: Amount paid (whether or not by insurance): Negotiated reduction, if any: Amount to be paid from proceeds of settlement orjudgment: Provider (name): Simon Med Imaging/Health Diagnostics Address:- P. O. Box 207465, Dallas, TX 75320 Amount charged: Amount paid (whether or not by insurance): Negotiated reduction, if any: Amount to be paid from proceeds of settlement orjudgment: Provider (name): El Camino Health Address: 2500 Grand Road, Mountain View, CA 94040 Amount charged: Amount paid (whether or not by insurance): Negotiated reduction, if any: Amount to be paid from proceeds of settlement orjudgment: $ 5,100.00 ($ 0-00) <$ 2.60000) $ 2.50000 $ 7,195.00 ($ 0‘00) ($ -4,195.00) $ 3,000.00 $ 14.64440 ($ 0‘00) ($ 40,983.30)LumE Continued on Attachment 12b(5). (Provide Information about additional providers in the above format, including providers paid or to be paid by petitioner, for Which payment reimbursement is requested in item 12b(1), above. You may use form MC-350(A-12b(5)) for this purpose.) 13. Claimant's attorney's fees and all other expenses (except for medical expenses), including expenses advanced by claimant's attorney or pald or incurred by petitioner, to be reimbursed from proceeds of settlement orjudgment a. Total amount of attorney's fees for which court approval is requested: (If fees are requested, attach as Attachment 13a a declaration from the attorney explaining the basis for the request, including a discussion of applicable factors listed in rule 7.955(1)) of the Cal. Rules of Court. Respond to item 1 7a(2) on page 7 and attach a copy of any written attorney fee agreement as Attachment 17a.) b. The following additional items of expense (other than medical expenses) have been incurred or paid, are reasonable. resulted from the incident or accident, and should be paid out of claimant‘s share of the proceeds of the settlement orjudgment: $ 50,000.00 Items Payees (names) Amounts See Attachment 13b. $ $ $ $ $ $ $ $ Continued on Attachment 13bA Total: $ 5,890.20 MC-350(Rev. January 1. 2021) Page 6 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 CASE NAME: Elliott Peter Gordon. a mlnor v. Sanh Cuong Lam, et al CASE NUMBER: 2OCV367470 ‘14. Relmbursement of fees and expenses paid by petitioner a. Petitioner has paid none of the fees or expenses listed in items 12 and 13 for which reimbursement is requested. b. Petitioner has paid (or become obligated to pay) the following total amounts of the claimant's fees and expenses for which reimbursement is requested. (1) Medicalexpenses listed in item 12: $ 9,161.10 (2) Attorney's fees included in the total fee amount shown in item 13a: $ 50;OO0.00 (3) Otherexpenses included in thetotal shown in item 13b: $ 5,890.20 ‘ Total: $ 65,051.30 (Attach proofs of the fees and expenses incurred and the payments made or obligations (o pay incurred, e.g., bills orinvoices, canceled checks, credit card statements, explanations of benefits from insurers, etc.) 15. Net balance of proceeds for the claimant The balance of the proceeds of the proposed settlement or judgment remaining for the ciaimant after payment of all requested fees and expenses is: $ 134,948.70 16. Summary a. Gross amount of proceeds of settlement or judgment: $ 200,000.00 b. Medical expenses to be paid from proceeds of settlement orjudgment: $ 9,161.10 c. Attorney‘s fees to be paid from proceeds of settlement orjudgment: $ 50,000.00 d. Expenses (other than medical) to be paid from proceeds of settlement or judgment: $ 5,890.20 e, Total fees and expenses to be paid from proceeds of settlement or judgment (add (b), (c), and (d)): ($ 65,051.80) f. Balance of proceeds of settlement or judgment available for claimant after payment of all fees and expenses (subtract (e) from (8)): $ 134,948.70 MC-35O [Rev. January 1. 2021] Page 8 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 CASE NAME: Elliott Peter Gordon. a minor v. Sanh Cuong Lam, et al CASE NUMBER: 200V36747O 17. Information about attorney representing or assisting petitioner a. (1) E Petitioner has not been represented or assisted by an attorney in preparing this petition or in any other way with respect to the claim asserted. (Skip the rest ofitem 17 and go to item 18.) ) Petitioner has been represented or assisted by an attorney in preparing this petition or with respect to the claim asserted. Pe’mioner and the attorney E do not n do have an agreement for services provided in connection with the c‘aim giving rise to this petition. (Ifyou answered ”do, " attach a copy of the agreement as Attachment 1 7a, and complete items 1 7b-1 7f.) b. ‘The attorney who has represented or assisted petitioner is (name): Arash Nematollahi (1) State Bar number: 225306 (2) Law firm: Adamson Ahdoot LLP (3) Address: 1150 S. Robertson Blvd., Los Angeles, CA 90035 (4) Tetephone number:(310)888-0024 (5) Email:arash@aa-llp.com c. The attorney has not [j has received attorney's fees or other compensation in addition to that requested in this petition for services provided in connection with the claim giving rise to this petition. (Ifyou answered "has, " identify the person who paid the fees or other compensation, the amounts paid, and the dates ofpayment): From whom (names) Amounts Dates Wfiwww E Continued on Attachment 17c. d. The attorney did not E] did become concerned with this matter, directly 0r indirectly, at the instance of a party against whom the claim is asserted or a party's insurance carrier. (Ifyou answered "did, " explain the cirCL/Imstances in Attachment 17d.) e. The attorney is not E is representing or empmyed by any other party or any insurance carrier involved in the matter. (If you answered “is, " identify the pan‘y or carrier and explain the relationship in Attachment 17a.) f. The attorney does not [j does expect to receive attorney's fees or other compensation in addition to that requested in this petition for servlces provided in connection with the claim giving rise to this petitlon. (If you answered ”does," identify the person who will pay the fees or other compensation, the amounts to be paid, and the expected dates ofpayment): From whom (names) Amounts Exgected dates $$$$$ E Continued on Attachment 17f. M0350 (Rev. January 1, 2021] Page 7 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 CASE NAME: Elllott Peter Gordon, a minor v. Sanh Cuong Lam, et al CASE NUMBER: ZOCV367470 18. Disposition of balance for clalmant (check either a or b, then check each option requested and enter amount(s)): a. D There is a guardianshlp of the estate of the minor or a conservatorship of the estate of the adult person wlth a disability filed in (name of court): Case no.1 (1) E Petitioner requests that $ of the proceeds In money or other property be paid or delivered to the guardian or the conservator of the estate. The money or other property is specified in Attachment 18a(1). (2) C] Petitioner is the guardian or conservator ofthe estate of the minor or the adult person with a disability. Petitioner requests authority to deposit or invest $ of the money or other property to be paid or delivered under 18a(1) in insured accounts in one or more financial institutions in this state or with a trust company, subject to withdrawal only on authorization ofthe court. The money or other property and the name. branch, and address of each financia! institution or trust company are specified in Attachment 183(2). (3) E Petitioner proposes that all or a portion ofthe proceeds not become part of the guardianship or conservatorship estate. Petitioner requests authority to deposit or transfer these proceeds as follows (check a/l that apply): (a) [j $ to be deposited in insured accounts in one or more financial institutions in this state. subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are specified in Attachment 18a(3)(a). (b) E: $ to be invested in a single~premium deferred annuity, subject to withdrawal only on authorization of the court The terms and conditions of the annuity are specified in Attachment 18a(3)(b). (c) E $ to be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the property to be transferred are specified in Attachment 18a(3)(c). (d) E $ to be transferred to the trustee of a trust that is either created by or approved in the order approving the settlement orjudgment for the minor. This trust is revocable when the minor reaches 18 years of age and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests. The terms of the proposed trust and the property to be transferred are specified in Attachment 18a(3) (d). E] A copy of the (proposed) judgment is attached as Attachment 3c. (e) E3 $ to be transferred to the trustee of a special needs trust under Probate Code section 3604 for the benefit ofthe minor or the adult person with a disability. The terms of the proposed special needs trust and the property to be transferred are specified in Attachment 183(3)(e). b. There is no guardianship or conservatorship of the estate ofthe claimant. Petitioner requests that the court order the disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested): (1) [j A guardian of the estate of the minor or a conservator of the estate of the adult person with a disability be appointed and $ of money or other property be paid or delivered to the person so appointed. The money or other property are specified in Attachment 18b(1)A (2) $134,948.70 be deposited in insured accounts in one or more financial institutions in this state, subject to withdrawal only on authorization of the court. The name, branch, and address of each depository are specified in Attachment 18b(2). (3) E $ be invested in a single-premium deferred annuity, subject to withdrawal only on authorization of the court. The terms and conditions of the annuity are specified in Attachment 18b(3). (4) E $ be paid or transferred to the trustee of a special needs trust established under Probate Code section 3604 for the benefit ofthe minor or the adult person with a disability. The terms of the proposed special needs trust and the money or other property to be paid or transferred are specified in Attachment 18b(4). (5) [j $ be paid or delivered to a parent of the minor, without bond, on the terms and under the conditions specified in Probate Code sections 3401-3402. The name and address of the parent and the money or other property to be delivered are specified in Attachment 18b(5). (Value of minor's entire estate, including the money or property to be delivered, must not exceed $5,000.) (6) [j $ be transferred to a custodian for the benefit of the minor under the California Uniform Transfers to Minors Act. The name and address of the proposed custodian and the money or other property to be transferred are specified in Attachment 18b(6)A M0350 [Rev. January 1. 2021] Page 8 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY MC-350 CASE NAME: Elliott Peter Gordon, a minor v. Sanh Cuong Lam, et a1 CASE NUMBER: 200V86747O 18. Disposition of balance of proceeds of settlement orjudgment (continued) b. E There is no guardianship or conservatorship ofthe estate of the claimant. Petitioner requests that the court order the disposition of the balance of the proceeds of the settlement or judgment as follows (check each option requested): (7) [:3 $ be transferred to the trustee of a trust that is either created by or approved in the order approving the settlement or judgment for the minor. This trust is revocable when the minor reaches 18 years of age, and contains all other terms and conditions determined to be necessary by the court to protect the minor's interests. The terms of the proposed trust and the money or other property to be transferred are specified in Attachment 18b(7), [j A copy of the (proposed) judgment is attached as Attachment 30. (8) E $ of money be held on any conditions the court determines are in the best interest of the minor or the adult person with a disability. The proposed conditions are specified on Attachment 18b(8). (Amountmust not exceed $20,000.) (9) E $ of property other than money be held on the conditions that the court determines to be in the best interest ofthe minor or adult person with a disabifity. The proposed conditions and the property are specified in Attachment 18b(9). (10)E $ be deposited with the county treasurer of the County of (name): The deposit is authorized under and subject to the conditions specified in Probate Code section 361 1(h). (1 1)E $ be paid or delivered to the adult person with a disability. The money or other property is specified in Attachment 18b(11). 19. [:3 Statutory liens for special needs trust Petitioner requests an order for payment of funds to a special needs trust (explain how statutory liens under Probate Code section 3604, if any, will be satisfied): E Continued on Attachment 19. 20.: Additional orders Petitioner requests the following additional orders (specify and explain): E Continued on Attachment 20. MC-350 [Rev. January 1, 2021] Page 9 of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY __ M0350 CASE NAME: Ellloll Peter Gordon. a minor v. Sanh Cuong Lam. el al - CASE NUMBER: ZOCV367470 21.: l, the clalmant named In Item 2. consent to the order orJudgment requested In thls petltlon. (Required If (he claimant is an adu/l wllh a disability who has (he capaclly, under Probale Code secllon 812, (o consenl (o (he order orjudgmenl and does no! have a conservalor of (he eslale. (See Prob. Code, § 3613.)) Date: (TYPE OR PRINT NAME OF CLAIMANT) (SIGNATURE OF CLAIMANT) 22. Petltloner recommends approval of the proposed compromlse, settlement, or dlsposltlon ofJudgment proceeds to the court as fair. reasonable. and In the best Interest of the clalmant. Petltloner requests that the court approve thls compromlse. settlement, or dlsposltlon and make any other orders that are Just and reasonable. 23. Number of pages attached: 127 Pages (total of 137) Date: March1. 2021 Arash Nematollahl } (TYPE 0R PRINT NAME 0F ATTORNEY) (SIGNATURE 0F ATTORNEY) I declare under penalty of perjury under the IaWS of the State of Callfornla that the foregolng Informatlon on thls form and al! attachments Is true and correct. Date: March .2021 > Tracy Gordon (TYPE 0R PRINT NAME 0F PETITIONER) (SIGNATURE 0F PETITIONER) Tracy Gordon Signature: W’flfiqgym Tracy co‘rfion (Ma.- 3, 2021 15:19 EST) Email: tracycgordon@gmall.com MC-350 [Rev. January 1. 2021) Page 1o of 10 PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY IN RE ELLIOTT PETER GORDON CASE NO.: 20CV36747O MC-350 ATTACHMENT 4 PERSONS INVOLVED 1. ELLIOTT PETER GORDON (Plaintiff/Claimant); and 2. SANH CUONG LAM (Defendant) 3. SOPH, INC., dba PAPA JOHN’S PIZZA, a corporation (Defendant) 4. PAPA JOHN’S USA, INC., dba PJ USA, INC., a corporation (Defendant) IN RE ELLIOTT PETER GORDON CASE NO.: 20CV36747O MC-350 ATTACHMENT 8 DOCTOR’S REPORTS 06/22/2020 12:11PM FAX 14086773101 MIND 8c BODY PAIN CLINIC @0002/0020 Consult Note for Gordon, Elliot Page 1 0f 5 Harpreet Singh, MD Mind and Body Pain Clinic 2516 Samaritan Drive, Ste M, San Jose, CA 95124, 6010 Hellyer Avenue, Ste 150, San Jose, CA 95138 Tel: (408)356-5900 Fax: (408)356-5902 0ct24, 2019 CONSULTATION NOTE Dr. Ding Li PCP Gordon, Ellirotr V V 460 Franklin St Mountain View, CA 94041 Tel: Fax: QogawFabgfiggoi§§§wa1eM M w N Thank you for referring your patient Gordon, Elliot to our office for consultation/treatment. Below are some relevant details ofthe office note which is a part of our electronic medical record for your patient. Chief Complaint: o skin abrasion on face, elbow, and shoulder Hx of Present Illness: Thank you for referring this patient to Mind and Body Pain Clinic for management of Neurological problem. This is a 14 year old male with no PMHX who presents to Clinic for injuries after MVA on 9/13/19. He was riding his bike at an intersection between California St. and Franklin when he was hit by a oar. The impact caused him to fall onto the road and he suffered injuries to his face, right arm, and left knee. He was wearing a helmet and denies any LOC. He was taken to the ER at El Camino Hospital where multiple imaging studies were done. They were negative and he was discharged home later that night He then followed up with his pediatrician within the next 3-4 days He missed about 2 weeks of school due to the accident and is now catching up. He is back to his regular routine of school and aftersohool activities. He is also back to riding his bike with safety gear on. In terms of symptoms, he states his pain overall has improved since the incident. He suffered abrasions to his face, right arm, and left knee. These are healing and he continues to apply vitamin E oil to avoid scarring. He also has headaches about once per week that are generalized to the entire head. He feels dizzy sometimes when he moves abruptly upon waking up. Headaches usually occur between his 3rd and 4th period classes at school towards the morning and he feels nauseated and has to vomit. He feels better after vomiting. He denies any activities that may trigger/aggravate headache. He denies any light or sound sensitivity. He denies any vision or hearing Changes. o Location: Head ° Shoulder, right ° Knee, left o Quality: Aching ° Dull ° Throbbing ° Sore o Severity: |cou|d live with a level of pain at 3/10 ° | would rate my pain today as 0/10 ° | would rate my pain when under control as 0/10 ° lwould rate my worst pain as 10/10 o Duration: since 9/1 3/19 Past Medical History: N/A 11ttpzs’x’76. 1 02. 1 3 0.9: 1000fs 61Vletr'Download‘hask:getfile&docid:1 5 720 71 5 44273&secure:. .. 6m’22fi2020 06/22/2020 12:11PM FAX 14086773101 MIND 8c BODY PAIN CLINIC .0003/0020 Consult Note for Gordon, Elliot Page 2 0f 5 Past Surgical History: Nothing on record Known Allergies: Name Family History: (-) Diabetes, (-) Stroke, (-) Hypertension, (-) Heart Disease, (-) Cancer, (-) Asthma, (-) Arthritis, (-) Osteoporosis, (-) Anemia, (-) Migraine, (-) Alzheimers, (-) Epilepsy, (-) Glaucoma Social History: (-) Alcohol Use, (-) Tobacco Use, (-) Drugs Use, (-) Marital stat, (-) Living with Legal Issues: Legal issues: Personal injury (not at work) Psychiatric treatment: Psychiatric: None Suicide: None Master Medication List: Nothing on record Master Problem List: - F0781 Postconcussional syndrome (Active) - R110 Nausea (Active) o R1110 Vomiting, unspecified (Active) o 880.812A Abrasion, left lowerleg (Active) v 850.311A Abrasion ofrightelbovv (Active) o 800‘91XA Abrasion of unspecified partofhead (Active) o 644.309 Post-traumatio headache, unspecified, not intractable (Active) - F4310 Post-traumatic stress disorder, unspecified (Active) History of Present Illness continued: Pain Onset: Motor vehicle accident Timing of pain: Occasionally (less than 30% of time Pain: Interferes with recreation Painful to: go to school at times Head Face Neck pain HPI contin ued: Pain Onset: Due to motor vehicle accident Timing of Pain: Occasionally (< 30% of the time) Pain worst: in the afternoon Worst symptom: headache Pain improves: with rest Pain worsens: with activity Pain treatments: Bed rest: Provided excellent relief Head Face Neck Pain Location and st: Head Pain is: generalized to entire head Headache: Does not occur frequently Diagnostic Studies: CT: head, sinuses/maxilla X-rays: R shoulder, L knee Notes: X-ray Right Shoulder Impression (9/1 3/1 9): No gross fracture or subluxation. X-ray Left Knee http://76. 102. 1 30.9: 1 000/5 ervlet,r"D0wn10ad?tasngetfilegcdocid:1 572071 544273&secure:. .. 6/22/2020 06/22/2020 12:12PM FAX 14086773101 MIND 8a BODY PAIN CLINIC .0004/0020 Consult Note for Gordon, Elliot Page 3 of 5 Impression (9/1 3/1 9): No gross fracture. CT SinuseslMaxilla Without Contrast Impression (9/1 3/1 9): No evidence of an acute fracture. CT Head Without IV Contrast Impression (9/1 3/1 9): No acute intracranial hemorrhage or large vessel infarct. Prior Consultations for current problem: Other: ER team at El Camino Hosp. Review of Systems: ~ General (-) Fevers, (-) Sweats, (-) Appetite loss, (-) Fatigue, (-) Weight change, (-) Insomnia o fig (-) Vision loss, (-) Double vision, (-) Blurred vision, (-) Eye disease, (-) Glasses or contacts o EN MT (-) Ringing in the ears, (-) Decreased hearing, (-) Nosebleeds, (-) Sinus problems, (-) Mouth sores, (-) Swollen glands in head or neck o Cardiovascular (-) Chest pain or discomfort, (-) Palpitations, (-) Swelling of hands or feet, (-) Heart murmur, (-) Hearttrouble, (-) Varicose veins o Resgiratog (-) Cough, (-) Shortness of breath, (-) Wheezing - Gastrointestinal (-) Nausea, (-) Abdominal pain, (-) Diarrhea, (-) Constipation, (-) Bloody stools - Musculoskeletal (-) Joint pain, (-) Joint stiffness or swelling, (-) Muscle cramps, (-) Muscle weakness, (-) Muscle aches, (-) Difficulty walking - fl (-) Rash (-)Changes in hair or nails (-)Changes in color ofskin o Neurolo ic (+‘g; mil” :r ea, (-) Poor balance m TWm. :nrg, (-) Faints or blackouts, (-) Seizures, (-) Tremors, (-) Memory loss (-) Dizzy or light headed (-) Weakness or paralysis, (-) Head injury o Psychiatric (-) Nervousness, (-) Depression, (-) Halucinations o Endocrine (-) Heat or cold intolerance, (-) Excessive thirst or hunger, (-) Hormone or glandular problems o Hematologic-Lymphatic (-) Bleeding, (-) Anemia, (-) Recurrent infections o Genitourinam (-) Frequent urination, (-) Blood in Urine, (-) Urinary Urgency, (-) Burning on urination, (-) Loss of bladder control or incontinence, (-) Sexual difficulty, (-) Kidney stones Physical Examination: - Vitals Weight: 107 lbs - Constitutional - General Appearance: NAD, well nourished & hydrated ° BE - Conjunctivae-Lids: Conjunctivae clear, no ptosis o ENMT - External Ears-Nose: No bulging, lesions or trauma - Hearing Assessment: No apparent hearing impairment o Resgiratog - Respiratory Effort: No distress, normal breathing - Lungs Auscultation: CTAB, normal respiratory sounds - Cardiovascular - Heart Auscultation: RRR, normal S‘l 82, no murmurs - Musculoskeletal - Gait-Station: Stable, coordinated & smooth - Digits-Nails: No clubbing, infection or cyanosis - Joints-Bones-Muscles: No abnormality detected o s_kin -‘~« 4“?” ”:rs ‘wé “t e: 5303?; (r: nwrnrwk F*Wee a .z {N:(W: - Skin Palpation: No induration nodules ortightness o Neurologio - Cranial Nerves: No cranial nerves deficits noted - DTR Exam: No hyporeflexia or hyperreflexia - Sensory Exam: No sensory or motor deficits noted o Psychiatric - Judgment-Insight: Judgment intact, insight present - Orientation TPP: Oriented to time, place & person - Recent Remote Memory: No memory impairment noted http://76. 102. 1 30.9: 1 000/servlet/Download?taskIgefl‘ile&dooid:1 572071 544273&secure:. .. 6/22/2020 06/22/2020 12:12PM FAX 14086773101 MIND 8c BODY PAIN CLINIC .0005/0020 Consult Note for Gordon, Elliot Page 4 0f 5 - Mood-Affect: No mood disorders, calm affect Notes: MSE: Appearance: Normal gait, normal posture, well dressed, well groomed Behavior: Normal mannerisms, expression, and eye contact. Able to follow commands. Attitude: Cooperative. LOC: Alert. Orientation: Oriented to person, place, time. SpeeCh/language: Normal speech rhythm and rate. Mood: Pleasant, no mood disorders noted. Affect: Normal affect. Thought processes: Logical, organized, linear, goaI-directed. Thought content: Denies rumination. Suicidality/homioidality: Denies/denies. Insight/judgement: Judgement/insight intact Attention: Normal attention span Memory: No issues noted. Intellectual: Fluent, consistent with education. Abstraction ability normal, MMSE on 10/24/19 30/30 Cranial Exam: Cranial nerves ll-Xll intact PERRLA Visual fields full to confrontation, extraocular movements intact, smooth pursuits, intact vertical/horizontal saccades Facial sensation, strength symmetrical Tongue, palate midline Hearing intact b/l Shoulder shrug symmetric Finger tapping normal Cerebellar exam normal Motor Assessment: 5/5 in bilateral upper and lower extremities Normal tone in upper and lower extremities No tremors Upper and Lower extremity reflexes: Brachioradialis 2+ bilaterally Biceps 2+ bilaterally Triceps 2+ bilaterally Patella 2+ bilaterally Achilles 2+ bilaterally Babinski- Toes are downgoing on both sides Ankle Clonus- Is not present on either side Hoffmans absent Sensory Assessment: Sensation in bilateral upper and lower extremities is intact and symmetrical to light touch and pinprick. There is no allodynia or hyperalgesia Assessment/ Diagnosis: o F0781 Postconoussional syndrome o R110 Nausea o R1110 Vomiting, unspecified o 880.812A Abrasion, leftlowerleg o 850.311A Abrasion ofrightelbow o 800.91XA Abrasion of unspecified part of head o G44_309 Post-traumatic headache, unspecified, not intractable o F4310 Post-traumatio stress disorder, unspecified Plan Notes: o This is a 14 year old male with no PMHX had MVA on 9/13/19. He was riding his bike at an intersection between California St. and Franklin when he was hit by a oar. The impact caused him to fall onto the road and he suffered injuries to his face, right arm, and left knee He was wearing a helmet and denies any LOO. He was taken to the ER at El Camino Hospital where multiple imaging studies were done. They were negative and he was discharged home later that night. He then followed up with his pediatrician within the next 3-4 days. He missed about 2 weeks of school due to the accident and is now catching up. He is back to his regular routine of school and afterschool activities. He is also back to riding his bike with safety gear on. o In terms of symptoms, he states his pain overall has improved since the incident. He suffered abrasions to his face, right arm, and left knee. These are healing and he continues to apply vitamin E oil to avoid scarring He also has headaches about once per week that are generalized to the entire head. He feels dizzy sometimes when he moves abruptly upon waking up. Headaches usually occur between his 3rd and 4th period Classes at school towards the morning and he feels nauseated and has to vomit. He feels better after vomiting. He denies any activities that may trigger/aggravate headache. He denies any light or sound sensitivity He denies any vision or hearing changes He is worried/anxious about catching up in school work as he does not want to held back. o Imaging: X-ray right shoulder on DOI showed no gross fracture or subluxation. X-ray left knee on DOI showed no gross fracture. CT sinuses/maxilla on DOI showed no evidence of an acute fracture. CT head on DOI showed no acute intraoranial hemorrhage or large vessel infarct. o Upon initial physical examination, patient is alert, oriented x 3, very pleasant. Cranial nerves || ’? XII are normal. Cerebellar exam normal, no evidence of pronator drift. Hoffman’s is negative bilaterally. DTRS +2 llttp:«"f76. 1 02. 1 30.9: 1 0005's ervlet,r"D0wn10ad?task:getfile&docid:1 572071 5 44273&secure:. .. 6/22-"2020 06/22/2020 12:13PM FAX 14086773101 MIND 8c BODY PAIN CLINIC @0006/0020 Consult Note for Gordon. Elliot Page 5 0f5 in BUE and BLE. Motor strength 5/5. Full ROM in RUE and LLE. Noted With well healed abrasions to his right Cheek: right arm, and left knee. o MMSE on 10/24/19: 30/30 o Detailed past medical, surgical: allergies, social: family history were documented in patient's intake questionnaire and personally reviewed by me. o The patient will benefit from integrative pain management including appropriate procedures/injeotions, physical rehabilitation, and medication optimization to address the chronic pain issues. o Based upon the history and physical exam, patient appears to have post concussion symptoms. Will start with conservative treatment to help decrease pain and improve function. Patient will benefit from the following: o 1. Brain MRI in the future if symptoms persist or worsen o 2. Zofran 2 mg1 PO QD PRN for nausea o 3. May initiate Nomiptyline or Gabapentin if headaches persist/worsen o 4. May refer to CBT if patient experiences anxiety, depression, or any PTSD symptoms related to the Injury. o Antiepileptic and psychiatric meds - Patient warned that these may cause increased suicidality. Patient agrees to contact me if starts experiencing increased depression or suicidal ideation. | informed patient that antiepileptio meds may be teratogenic and should be stopped if pregnant. The patient verbalized understanding. o PHQ 9 score on 10/24/19 was 6. There is mild indication of depression. The patient was educated that Chronic pain is often associated with depression or depression symptoms and will need to be monitored. Psychological assessment included risk of addictive disorders. o Psychological testing done, including psychodiagnostic assessment of emotionality: personality: intellectual abilities and psychopathology per hour of the physicians time, including face to face time administering test to the patient and time spent interpreting this test result and preparing the report. Total time spent 32 minutes. o This note has been electronically signed off by the following providers: Shalla Ahmed, AGNP, and Harpreet Singh, MD, QME on 10/24/19. Followup: 3-4 weeks Again, thank you for allowing us to participate in the care of your patient. If you have questions or concerns about any related aspect of the care, please do not hesitate to contact us‘ Yours sincerely, [Cosigned Singh, Harpreet MD License A71 470] http : 76 1 02. 13 0 . 9: l0005sen‘let«Download?task:getfile& docid:1 5 720 71 5 442738; secure? .. 652232020 06/22/2020 12:14PM FAX 14086773101 MIND 8a BODY PAIN CLINIC .0007/0020 Encounter Note for Gordon, Elliot Page l 0f 5 Harpreet Singh, MD Mind and Body Pain Clinic 2516 Samaritan Drive, Ste M, San Jose, CA 95124, 6010 Hellyer Avenue, Ste 150, San Jose, CA 951 38 Tel: (408)356-5900 Fax: (408)356-5902 Encounter Note for Gordon, Elliot on Nov 21, 2019 DoB: Feb 08, 2005 Chief Complaint: o headache Hx of Present Illness: This patient is being seen in Mind and Body Pain Clinic for management of pain issues. Elliot has been having increased headaches and missing school. - Location: Head ° Shoulder, right ° Knee, left ' Quality: Aching ° Dull ° Throbbing ° Sore o Severity: | could live with a level of pain at 3/10 ° Iwould rate my pain today as 0/10 ° | would rate my pain when under control as 0/10 ° Iwould rate my worst pain as 10/10 o Duration: since 9/1 3/19 Past Medical History: N/A Past Surgical History: Nothing on record Known Allergies: Ns::<§";<-} Family History: (-) Diabetes, (-) Stroke, (-) Hypertension, (-) Heart Disease, (-) Cancer, (-) Asthma, (-) Arthritis, (-) Osteoporosis, (-) Anemia, (-) Migraine, (-) Alzheimers, (-) Epilepsy, (-) Glaucoma Social History: (-) Alcohol Use, (-) Tobacco Use, (-) Drugs Use, (-) Marital stat, (-) Living with Legal Issues: Legal issues: Personal injury (not at work) Psychiatric treatment: Psychiatric: None Suicide: None Master Medication List: o Notriptyline 10 mg (1 tab po qHS) Active Master Problem List: o F0781 Postconcussionalsyndrome o R110 Nausea R1110 Vomiting, unspecified 880.812A Abrasion, left lower leg 850.311A Abrasion of right elbow 800.91XA Abrasion of unspecified part of head 644.309 Post-traumatic headache, unspecified, not intractable http://76. 102. 1 30.9: 1 000/servlet/Download?task=getfile&docid=l 574497439345&secure=. .. 6/22/2020 06/22/2020 12:14PM FAX 14086773101 MIND 8c BODY PAIN CLINIC .0008/0020 Encounter Note for Gordon, Elliot Page 2 0f 5 - F4310 Post-traumatic stress disorder, unspecified History of Present Illness continued: Pain Onset: Motor vehicle accident Timing of pain: Occasionally (less than 30% of time Pain: Interferes with recreation Painful to: go to school at times Head Face Neck pain HPI continued: Pain Onset: Due to motor vehicle accident Timing of Pain: Occasionally (< 30% of the time) Pain worst: in the afternoon Worst symptom: headache Pain improves: with rest Pain worsens: with activity Pain treatments: Bed rest: Provided excellent relief Head Face Neck Pain Location and st: Head Pain is: generalized to entire head Headache: Does not occur frequently Diagnostic Studies: CT: head, sinuses/maxilla X-rays: R shoulder, L knee Notes: X-ray Right Shoulder Impression (9/1 3/1 9): No gross fracture or subluxation. X-ray Left Knee Impression (9/1 3/1 9): No gross fracture. CT Sinuses/Maxilla Without Contrast Impression (9/1 3/1 9): No evidence of an acute fracture. CT Head Without IV Contrast Impression (9/1 3/1 9): No acute intracranial hemorrhage or large vessel infarct Prior Consultations for current problem: Other: ER team at El Camino Hosp. Review of Systems: o General (-) Fevers, (-) Sweats, (-) Appetite loss, (-) Fatigue, (-) Weightchange, (-) Insomnia o fig (-) Vision loss, (-) Double vision, (-) Blurred vision, (-) Eye disease, (-) Glasses or contacts o ENMT (-) Ringing in the ears, (-) Decreased hearing, (-) Nosebleeds, (-) Sinus problems, (-) Mouth sores, (-) Swollen glands in head or neck o Cardiovascular (-) Chest pain or discomfort, (-) Palpitations, (-) Swelling of hands or feet, (-) Heart murmur, (-) Heart trouble, (-) Varicose veins o Resgiratom (-) Cough, (-) Shortness of breath, (-) Wheezing o Gastrointestinal (-) Nausea, (-) Abdominal pain, (-) Diarrhea, (-) Constipation, (-) Bloody stools o Musculoskeletal (-) Joint pain, (-) Joint stiffness or swelling, (-) Muscle cramps, (-) Muscle weakness, (-) Muscle aches (- ) Difficulty walking o m (-) Rash (-)Changes in hair or nails (-)Changes in color of skin o Neurologio g - . (-) Poor balance 3::- (-)Faints or blackouts (-)Seizures, (-) Tremors, (-) Memory loss (-) Dizzy or light headed (- ) Weakness or paralysis (- ) Head injury o Psychiatric (-) Nervousness, (-) Depression, (-) Haluoinations o Endocrine (-) Heat or cold intolerance, (-) Excessive thirst or hunger, (-) Hormone or glandular problems o Hematologio-Lymghatio (-) Bleeding, (-) Anemia, (-) Recurrent infections o Genitourinay (-) Frequent urination, (-) Blood in Urine, (-) Urinary Urgency, (-) Burning on urination, (-) Loss of bladder control or incontinence, (-) Sexual difficulty, (-) Kidney stones Physical Examination: o Vitals Weight: 107 lbs llttp:«"f76. 1 02. 1 30.9: 1 0005's ervlet,r"D0wn10ad?task:getfile&docid:1 574497439345&secure:. .. 6%‘22/2020 06/22/2020 12:15PM FAX 14086773101 MIND 8c BODY PAIN CLINIC @0009/0020 Encounter Note for Gordon, Elliot Page 3 0f 5 o Constitutional r General Appearance: NAD, well nourished & hydrated ° fig ‘ Conjunctivae-Lids: Conjunctivae Clear, no ptosis o ENMT - External Ears-Nose: No bulging, lesions ortrauma - Hearing Assessment: No apparent hearing impairment o Resgiratom r Respiratory Effort: No distress, normal breathing - Lungs Ausoultation: CTAB, normal respiratory sounds o Cardiovascular - Heart Auscultation: RRR, normal S1 82, no murmurs o Musouloskeletal ' Gait-Station: Stable, coordinated & smooth - Digits-Nails: No Clubbing, infection or cyanosis - Joints-Bones-Muscles: No abnormality detected o Skin r Skin Palpation: No induration, nodules or tightness o Neurologio - Cranial Nerves: No cranial nerves deficits noted - DTR Exam: No hyporeflexia or hyperreflexia - Sensory Exam: No sensory or motor deficits noted o Psychiatric r Judgment-lnsight: Judgment intact, insight present - Orientation TPP: Oriented to time, place & person ‘ Recent Remote Memory: No memory impairment noted - Mood-Affeot: No mood disorders, calm affect Notes: MSE: Appearance: Normal gait, normal posture, well dressed, well groomed. Behavior: Normal mannerisms, expression, and eye contact. Able to follow commands, Attitude: Cooperative. LOC: Alert. Orientation: Oriented to person, place, time. SpeeCh/language: Normal speech rhythm and rate. Mood: Pleasant, no mood disorders noted. Affect: Normal affect. Thought processes: Logical, organized, linear, goal-direoted. Thought content: Denies rumination. Suicidality/homioidality: Denies/denies. Insight/judgement: Judgement/insight intact Attention: Normal attention span. Memory: No issues noted. Intellectual: Fluent, consistent with education. Abstraction ability normal. MMSE on 10/24/19 30/30 Cranial Exam: Cranial nerves Il-Xll intact PERRLA Visual fields full to confrontation, extraocular movements intact, smooth pursuits, intact verticaI/horizontal saccades Facial sensation, strength symmetrical Tongue, palate midline Hearing intact b/l Shoulder shrug symmetric Finger tapping normal Cerebellar exam normal Motor Assessment: 5/5 in bilateral upper and lower extremities Normal tone in upper and lower extremities No tremors Upper and Lower extremity reflexes: Brachioradialis 2+ bilaterally Biceps 2+ bilaterally Triceps 2+ bilaterally Patella 2+ bilaterally Achilles 2+ bilaterally Babinski- Toes are downgoing on both sides Ankle olonus- Is not present on either side Hoffmans absent Sensory Assessment: Sensation in bilateral upper and lower extremities is intact and symmetrical to light touch and pinprick. There is no allodynia or hyperalgesia Assessment] Diagnosis: o F0781 Postconcussional syndrome o R110 Nausea ~ R1110 Vomiting, unspecified o 880‘812A Abrasion, leftlowerleg o 850‘311A Abrasion ofrightelbow o 800‘91XA Abrasion of unspecified part of head o (344.309 Post-traumatic headache, unspecified, not intractable o F4310 Post-traumatio stress disorder, unspecified httpzw'x’76. 1 02. 1 3 0.9: 1000’s ervletr'Download‘hask:getfile&docid:1 5 74497439345&secure:. .. 6m’22s’2020 06/22/2020 12:16PM FAX 14086773101 MIND 8c BODY PAIN CLINIC .0010/0020 Encounter Note for Gordon, Elliot Page 4 0f 5 Orders & Requisitions: MRI brain Prescription: Notriptyline 10 mg (1 tab po qHS) Plan Notes: o This is a 14 year old male with no PMHX had MVA on 9/13/19. He was riding his bike at an intersection between California St‘ and Franklin when he was hit by a car, The impact caused him to fall onto the road and he suffered injuries to his face, right arm, and left knee. He was wearing a helmet and denies any LOC. He was taken to the ER at El Camino Hospital where multiple imaging studies were done, They were negative and he was discharged home later that night. He then followed up with his pediatrician within the next 3-4 days. He missed about 2 weeks of school due to the accident and is now catching up. He is back to his regular routine of school and afterschool activities. He is also back to riding his bike with safety gear on. o In terms of symptoms, he states his pain overall has improved since the incident. He suffered abrasions to his face, right arm, and left knee. These are healing and he continues to apply vitamin E oil to avoid scarring. He also has headaches about once per week that are generalized to the entire head, He feels dizzy sometimes when he moves abruptly upon waking up. Headaches usually occur between his 3rd and 4th period classes at school towards the morning and he feels nauseated and has to vomit. He feels better after vomiting. He denies any activities that may trigger/aggravate headache. He denies any light or sound sensitivity. He denies any vision or hearing changes. He is worried/anxious about catching up in school work as he does not want to held back. o Imaging: X-ray right shoulder on DOI showed no gross fracture or subluxation. X-ray left knee on DOI showed no gross fracture. CT sinuses/maxilla on DOI showed no evidence of an acute fracture. CT head on DOI showed no acute intracranial hemorrhage or large vessel infarct. - Upon initial physical examination, patient is alert, oriented x 3, very pleasant. Cranial nerves || ?Xll are normal. Cerebellar exam normal, no evidence of pronator drift. Hoffman’s is negative bilaterally. DTRs +2 in BUE and BLE. Motor strength 5/5‘ Full ROM in RUE and LLE‘ Noted with well healed abrasionsto his right cheek, right arm, and left knee. o MMSE on 10/24/19: 30/30 o Detailed past medical, surgical, allergies, social, family history were documented in patient's intake questionnaire and personally reviewed by me. - The patient will benefit from integrative pain management including appropriate procedures/injections, physical rehabilitation, and medication optimization to address the chronic pain issues. o Based upon the history and physical exam, patient appears to have post concussion symptoms. Will start with conservative treatment to help decrease pain and improve function. Patient will benefitfrom the following: o 1‘ Brain MRI in the future ifsymptoms persist orvvorsen o 2. Zofran 2 mg ‘l PO QD PRN for nausea o 3. May initiate Nortriptyline or Gabapentin if headaches persist/worsen o 4. May refer to CBT if patient experiences anxiety, depression, or any PTSD symptoms related to the Injury‘ o 11/21/19 - Elliot is here for follow up with his father present during visit He is having increased headaches at this time. He states the headaches are constant and focused in the frontal lobe and radiates to the temples. He has nausea associated with the headache for which he is taking Zofran PRN with benefit. He notices that schoolwork/homework trigger the headache at times. Parents have been limiting digital screen time and ensuring he gets plenty of rest. However, he has been missing school due to the headache about 2-3 times per week. He has been struggling with keeping grades up and withdrew from honors classes. He also stopped playing sports after school for now‘ At this time, it is feasible to proceed with an MRI brain to thoroughly evaluate and initiate Nortriptyline 1O mg QHS to help manage the headache. He currently takes OTC Advil PRN for the pain. We anticipate with initiation of Nonriptyline, his headache frequency and intensity will be reduced allowing him to be more productive and attend school regularly, o Antiepileptic and psychiatric meds - Patient warned that these may cause increased suicidality. Patient agrees to contact me if starts experiencing increased depression or suicidal ideation. | informed patient that antiepileptic meds may be teratogenic and should be stopped if pregnant. The patient verbalized understanding. http://76. 102. 1 30.9: 1 000/5ervlet/Download?t3sngetfile&docid:1 574497439345&secure:. .. 6/22/2020 06/22/2020 12:16PM FAX 14086773101 MIND 8c BODY PAIN CLINIC .0011/0020 Encounter Note for Gordon, Elliot Page 5 0f 5 o PHQ 9 score on 10/24/19 was 6. There is mild indication of depression. The patient was educated that chronic pain is often associated with depression or depression symptoms and will need to be monitored. Psychological assessment included risk of addictive disorders. o Psychological testing done, including psychodiagnostic assessment of emotionality, personality, intellectual abilities and psychopathology per hour of the physicians time, including face to face time administering test to the patient and time spent interpreting this test result and preparing the report Total time spent 32 minutes. o This note has been electronically signed off by the following providers: Shalla Ahmed, AGNP, and Harpreet Singh, MD, QME on 11/22/19 Followup: 2 weeks Signed [Cosigned3 Singh, Harpreet MD License A71 470] Ahmed, Shalla AGPCNP License: 95003528 http://76. 102. 1 30.9: 1 000/5 ervlet,r"D0wn10ad?tasngetfilegcdocid:1 574497439345&secure:. .. 6/22/2020 06/22/2020 12:17PM FAX 14086773101 MIND 8a BODY PAIN CLINIC .0012/0020 Encounter Note for Gordon, Elliot Page l 0f 5 Harpreet Singh, MD Mind and Body Pain Clinic 2516 Samaritan Drive, Ste M, San Jose, CA 95124, 6010 Hellyer Avenue, Ste 150, San Jose, CA 951 38 Tel: (408)356-5900 Fax: (408)356-5902 Encounter Note for Gordon, Elliot on Jan 10, 2020 DoB: Feb 08, 2005 Chief Complaint: o headache Hx of Present Illness: This patient is being seen in Mind and Body Pain Clinic for management of pain issues. Patient presents for MRI Brain review. - Location: Head ° Shoulder, right ° Knee, left ' Quality: Aching ° Dull ° Throbbing ° Sore o Severity: | could live with a level of pain at 3/10 ° Iwould rate my pain today as 0/10 ° | would rate my pain when under control as 0/10 ° Iwould rate my worst pain as 10/10 o Duration: since 9/1 3/19 Past Medical History: N/A Past Surgical History: Nothing on record Known Allergies: Ns::<§";<-} Family History: (-) Diabetes, (-) Stroke, (-) Hypertension, (-) Heart Disease, (-) Cancer, (-) Asthma, (-) Arthritis, (-) Osteoporosis, (-) Anemia, (-) Migraine, (-) Alzheimers, (-) Epilepsy, (-) Glaucoma Social History: (-) Alcohol Use, (-) Tobacco Use, (-) Drugs Use, (-) Marital stat, (-) Living with Legal Issues: Legal issues: Personal injury (not at work) Psychiatric treatment: Psychiatric: None Suicide: None Master Medication List: o Notriptyline 10 mg (1 tab po qHS) Active Master Problem List: o F0781 Postconcussionalsyndrome o R110 Nausea R1110 Vomiting, unspecified 880.812A Abrasion, left lower leg 850.311A Abrasion of right elbow 800.91XA Abrasion of unspecified part of head 644.309 Post-traumatic headache, unspecified, not intractable http://76. 102. 1 30.9: 1 000/servlet/Download?task=getfile&docid=l 578722802737&secure=. .. 6/22/2020 06/22/2020 12:17PM FAX 14086773101 MIND 8c BODY PAIN CLINIC @0013/0020 Encounter Note for Gordon, Elliot Page 2 0f 5 o F4310 Post-traumatio stress disorder, unspecified History of Present Illness continued: Pain Onset: Motor vehicle accident Timing of pain: Occasionally (less than 30% of time Pain: Interferes with recreation Painful to: go to school at times Head Face Neck pain HPI continued: Pain Onset: Due to motor vehicle accident Timing of Pain: Occasionally (< 30% of the time) Pain worst: in the afternoon Worst symptom: headache Pain improves: with rest Pain worsens: with activity Pain treatments: Bed rest: Provided excellent relief Head Face Neck Pain Location and st: Head Pain is: generalized to entire head Headache: Does not occur frequently Diagnostic Studies: CT: head, sinuses/maxilla X-rays: R shoulder, L knee Notes: X-ray Right Shoulder Impression (9/1 3/1 9): No gross fracture or subluxation. X-ray Left Knee Impression (9/13/19): No gross fracture. CT Sinuses/Maxilla Without Contrast Impression (9/13/19): No evidence of an acute fracture CT Head Without |V Contrast Impression (9/1 3/19): No acute intraoranial hemorrhage or large vessel infarct. MRI Brain 1/3/20 Impression: 1. Examination of the bifrontal regions is limited due to magnetic susceptibility artifact, likely from dental hardware. 2. There are a few scattered predominantly subcortical white matter hyperintensities on T2 and FLAIR weighted imaging which are nonspecific. Given the patient's history, the differential diagnosis includes trauma/traumatic brain injury. Other etiologies such as demyelinating process and vasoulitis should be ruled out clinically. Axial FLAIR series 8, image 22. The arrows show bifrontal and left parietal subcortical white matter hyperintensities. 3. Neuroquantitative analysis demonstrates that there is no evidence for atrophy of the medial temporal lobes. Prior Consultations for current problem: Other: ER team at El Camino Hosp. Review of Systems: o General (-) Fevers, (-) Sweats, (-) Appetite loss, (-) Fatigue, (-) Weight Change, (-) Insomnia o fig (-) Vision loss, (-) Double vision, (-) Blurred vision, (-) Eye disease, (-) Glasses or contacts o ENMT (-) Ringing in the ears, (-) Decreased hearing, (-) Nosebleeds, (-) Sinus problems, (-) Mouth sores, (-) Swollen glands in head or neck o Cardiovascular (-) Chest pain or discomfort, (-) Palpitations, (-) Swelling of hands or feet, (-) Heart murmur, (-) Heart trouble, (-) Varicose veins ° Resgiratog (-) Cough, (-) Shofiness of breath, (-) Wheezing o Gastrointestinal (-) Nausea, (-) Abdominal pain, (-) Diarrhea, (-) Constipation, (-) Bloody stools o Musculoskeletal (-) Joint pain, (-) Joint stiffness or swelling, (-) Muscle cramps, (-) Muscle weakness, (-) Muscle aches, (-) Difficulty walking o w (-) Rash, (-) Changes in hair or nails, (-) Changes in color of skin o Neurologio .j ,. . (-) Poor balance, :-=-} (-) Faints or blackouts, (-) Seizures, (-) Tremors, (-) Memory loss, (-) Dizzy or light headed, (-) Weakness or paralysis, (-) Head injury o Psychiatric (-) Nervousness, (-) Depression, (-) Halucinations o Endocrine (-) Heat or cold intolerance, (-) Excessive thirst or hunger, (-) Hormone or glandular problems http : H.76 1 02. 1 3 0 . 9: 1000’s61Vlethownload‘hask:getfile&docid:1 5 78 72280273 7&secure:. .. 6w’22s’2020 06/22/2020 12:18PM FAX 14086773101 MIND 8c BODY PAIN CLINIC @0014/0020 Encounter Note for Gordon, Elliot Page 3 0f 5 o Hematologic-Lymghatio (-) Bleeding, (-) Anemia, (-) Recurrent infections o Genitourinam (-) Frequent urination, (-) Blood in Urine, (-) Urinary Urgency, (-) Burning on urination, (-) Loss of bladder control or incontinence, (-) Sexual difficulty, (-) Kidney stones Physical Examination: o Vitals Weight: 107 lbs o Constitutional r General Appearance: NAD, well nourished & hydrated ~ Ea - Conjunctivae-Lids: Conjunctivae Clear, no ptosis o ENMT - External Ears-Nose: No bulging, lesions ortrauma r Hearing Assessment: No apparent hearing impairment ° Resgiratom ‘ Respiratory Effort: No distress, normal breathing - Lungs Ausoultation: CTAB, normal respiratory sounds o Cardiovascular - Heart Auscultation: RRR, normal S1 S2, no murmurs o Musouloskeletal - Gait-Station: Stable, coordinated & smooth - Digits-Nails: No clubbing, infection or cyanosis - Joints-Bones-Muscles: No abnormality detected o Skin ' Skin Palpation: No induration, nodules or tightness ~ Neurologic ‘ Cranial Nerves: No cranial nerves deficits noted - DTR Exam: No hyporeflexia or hyperreflexia - Sensory Exam: No sensory or motor deficits noted o Psychiatric - Judgment-lnsight: Judgment intact, insight present - Orientation TPP: Oriented to time, place & person - Recent Remote Memory: No memory impairment noted - Mood-Affect: No mood disorders, calm affect Notes: MSE: Appearance: Normal gait, normal posture, well dressed, well groomed. Behavior: Normal mannerisms, expression, and eye contact. Able to follow commands. Attitude: Cooperative. LOC: Alert. Orientation: Oriented to person, place, time. SpeeCh/language: Normal speech rhythm and rate. Mood: Pleasant, no mood disorders noted. Affect: Normal affect. Thought processes: Logical, organized, linear, goal-directed. Thought content: Denies rumination. Suicidality/homioidality: Denies/denies. Insight/judgement: Judgement/insight intact Attention: Normal attention span. Memory: No issues noted. Intellectual: Fluent, consistent with education, Abstraction ability normal. MMSE on 10/24/19 30/30 Cranial Exam: Cranial nerves ll-Xll intact PERRLA Visual fields full to confrontation, extraocular movements intact, smooth pursuits, intact verticaI/horizontal saccades Facial sensation, strength symmetrical Tongue; palate midline Hearing intact b/l Shoulder shrug symmetric Finger tapping normal Cerebellar exam normal Motor Assessment: 5/5 in bilateral upper and lower extremities Normal tone in upper and lower extremities No tremors Upper and Lower extremity reflexes: Brachioradialis 2+ bilaterally Biceps 2+ bilaterally Triceps 2+ bilaterally Patella 2+ bilaterally Achilles 2+ bilaterally Babinski- Toes are downgoing on both sides Ankle Clonus- Is not present on either side Hoffmans absent Sensory Assessment: Sensation in bilateral upper and lower extremities is intact and symmetrical to light touch and pinprick. There is no allodynia or hyperalgesia Assessment/ Diagnosis: o F0781 Postooncussional syndrome ~ R110 Nausea o R1110 Vomiting, unspecified o 880.812A Abrasion, leftlowerleg http : H.76 1 02. 1 3 0 . 9: 1000’s61Vlethownload‘hask:getfile&docid:1 5 78 72280273 7&secure:. .. 6w’22s’2020 06/22/2020 12:19PM FAX 14086773101 MIND 8c BODY PAIN CLINIC .0015/0020 Encounter Note for Gordon, Elliot Page 4 0f 5 o 850.311A Abrasion of right elbow 800.91XA Abrasion of unspecified part of head G44‘309 Post-traumatic headache, unspecified, not intractable F4310 Post-traumatio stress disorder, unspecified Plan Notes: o This is a 14 year old male with no PMHX had MVA on 9/13/19. He was riding his bike at an intersection between California St‘ and Franklin when he was hit by a car, The impact caused him to fall onto the road and he suffered injuries to his face, right arm, and left knee. He was wearing a helmet and denies any LOC. He was taken to the ER at El Camino Hospital where multiple imaging studies were done. They were negative and he was discharged home later that night. He then followed up with his pediatrician within the next 3-4 days. He missed about 2 weeks of school due to the accident and is now catching up. He is back to his regular routine of school and afterschool activities. He is also back to riding his bike with safety gear on‘ o In terms of symptoms, he states his pain overall has improved since the incident. He suffered abrasions to his face, right arm, and left knee. These are healing and he continues to apply vitamin E oil to avoid scarring. He also has headaches about once per week that are generalized to the entire head, He feels dizzy sometimes when he moves abruptly upon waking up. Headaches usually occur between his 3rd and 4th period classes at school towards the morning and he feels nauseated and has to vomit. He feels better after vomiting. He denies any activities that may trigger/aggravate headache. He denies any light or sound sensitivity. He denies any vision or hearing changes. He is worried/anxious about catching up in school work as he does not want to held back. o Imaging: X-ray right shoulder on DOI showed no gross fracture or subluxation. X-ray left knee on DOI showed no gross fracture CT sinuses/maxilla on DOI showed no evidence of an acute fracture. CT head on DOI showed no acute intracranial hemorrhage or large vessel infarct. o Upon initial physical examination, patient is alert, oriented x 3, very pleasant. Cranial nerves || 7 XII are normal. Cerebellar exam normal, no evidence of pronator drift. Hoffman’s is negative bilaterally. DTRs +2 in BUE and BLE‘ Motor strength 5/5. Full ROM in RUE and LLE. Noted with well healed abrasionsto his right cheek, right arm, and left knee. o MMSE on 10/24/19: 30/30 - Detailed past medical, surgical, allergies, social, family history were documented in patient's intake questionnaire and personally reviewed by me. o The patient will benefit from integrative pain management including appropriate procedures/injections, physical rehabilitation, and medication optimization to address the chronic pain issues. - Based upon the history and physical exam, patient appears to have post concussion symptoms. Will start with conservative treatment to help decrease pain and improve function. Patient will benefitfrom the following: o 1. Brain MRI in the future ifsymptoms persist orvvorsen o 2. Zofran 2 mg 1 PO QD PRN for nausea o 3. May initiate Nortriptyline or Gabapentin if headaches persist/worsen o 4. May refer to CBT if patient experiences anxiety, depression, or any PTSD symptoms related to the Injury. - 11/21/19 - Elliot is here for follow up with his father present during visit. He is having increased headaches at this time. He states the headaches are constant and focused in the frontal lobe and radiates to the temples. He has nausea associated with the headache for which he is taking Zofran PRN with benefit. He notices that schoolwork/homework trigger the headache at times. Parents have been limiting digital screen time and ensuring he gets plenty of rest. However, he has been missing school due to the headache about 2-3 times per week‘ He has been struggling with keeping grades up and withdrew from honors classes. He also stopped playing sports after school for now. At this time, it is feasible to proceed with an MRI brain to thoroughly evaluate and initiate Nortriptyline 1O mg QHS to help manage the headache. He currently takes OTC Advil PRN for the pain. We anticipate with initiation of Nortriptyline, his headache frequency and intensity will be reduced allowing him to be more productive and attend school regularly. - 1/1 0/2020 - Elliot presents with his mother to review MRI findings. Summarized below: o MRI Brain 1/3/20 Impression: http://76. 102. 1 30.9: 1 000/5ervlet/Download?t3sngetfile&docid:1 578722802737&secure:. .. 6/22/2020 06/22/2020 12:20PM FAX 14086773101 MIND 8c BODY PAIN CLINIC @0016/0020 Encounter Note for Gordon. Elliot Page 5 0f 5 ° 1. Examination ofthe bifrontal regions is limited due to magnetic susceptibility artifact, likely from dental hardware. o 2. There are a few scattered predominantly subcortical white matter hyperintensities on T2 and FLAIR weighted imaging which are nonspecific. Given the patient's history: the differential diagnosis includes trauma/traumatic brain injury. Other etiologies such as demyelinating process and vasculitis should be ruled out Clinically. Axial FLAIR series 8, image 22. The arrows show bifrontal and left parietal subcortical white matter hyperintensities. o 3‘ Neuroquantitative analysis demonstrates that there is no evidence for atrophy of the medial temporal lobes. ~ The white matter changes reflected in the MRI are likely related to the trauma that he suffered due to the head injury. His headaches and nausea have improved but he still gets headaches about 1-2 times per week currently. He continues to use Zofran on as needed basis. He will monitor the headaches and let us know ifthey worsen. If headaches worsen, we discussed initiation of Gabapentin 100 mg PO QHS. He is agreeable to this. o Antiepileptic and psychiatric meds - Patient warned that these may cause increased suicidality. Patient agrees to contact me if starts experiencing increased depression or suicidal ideation. | informed patient that antiepileptio meds may be teratogenic and should be stopped if pregnant. The patient verbalized understanding. o PHQ 9 score on 10/24/19 was 6. There is mild indication of depression. The patient was educated that Chronic pain is often associated with depression or depression symptoms and will need to be monitored. Psychological assessment included risk of addictive disorders. o Psychological testing done, including psychodiagnostio assessment of emotionality: personality: intellectual abilities and psychopathology per hour of the physicians time, including face to face time administering test to the patient and time spent interpreting this test result and preparing the report. Total time spent 32 minutes. o This note has been electronically signed off by the following providers: Shalla Ahmed, AGNP, and Harpreet Singh.’ MD, QME on 1/1 0/2020. Followup: 4 weeks Signed 7777777777 [Cosigned Singh, Harpreet MD License A71 470] Ahmed, Shalla AGPCNP License: 95003528 http : 76 1 02. 13 0 . 9: l0005sen‘let«Download?task:getfile& docid:1 5 78 72280273 78; secure? .. 652232020 06/22/2020 12:23PM FAX 14086773101 MIND 8a BODY PAIN CLINIC .0020/0020 Fm w.9 Request for Taxpayer _ Gm Fommhe momma“, Identification Number and Certification requester. no no: Department nuns Treasury _ send to the IRS. Imam! Revenue Service D Go to wwars.govlFonnW9 for inmofiona and moMam lnfonnahun. ZBWnnmaldisregarmda ' namJldmenmfvomabove h]mmcg J) 603V PA! I Name (as shown on your income tax return). Name isrequked on thin fine: do not leave this line blank. HARPRiaT SINa-I: Mag, Inc aL/Nl/ luflowing avert Dams. D Infivéduallsolo pmpriatnr or D c Camfian seommfion singla-rnember LLC miner LLC that is nom‘ U Ofl'ler (see 'u-Btuclions) D 5 Check appropr’ntom tortednrd melassifieanon o! Ina person whose name is amend on lino 1. Check only on. o! ma D Limited I‘ahlity company. 31m tho wt dass'rfication (C=c corporation. Sus corporation. PnParmarshiplD Non: Check the appropriate box in me line above lor 1h: tax ciasnificalien a! tho sinqla-membnt owner. Do not check IJ.C If II'Ie LLc is clasdfied asas'ngle-memberuc mat is disregarded 1mm the owner uniess ma owner of the LLC '3 from 1M owner tor us. federal tax putposes. Olhemise. a single-memlasl' Llc that Is dlsragarded 1mm Ihe owns: should check tho appropriate box lot the lax dassifieafion of its owner. 4 Exemphna (codes apply orly Io certain animus. n01 MMduals: see Inshucllons on page 3}: U Pannmhip U Trusuemle Exempt payee code 0f any) Exemption from FATCA Iaponiw code (i1 any) wuss Iomummmmmm USJ 5 Adams (umber. street. end apt ov suite no.) Soc inmmcflcns. P0 80X BLOWOQ Prlnt or type. Sea Specific lnstructlons on page 3. 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I am not subject tn backupwilhholding because: (a) lam exempt lrom backup withholding, or (b)| have nol been notiflad by the Internal Revenue Servlce (IRS) that I arn subioct to backup wizhholding as a result o! a lafluro 10 report all interest or dividsnds, or (c) lhe IRS has notified me that I am no Innger subject Io backup withholding; md 3. lam a U.S. citizen or other U.S.pm (defined below): and 4. The FATGA code(5) entered on th's form (if any) indicating that I urn exempt from FATCA repeating is correct. Mflcaflon Instructions. You must cross oul item 2 abate if you have been notifiedw the IRS that you are cunenfly subject to backup withholding because you have laied to repon all interesl and dividends on your tax Mum. For real 951319 transactions. 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Purpose of Form An Individual or entity (Form Wv9 requesten who ls required to file an information Mum wlth the IRS must obtain your correct taxpayer Identification number mN} whlch may be your social security number (SSW. lndvidunl taxpayer Identification number (ITIN). adoption taxpayer idamlflcatlon number (ATIN), or employer identification number (EN). to report on an information Mum tho amount paid to you. or other amount reportable on an information return. Exampies of Eniormatlon Mums Include. but ate not llmllod to. the tollowlng. o Form 1099-INT (interest eamed or paid) Cat. No. 1023M Mar ”222/920,? ' o Fawn 1099-0“! 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FaunW-s mew. 10-2018) 06/22/2020 12:10PM FAX 14086773101 MIND 8c BODY PAIN CLINIC .0001/0020 Harpreet Singh MD, QME Mind and Body Pain Clinic 2516 Samaritan Drive, Suite M 6010 Hellyer Ave, Suite 100 San Jose, CA 95124 San Jose, CA 95 138 Phone: (408) 356-5900 Fax: (408) 356-5902 Phone: (408) 677-3 101 Fax: (408) 677-3398 To: Adamson and Adhoot Law Firm Date: 06/22/2020 1150 S. Robertson Blvd 20 pages Los Angeles, CA 90035 P: 310-888-0024 F: 888-895-4665 Good afternoon, Thank you for referring Elliot Gordon. Mr. Gordon was last seen at our clinic on June 10, 2020. Attached are all records and bills for the visits he had with our clinic. | have also included ourW-9. Patient is currently not scheduled for another appointment. If you have any questions or need additional information, please feel free to contact our office directly at 408-356-5900. Best Regards, Alisha Diaz Billing Department Mind and Body Pain Clinic CONFIDENTIALITY NOTICE: This transmission is covered by the Electronic Communications Privacy Act, 18 U.S.C. 2510-2521 and may contain HIGHLY CONFIDENTIAL Personal Health Information (PHI) orother confidential or legally privileged information, intended for the exclusive use of the individual or entity named in above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or reliance upon the contents of this transmission is strictly prohibited and may constitute a violation of Federal Law (HIPAA) and will be reported as such. If you have received this transmission in error, please notify Sender immediately by telephone at (669) 264-9698 and delete the message from any and all machines. 06/22/2020 12:11PM FAX 14086773101 MIND 8c BODY PAIN CLINIC @0002/0020 Consult Note for Gordon, Elliot Page 1 0f 5 Harpreet Singh, MD Mind and Body Pain Clinic 2516 Samaritan Drive, Ste M, San Jose, CA 95124, 6010 Hellyer Avenue, Ste 150, San Jose, CA 95138 Tel: (408)356-5900 Fax: (408)356-5902 0ct24, 2019 CONSULTATION NOTE Dr. Ding Li PCP Gordon, Ellirotr V V 460 Franklin St Mountain View, CA 94041 Tel: Fax: QogawFabgfiggoi§§§wa1eM M w N Thank you for referring your patient Gordon, Elliot to our office for consultation/treatment. Below are some relevant details ofthe office note which is a part of our electronic medical record for your patient. Chief Complaint: o skin abrasion on face, elbow, and shoulder Hx of Present Illness: Thank you for referring this patient to Mind and Body Pain Clinic for management of Neurological problem. This is a 14 year old male with no PMHX who presents to Clinic for injuries after MVA on 9/13/19. He was riding his bike at an intersection between California St. and Franklin when he was hit by a oar. The impact caused him to fall onto the road and he suffered injuries to his face, right arm, and left knee. He was wearing a helmet and denies any LOC. He was taken to the ER at El Camino Hospital where multiple imaging studies were done. They were negative and he was discharged home later that night He then followed up with his pediatrician within the next 3-4 days He missed about 2 weeks of school due to the accident and is now catching up. He is back to his regular routine of school and aftersohool activities. He is also back to riding his bike with safety gear on. In terms of symptoms, he states his pain overall has improved since the incident. He suffered abrasions to his face, right arm, and left knee. These are healing and he continues to apply vitamin E oil to avoid scarring. He also has headaches about once per week that are generalized to the entire head. He feels dizzy sometimes when he moves abruptly upon waking up. Headaches usually occur between his 3rd and 4th period classes at school towards the morning and he feels nauseated and has to vomit. He feels better after vomiting. He denies any activities that may trigger/aggravate headache. He denies any light or sound sensitivity. He denies any vision or hearing Changes. o Location: Head ° Shoulder, right ° Knee, left o Quality: Aching ° Dull ° Throbbing ° Sore o Severity: |cou|d live with a level of pain at 3/10 ° | would rate my pain today as 0/10 ° | would rate my pain when under control as 0/10 ° lwould rate my worst pain as 10/10 o Duration: since 9/1 3/19 Past Medical History: N/A 11ttpzs’x’76. 1 02. 1 3 0.9: 1000fs 61Vletr'Download‘hask:getfile&docid:1 5 720 71 5 44273&secure:. .. 6m’22fi2020 06/22/2020 12:11PM FAX 14086773101 MIND 8c BODY PAIN CLINIC .0003/0020 Consult Note for Gordon, Elliot Page 2 0f 5 Past Surgical History: Nothing on record Known Allergies: Name Family History: (-) Diabetes, (-) Stroke, (-) Hypertension, (-) Heart Disease, (-) Cancer, (-) Asthma, (-) Arthritis, (-) Osteoporosis, (-) Anemia, (-) Migraine, (-) Alzheimers, (-) Epilepsy, (-) Glaucoma Social History: (-) Alcohol Use, (-) Tobacco Use, (-) Drugs Use, (-) Marital stat, (-) Living with Legal Issues: Legal issues: Personal injury (not at work) Psychiatric treatment: Psychiatric: None Suicide: None Master Medication List: Nothing on record Master Problem List: - F0781 Postconcussional syndrome (Active) - R110 Nausea (Active) o R1110 Vomiting, unspecified (Active) o 880.812A Abrasion, left lowerleg (Active) v 850.311A Abrasion ofrightelbovv (Active) o 800‘91XA Abrasion of unspecified partofhead (Active) o 644.309 Post-traumatio headache, unspecified, not intractable (Active) - F4310 Post-traumatic stress disorder, unspecified (Active) History of Present Illness continued: Pain Onset: Motor vehicle accident Timing of pain: Occasionally (less than 30% of time Pain: Interferes with recreation Painful to: go to school at times Head Face Neck pain HPI contin ued: Pain Onset: Due to motor vehicle accident Timing of Pain: Occasionally (< 30% of the time) Pain worst: in the afternoon Worst symptom: headache Pain improves: with rest Pain worsens: with activity Pain treatments: Bed rest: Provided excellent relief Head Face Neck Pain Location and st: Head Pain is: generalized to entire head Headache: Does not occur frequently Diagnostic Studies: CT: head, sinuses/maxilla X-rays: R shoulder, L knee Notes: X-ray Right Shoulder Impression (9/1 3/1 9): No gross fracture or subluxation. X-ray Left Knee http://76. 102. 1 30.9: 1 000/5 ervlet,r"D0wn10ad?tasngetfilegcdocid:1 572071 544273&secure:. .. 6/22/2020 06/22/2020 12:12PM FAX 14086773101 MIND 8a BODY PAIN CLINIC .0004/0020 Consult Note for Gordon, Elliot Page 3 of 5 Impression (9/1 3/1 9): No gross fracture. CT SinuseslMaxilla Without Contrast Impression (9/1 3/1 9): No evidence of an acute fracture. CT Head Without IV Contrast Impression (9/1 3/1 9): No acute intracranial hemorrhage or large vessel infarct. Prior Consultations for current problem: Other: ER team at El Camino Hosp. Review of Systems: ~ General (-) Fevers, (-) Sweats, (-) Appetite loss, (-) Fatigue, (-) Weight change, (-) Insomnia o fig (-) Vision loss, (-) Double vision, (-) Blurred vision, (-) Eye disease, (-) Glasses or contacts o EN MT (-) Ringing in the ears, (-) Decreased hearing, (-) Nosebleeds, (-) Sinus problems, (-) Mouth sores, (-) Swollen glands in head or neck o Cardiovascular (-) Chest pain or discomfort, (-) Palpitations, (-) Swelling of hands or feet, (-) Heart murmur, (-) Hearttrouble, (-) Varicose veins o Resgiratog (-) Cough, (-) Shortness of breath, (-) Wheezing - Gastrointestinal (-) Nausea, (-) Abdominal pain, (-) Diarrhea, (-) Constipation, (-) Bloody stools - Musculoskeletal (-) Joint pain, (-) Joint stiffness or swelling, (-) Muscle cramps, (-) Muscle weakness, (-) Muscle aches, (-) Difficulty walking - fl (-) Rash (-)Changes in hair or nails (-)Changes in color ofskin o Neurolo ic (+‘g; mil” :r ea, (-) Poor balance m TWm. :nrg, (-) Faints or blackouts, (-) Seizures, (-) Tremors, (-) Memory loss (-) Dizzy or light headed (-) Weakness or paralysis, (-) Head injury o Psychiatric (-) Nervousness, (-) Depression, (-) Halucinations o Endocrine (-) Heat or cold intolerance, (-) Excessive thirst or hunger, (-) Hormone or glandular problems o Hematologic-Lymphatic (-) Bleeding, (-) Anemia, (-) Recurrent infections o Genitourinam (-) Frequent urination, (-) Blood in Urine, (-) Urinary Urgency, (-) Burning on urination, (-) Loss of bladder control or incontinence, (-) Sexual difficulty, (-) Kidney stones Physical Examination: - Vitals Weight: 107 lbs - Constitutional - General Appearance: NAD, well nourished & hydrated ° BE - Conjunctivae-Lids: Conjunctivae clear, no ptosis o ENMT - External Ears-Nose: No bulging, lesions or trauma - Hearing Assessment: No apparent hearing impairment o Resgiratog - Respiratory Effort: No distress, normal breathing - Lungs Auscultation: CTAB, normal respiratory sounds - Cardiovascular - Heart Auscultation: RRR, normal S‘l 82, no murmurs - Musculoskeletal - Gait-Station: Stable, coordinated & smooth - Digits-Nails: No clubbing, infection or cyanosis - Joints-Bones-Muscles: No abnormality detected o s_kin -‘~« 4“?” ”:rs ‘wé “t e: 5303?; (r: nwrnrwk F*Wee a .z {N:(W: - Skin Palpation: No induration nodules ortightness o Neurologio - Cranial Nerves: No cranial nerves deficits noted - DTR Exam: No hyporeflexia or hyperreflexia - Sensory Exam: No sensory or motor deficits noted o Psychiatric - Judgment-Insight: Judgment intact, insight present - Orientation TPP: Oriented to time, place & person - Recent Remote Memory: No memory impairment noted http://76. 102. 1 30.9: 1 000/servlet/Download?taskIgefl‘ile&dooid:1 572071 544273&secure:. .. 6/22/2020 06/22/2020 12:12PM FAX 14086773101 MIND 8c BODY PAIN CLINIC .0005/0020 Consult Note for Gordon, Elliot Page 4 0f 5 - Mood-Affect: No mood disorders, calm affect Notes: MSE: Appearance: Normal gait, normal posture, well dressed, well groomed Behavior: Normal mannerisms, expression, and eye contact. Able to follow commands. Attitude: Cooperative. LOC: Alert. Orientation: Oriented to person, place, time. SpeeCh/language: Normal speech rhythm and rate. Mood: Pleasant, no mood disorders noted. Affect: Normal affect. Thought processes: Logical, organized, linear, goaI-directed. Thought content: Denies rumination. Suicidality/homioidality: Denies/denies. Insight/judgement: Judgement/insight intact Attention: Normal attention span Memory: No issues noted. Intellectual: Fluent, consistent with education. Abstraction ability normal, MMSE on 10/24/19 30/30 Cranial Exam: Cranial nerves ll-Xll intact PERRLA Visual fields full to confrontation, extraocular movements intact, smooth pursuits, intact vertical/horizontal saccades Facial sensation, strength symmetrical Tongue, palate midline Hearing intact b/l Shoulder shrug symmetric Finger tapping normal Cerebellar exam normal Motor Assessment: 5/5 in bilateral upper and lower extremities Normal tone in upper and lower extremities No tremors Upper and Lower extremity reflexes: Brachioradialis 2+ bilaterally Biceps 2+ bilaterally Triceps 2+ bilaterally Patella 2+ bilaterally Achilles 2+ bilaterally Babinski- Toes are downgoing on both sides Ankle Clonus- Is not present on either side Hoffmans absent Sensory Assessment: Sensation in bilateral upper and lower extremities is intact and symmetrical to light touch and pinprick. There is no allodynia or hyperalgesia Assessment/ Diagnosis: o F0781 Postconoussional syndrome o R110 Nausea o R1110 Vomiting, unspecified o 880.812A Abrasion, leftlowerleg o 850.311A Abrasion ofrightelbow o 800.91XA Abrasion of unspecified part of head o G44_309 Post-traumatic headache, unspecified, not intractable o F4310 Post-traumatio stress disorder, unspecified Plan Notes: o This is a 14 year old male with no PMHX had MVA on 9/13/19. He was riding his bike at an intersection between California St. and Franklin when he was hit by a oar. The impact caused him to fall onto the road and he suffered injuries to his face, right arm, and left knee He was wearing a helmet and denies any LOO. He was taken to the ER at El Camino Hospital where multiple imaging studies were done. They were negative and he was discharged home later that night. He then followed up with his pediatrician within the next 3-4 days. He missed about 2 weeks of school due to the accident and is now catching up. He is back to his regular routine of school and afterschool activities. He is also back to riding his bike with safety gear on. o In terms of symptoms, he states his pain overall has improved since the incident. He suffered abrasions to his face, right arm, and left knee. These are healing and he continues to apply vitamin E oil to avoid scarring He also has headaches about once per week that are generalized to the entire head. He feels dizzy sometimes when he moves abruptly upon waking up. Headaches usually occur between his 3rd and 4th period Classes at school towards the morning and he feels nauseated and has to vomit. He feels better after vomiting. He denies any activities that may trigger/aggravate headache. He denies any light or sound sensitivity He denies any vision or hearing changes He is worried/anxious about catching up in school work as he does not want to held back. o Imaging: X-ray right shoulder on DOI showed no gross fracture or subluxation. X-ray left knee on DOI showed no gross fracture. CT sinuses/maxilla on DOI showed no evidence of an acute fracture. CT head on DOI showed no acute intraoranial hemorrhage or large vessel infarct. o Upon initial physical examination, patient is alert, oriented x 3, very pleasant. Cranial nerves || ’? XII are normal. Cerebellar exam normal, no evidence of pronator drift. Hoffman’s is negative bilaterally. DTRS +2 llttp:«"f76. 1 02. 1 30.9: 1 0005's ervlet,r"D0wn10ad?task:getfile&docid:1 572071 5 44273&secure:. .. 6/22-"2020 06/22/2020 12:13PM FAX 14086773101 MIND 8c BODY PAIN CLINIC @0006/0020 Consult Note for Gordon. Elliot Page 5 0f5 in BUE and BLE. Motor strength 5/5. Full ROM in RUE and LLE. Noted With well healed abrasions to his right Cheek: right arm, and left knee. o MMSE on 10/24/19: 30/30 o Detailed past medical, surgical: allergies, social: family history were documented in patient's intake questionnaire and personally reviewed by me. o The patient will benefit from integrative pain management including appropriate procedures/injeotions, physical rehabilitation, and medication optimization to address the chronic pain issues. o Based upon the history and physical exam, patient appears to have post concussion symptoms. Will start with conservative treatment to help decrease pain and improve function. Patient will benefit from the following: o 1. Brain MRI in the future if symptoms persist or worsen o 2. Zofran 2 mg1 PO QD PRN for nausea o 3. May initiate Nomiptyline or Gabapentin if headaches persist/worsen o 4. May refer to CBT if patient experiences anxiety, depression, or any PTSD symptoms related to the Injury. o Antiepileptic and psychiatric meds - Patient warned that these may cause increased suicidality. Patient agrees to contact me if starts experiencing increased depression or suicidal ideation. | informed patient that antiepileptio meds may be teratogenic and should be stopped if pregnant. The patient verbalized understanding. o PHQ 9 score on 10/24/19 was 6. There is mild indication of depression. The patient was educated that Chronic pain is often associated with depression or depression symptoms and will need to be monitored. Psychological assessment included risk of addictive disorders. o Psychological testing done, including psychodiagnostic assessment of emotionality: personality: intellectual abilities and psychopathology per hour of the physicians time, including face to face time administering test to the patient and time spent interpreting this test result and preparing the report. Total time spent 32 minutes. o This note has been electronically signed off by the following providers: Shalla Ahmed, AGNP, and Harpreet Singh, MD, QME on 10/24/19. Followup: 3-4 weeks Again, thank you for allowing us to participate in the care of your patient. If you have questions or concerns about any related aspect of the care, please do not hesitate to contact us‘ Yours sincerely, [Cosigned Singh, Harpreet MD License A71 470] http : 76 1 02. 13 0 . 9: l0005sen‘let«Download?task:getfile& docid:1 5 720 71 5 442738; secure? .. 652232020 06/22/2020 12:14PM FAX 14086773101 MIND 8a BODY PAIN CLINIC .0007/0020 Encounter Note for Gordon, Elliot Page l 0f 5 Harpreet Singh, MD Mind and Body Pain Clinic 2516 Samaritan Drive, Ste M, San Jose, CA 95124, 6010 Hellyer Avenue, Ste 150, San Jose, CA 951 38 Tel: (408)356-5900 Fax: (408)356-5902 Encounter Note for Gordon, Elliot on Nov 21, 2019 DoB: Feb 08, 2005 Chief Complaint: o headache Hx of Present Illness: This patient is being seen in Mind and Body Pain Clinic for management of pain issues. Elliot has been having increased headaches and missing school. - Location: Head ° Shoulder, right ° Knee, left ' Quality: Aching ° Dull ° Throbbing ° Sore o Severity: | could live with a level of pain at 3/10 ° Iwould rate my pain today as 0/10 ° | would rate my pain when under control as 0/10 ° Iwould rate my worst pain as 10/10 o Duration: since 9/1 3/19 Past Medical History: N/A Past Surgical History: Nothing on record Known Allergies: Ns::<§";<-} Family History: (-) Diabetes, (-) Stroke, (-) Hypertension, (-) Heart Disease, (-) Cancer, (-) Asthma, (-) Arthritis, (-) Osteoporosis, (-) Anemia, (-) Migraine, (-) Alzheimers, (-) Epilepsy, (-) Glaucoma Social History: (-) Alcohol Use, (-) Tobacco Use, (-) Drugs Use, (-) Marital stat, (-) Living with Legal Issues: Legal issues: Personal injury (not at work) Psychiatric treatment: Psychiatric: None Suicide: None Master Medication List: o Notriptyline 10 mg (1 tab po qHS) Active Master Problem List: o F0781 Postconcussionalsyndrome o R110 Nausea R1110 Vomiting, unspecified 880.812A Abrasion, left lower leg 850.311A Abrasion of right elbow 800.91XA Abrasion of unspecified part of head 644.309 Post-traumatic headache, unspecified, not intractable http://76. 102. 1 30.9: 1 000/servlet/Download?task=getfile&docid=l 574497439345&secure=. .. 6/22/2020 06/22/2020 12:14PM FAX 14086773101 MIND 8c BODY PAIN CLINIC .0008/0020 Encounter Note for Gordon, Elliot Page 2 0f 5 - F4310 Post-traumatic stress disorder, unspecified History of Present Illness continued: Pain Onset: Motor vehicle accident Timing of pain: Occasionally (less than 30% of time Pain: Interferes with recreation Painful to: go to school at times Head Face Neck pain HPI continued: Pain Onset: Due to motor vehicle accident Timing of Pain: Occasionally (< 30% of the time) Pain worst: in the afternoon Worst symptom: headache Pain improves: with rest Pain worsens: with activity Pain treatments: Bed rest: Provided excellent relief Head Face Neck Pain Location and st: Head Pain is: generalized to entire head Headache: Does not occur frequently Diagnostic Studies: CT: head, sinuses/maxilla X-rays: R shoulder, L knee Notes: X-ray Right Shoulder Impression (9/1 3/1 9): No gross fracture or subluxation. X-ray Left Knee Impression (9/1 3/1 9): No gross fracture. CT Sinuses/Maxilla Without Contrast Impression (9/1 3/1 9): No evidence of an acute fracture. CT Head Without IV Contrast Impression (9/1 3/1 9): No acute intracranial hemorrhage or large vessel infarct Prior Consultations for current problem: Other: ER team at El Camino Hosp. Review of Systems: o General (-) Fevers, (-) Sweats, (-) Appetite loss, (-) Fatigue, (-) Weightchange, (-) Insomnia o fig (-) Vision loss, (-) Double vision, (-) Blurred vision, (-) Eye disease, (-) Glasses or contacts o ENMT (-) Ringing in the ears, (-) Decreased hearing, (-) Nosebleeds, (-) Sinus problems, (-) Mouth sores, (-) Swollen glands in head or neck o Cardiovascular (-) Chest pain or discomfort, (-) Palpitations, (-) Swelling of hands or feet, (-) Heart murmur, (-) Heart trouble, (-) Varicose veins o Resgiratom (-) Cough, (-) Shortness of breath, (-) Wheezing o Gastrointestinal (-) Nausea, (-) Abdominal pain, (-) Diarrhea, (-) Constipation, (-) Bloody stools o Musculoskeletal (-) Joint pain, (-) Joint stiffness or swelling, (-) Muscle cramps, (-) Muscle weakness, (-) Muscle aches (- ) Difficulty walking o m (-) Rash (-)Changes in hair or nails (-)Changes in color of skin o Neurologio g - . (-) Poor balance 3::- (-)Faints or blackouts (-)Seizures, (-) Tremors, (-) Memory loss (-) Dizzy or light headed (- ) Weakness or paralysis (- ) Head injury o Psychiatric (-) Nervousness, (-) Depression, (-) Haluoinations o Endocrine (-) Heat or cold intolerance, (-) Excessive thirst or hunger, (-) Hormone or glandular problems o Hematologio-Lymghatio (-) Bleeding, (-) Anemia, (-) Recurrent infections o Genitourinay (-) Frequent urination, (-) Blood in Urine, (-) Urinary Urgency, (-) Burning on urination, (-) Loss of bladder control or incontinence, (-) Sexual difficulty, (-) Kidney stones Physical Examination: o Vitals Weight: 107 lbs llttp:«"f76. 1 02. 1 30.9: 1 0005's ervlet,r"D0wn10ad?task:getfile&docid:1 574497439345&secure:. .. 6%‘22/2020 06/22/2020 12:15PM FAX 14086773101 MIND 8c BODY PAIN CLINIC @0009/0020 Encounter Note for Gordon, Elliot Page 3 0f 5 o Constitutional r General Appearance: NAD, well nourished & hydrated ° fig ‘ Conjunctivae-Lids: Conjunctivae Clear, no ptosis o ENMT - External Ears-Nose: No bulging, lesions ortrauma - Hearing Assessment: No apparent hearing impairment o Resgiratom r Respiratory Effort: No distress, normal breathing - Lungs Ausoultation: CTAB, normal respiratory sounds o Cardiovascular - Heart Auscultation: RRR, normal S1 82, no murmurs o Musouloskeletal ' Gait-Station: Stable, coordinated & smooth - Digits-Nails: No Clubbing, infection or cyanosis - Joints-Bones-Muscles: No abnormality detected o Skin r Skin Palpation: No induration, nodules or tightness o Neurologio - Cranial Nerves: No cranial nerves deficits noted - DTR Exam: No hyporeflexia or hyperreflexia - Sensory Exam: No sensory or motor deficits noted o Psychiatric r Judgment-lnsight: Judgment intact, insight present - Orientation TPP: Oriented to time, place & person ‘ Recent Remote Memory: No memory impairment noted - Mood-Affeot: No mood disorders, calm affect Notes: MSE: Appearance: Normal gait, normal posture, well dressed, well groomed. Behavior: Normal mannerisms, expression, and eye contact. Able to follow commands, Attitude: Cooperative. LOC: Alert. Orientation: Oriented to person, place, time. SpeeCh/language: Normal speech rhythm and rate. Mood: Pleasant, no mood disorders noted. Affect: Normal affect. Thought processes: Logical, organized, linear, goal-direoted. Thought content: Denies rumination. Suicidality/homioidality: Denies/denies. Insight/judgement: Judgement/insight intact Attention: Normal attention span. Memory: No issues noted. Intellectual: Fluent, consistent with education. Abstraction ability normal. MMSE on 10/24/19 30/30 Cranial Exam: Cranial nerves Il-Xll intact PERRLA Visual fields full to confrontation, extraocular movements intact, smooth pursuits, intact verticaI/horizontal saccades Facial sensation, strength symmetrical Tongue, palate midline Hearing intact b/l Shoulder shrug symmetric Finger tapping normal Cerebellar exam normal Motor Assessment: 5/5 in bilateral upper and lower extremities Normal tone in upper and lower extremities No tremors Upper and Lower extremity reflexes: Brachioradialis 2+ bilaterally Biceps 2+ bilaterally Triceps 2+ bilaterally Patella 2+ bilaterally Achilles 2+ bilaterally Babinski- Toes are downgoing on both sides Ankle olonus- Is not present on either side Hoffmans absent Sensory Assessment: Sensation in bilateral upper and lower extremities is intact and symmetrical to light touch and pinprick. There is no allodynia or hyperalgesia Assessment] Diagnosis: o F0781 Postconcussional syndrome o R110 Nausea ~ R1110 Vomiting, unspecified o 880‘812A Abrasion, leftlowerleg o 850‘311A Abrasion ofrightelbow o 800‘91XA Abrasion of unspecified part of head o (344.309 Post-traumatic headache, unspecified, not intractable o F4310 Post-traumatio stress disorder, unspecified httpzw'x’76. 1 02. 1 3 0.9: 1000’s ervletr'Download‘hask:getfile&docid:1 5 74497439345&secure:. .. 6m’22s’2020 06/22/2020 12:16PM FAX 14086773101 MIND 8c BODY PAIN CLINIC .0010/0020 Encounter Note for Gordon, Elliot Page 4 0f 5 Orders & Requisitions: MRI brain Prescription: Notriptyline 10 mg (1 tab po qHS) Plan Notes: o This is a 14 year old male with no PMHX had MVA on 9/13/19. He was riding his bike at an intersection between California St‘ and Franklin when he was hit by a car, The impact caused him to fall onto the road and he suffered injuries to his face, right arm, and left knee. He was wearing a helmet and denies any LOC. He was taken to the ER at El Camino Hospital where multiple imaging studies were done, They were negative and he was discharged home later that night. He then followed up with his pediatrician within the next 3-4 days. He missed about 2 weeks of school due to the accident and is now catching up. He is back to his regular routine of school and afterschool activities. He is also back to riding his bike with safety gear on. o In terms of symptoms, he states his pain overall has improved since the incident. He suffered abrasions to his face, right arm, and left knee. These are healing and he continues to apply vitamin E oil to avoid scarring. He also has headaches about once per week that are generalized to the entire head, He feels dizzy sometimes when he moves abruptly upon waking up. Headaches usually occur between his 3rd and 4th period classes at school towards the morning and he feels nauseated and has to vomit. He feels better after vomiting. He denies any activities that may trigger/aggravate headache. He denies any light or sound sensitivity. He denies any vision or hearing changes. He is worried/anxious about catching up in school work as he does not want to held back. o Imaging: X-ray right shoulder on DOI showed no gross fracture or subluxation. X-ray left knee on DOI showed no gross fracture. CT sinuses/maxilla on DOI showed no evidence of an acute fracture. CT head on DOI showed no acute intracranial hemorrhage or large vessel infarct. - Upon initial physical examination, patient is alert, oriented x 3, very pleasant. Cranial nerves || ?Xll are normal. Cerebellar exam normal, no evidence of pronator drift. Hoffman’s is negative bilaterally. DTRs +2 in BUE and BLE. Motor strength 5/5‘ Full ROM in RUE and LLE‘ Noted with well healed abrasionsto his right cheek, right arm, and left knee. o MMSE on 10/24/19: 30/30 o Detailed past medical, surgical, allergies, social, family history were documented in patient's intake questionnaire and personally reviewed by me. - The patient will benefit from integrative pain management including appropriate procedures/injections, physical rehabilitation, and medication optimization to address the chronic pain issues. o Based upon the history and physical exam, patient appears to have post concussion symptoms. Will start with conservative treatment to help decrease pain and improve function. Patient will benefitfrom the following: o 1‘ Brain MRI in the future ifsymptoms persist orvvorsen o 2. Zofran 2 mg ‘l PO QD PRN for nausea o 3. May initiate Nortriptyline or Gabapentin if headaches persist/worsen o 4. May refer to CBT if patient experiences anxiety, depression, or any PTSD symptoms related to the Injury‘ o 11/21/19 - Elliot is here for follow up with his father present during visit He is having increased headaches at this time. He states the headaches are constant and focused in the frontal lobe and radiates to the temples. He has nausea associated with the headache for which he is taking Zofran PRN with benefit. He notices that schoolwork/homework trigger the headache at times. Parents have been limiting digital screen time and ensuring he gets plenty of rest. However, he has been missing school due to the headache about 2-3 times per week. He has been struggling with keeping grades up and withdrew from honors classes. He also stopped playing sports after school for now‘ At this time, it is feasible to proceed with an MRI brain to thoroughly evaluate and initiate Nortriptyline 1O mg QHS to help manage the headache. He currently takes OTC Advil PRN for the pain. We anticipate with initiation of Nonriptyline, his headache frequency and intensity will be reduced allowing him to be more productive and attend school regularly, o Antiepileptic and psychiatric meds - Patient warned that these may cause increased suicidality. Patient agrees to contact me if starts experiencing increased depression or suicidal ideation. | informed patient that antiepileptic meds may be teratogenic and should be stopped if pregnant. The patient verbalized understanding. http://76. 102. 1 30.9: 1 000/5ervlet/Download?t3sngetfile&docid:1 574497439345&secure:. .. 6/22/2020 06/22/2020 12:16PM FAX 14086773101 MIND 8c BODY PAIN CLINIC .0011/0020 Encounter Note for Gordon, Elliot Page 5 0f 5 o PHQ 9 score on 10/24/19 was 6. There is mild indication of depression. The patient was educated that chronic pain is often associated with depression or depression symptoms and will need to be monitored. Psychological assessment included risk of addictive disorders. o Psychological testing done, including psychodiagnostic assessment of emotionality, personality, intellectual abilities and psychopathology per hour of the physicians time, including face to face time administering test to the patient and time spent interpreting this test result and preparing the report Total time spent 32 minutes. o This note has been electronically signed off by the following providers: Shalla Ahmed, AGNP, and Harpreet Singh, MD, QME on 11/22/19 Followup: 2 weeks Signed [Cosigned3 Singh, Harpreet MD License A71 470] Ahmed, Shalla AGPCNP License: 95003528 http://76. 102. 1 30.9: 1 000/5 ervlet,r"D0wn10ad?tasngetfilegcdocid:1 574497439345&secure:. .. 6/22/2020 06/22/2020 12:17PM FAX 14086773101 MIND 8a BODY PAIN CLINIC .0012/0020 Encounter Note for Gordon, Elliot Page l 0f 5 Harpreet Singh, MD Mind and Body Pain Clinic 2516 Samaritan Drive, Ste M, San Jose, CA 95124, 6010 Hellyer Avenue, Ste 150, San Jose, CA 951 38 Tel: (408)356-5900 Fax: (408)356-5902 Encounter Note for Gordon, Elliot on Jan 10, 2020 DoB: Feb 08, 2005 Chief Complaint: o headache Hx of Present Illness: This patient is being seen in Mind and Body Pain Clinic for management of pain issues. Patient presents for MRI Brain review. - Location: Head ° Shoulder, right ° Knee, left ' Quality: Aching ° Dull ° Throbbing ° Sore o Severity: | could live with a level of pain at 3/10 ° Iwould rate my pain today as 0/10 ° | would rate my pain when under control as 0/10 ° Iwould rate my worst pain as 10/10 o Duration: since 9/1 3/19 Past Medical History: N/A Past Surgical History: Nothing on record Known Allergies: Ns::<§";<-} Family History: (-) Diabetes, (-) Stroke, (-) Hypertension, (-) Heart Disease, (-) Cancer, (-) Asthma, (-) Arthritis, (-) Osteoporosis, (-) Anemia, (-) Migraine, (-) Alzheimers, (-) Epilepsy, (-) Glaucoma Social History: (-) Alcohol Use, (-) Tobacco Use, (-) Drugs Use, (-) Marital stat, (-) Living with Legal Issues: Legal issues: Personal injury (not at work) Psychiatric treatment: Psychiatric: None Suicide: None Master Medication List: o Notriptyline 10 mg (1 tab po qHS) Active Master Problem List: o F0781 Postconcussionalsyndrome o R110 Nausea R1110 Vomiting, unspecified 880.812A Abrasion, left lower leg 850.311A Abrasion of right elbow 800.91XA Abrasion of unspecified part of head 644.309 Post-traumatic headache, unspecified, not intractable http://76. 102. 1 30.9: 1 000/servlet/Download?task=getfile&docid=l 578722802737&secure=. .. 6/22/2020 06/22/2020 12:17PM FAX 14086773101 MIND 8c BODY PAIN CLINIC @0013/0020 Encounter Note for Gordon, Elliot Page 2 0f 5 o F4310 Post-traumatio stress disorder, unspecified History of Present Illness continued: Pain Onset: Motor vehicle accident Timing of pain: Occasionally (less than 30% of time Pain: Interferes with recreation Painful to: go to school at times Head Face Neck pain HPI continued: Pain Onset: Due to motor vehicle accident Timing of Pain: Occasionally (< 30% of the time) Pain worst: in the afternoon Worst symptom: headache Pain improves: with rest Pain worsens: with activity Pain treatments: Bed rest: Provided excellent relief Head Face Neck Pain Location and st: Head Pain is: generalized to entire head Headache: Does not occur frequently Diagnostic Studies: CT: head, sinuses/maxilla X-rays: R shoulder, L knee Notes: X-ray Right Shoulder Impression (9/1 3/1 9): No gross fracture or subluxation. X-ray Left Knee Impression (9/13/19): No gross fracture. CT Sinuses/Maxilla Without Contrast Impression (9/13/19): No evidence of an acute fracture CT Head Without |V Contrast Impression (9/1 3/19): No acute intraoranial hemorrhage or large vessel infarct. MRI Brain 1/3/20 Impression: 1. Examination of the bifrontal regions is limited due to magnetic susceptibility artifact, likely from dental hardware. 2. There are a few scattered predominantly subcortical white matter hyperintensities on T2 and FLAIR weighted imaging which are nonspecific. Given the patient's history, the differential diagnosis includes trauma/traumatic brain injury. Other etiologies such as demyelinating process and vasoulitis should be ruled out clinically. Axial FLAIR series 8, image 22. The arrows show bifrontal and left parietal subcortical white matter hyperintensities. 3. Neuroquantitative analysis demonstrates that there is no evidence for atrophy of the medial temporal lobes. Prior Consultations for current problem: Other: ER team at El Camino Hosp. Review of Systems: o General (-) Fevers, (-) Sweats, (-) Appetite loss, (-) Fatigue, (-) Weight Change, (-) Insomnia o fig (-) Vision loss, (-) Double vision, (-) Blurred vision, (-) Eye disease, (-) Glasses or contacts o ENMT (-) Ringing in the ears, (-) Decreased hearing, (-) Nosebleeds, (-) Sinus problems, (-) Mouth sores, (-) Swollen glands in head or neck o Cardiovascular (-) Chest pain or discomfort, (-) Palpitations, (-) Swelling of hands or feet, (-) Heart murmur, (-) Heart trouble, (-) Varicose veins ° Resgiratog (-) Cough, (-) Shofiness of breath, (-) Wheezing o Gastrointestinal (-) Nausea, (-) Abdominal pain, (-) Diarrhea, (-) Constipation, (-) Bloody stools o Musculoskeletal (-) Joint pain, (-) Joint stiffness or swelling, (-) Muscle cramps, (-) Muscle weakness, (-) Muscle aches, (-) Difficulty walking o w (-) Rash, (-) Changes in hair or nails, (-) Changes in color of skin o Neurologio .j ,. . (-) Poor balance, :-=-} (-) Faints or blackouts, (-) Seizures, (-) Tremors, (-) Memory loss, (-) Dizzy or light headed, (-) Weakness or paralysis, (-) Head injury o Psychiatric (-) Nervousness, (-) Depression, (-) Halucinations o Endocrine (-) Heat or cold intolerance, (-) Excessive thirst or hunger, (-) Hormone or glandular problems http : H.76 1 02. 1 3 0 . 9: 1000’s61Vlethownload‘hask:getfile&docid:1 5 78 72280273 7&secure:. .. 6w’22s’2020 06/22/2020 12:18PM FAX 14086773101 MIND 8c BODY PAIN CLINIC @0014/0020 Encounter Note for Gordon, Elliot Page 3 0f 5 o Hematologic-Lymghatio (-) Bleeding, (-) Anemia, (-) Recurrent infections o Genitourinam (-) Frequent urination, (-) Blood in Urine, (-) Urinary Urgency, (-) Burning on urination, (-) Loss of bladder control or incontinence, (-) Sexual difficulty, (-) Kidney stones Physical Examination: o Vitals Weight: 107 lbs o Constitutional r General Appearance: NAD, well nourished & hydrated ~ Ea - Conjunctivae-Lids: Conjunctivae Clear, no ptosis o ENMT - External Ears-Nose: No bulging, lesions ortrauma r Hearing Assessment: No apparent hearing impairment ° Resgiratom ‘ Respiratory Effort: No distress, normal breathing - Lungs Ausoultation: CTAB, normal respiratory sounds o Cardiovascular - Heart Auscultation: RRR, normal S1 S2, no murmurs o Musouloskeletal - Gait-Station: Stable, coordinated & smooth - Digits-Nails: No clubbing, infection or cyanosis - Joints-Bones-Muscles: No abnormality detected o Skin ' Skin Palpation: No induration, nodules or tightness ~ Neurologic ‘ Cranial Nerves: No cranial nerves deficits noted - DTR Exam: No hyporeflexia or hyperreflexia - Sensory Exam: No sensory or motor deficits noted o Psychiatric - Judgment-lnsight: Judgment intact, insight present - Orientation TPP: Oriented to time, place & person - Recent Remote Memory: No memory impairment noted - Mood-Affect: No mood disorders, calm affect Notes: MSE: Appearance: Normal gait, normal posture, well dressed, well groomed. Behavior: Normal mannerisms, expression, and eye contact. Able to follow commands. Attitude: Cooperative. LOC: Alert. Orientation: Oriented to person, place, time. SpeeCh/language: Normal speech rhythm and rate. Mood: Pleasant, no mood disorders noted. Affect: Normal affect. Thought processes: Logical, organized, linear, goal-directed. Thought content: Denies rumination. Suicidality/homioidality: Denies/denies. Insight/judgement: Judgement/insight intact Attention: Normal attention span. Memory: No issues noted. Intellectual: Fluent, consistent with education, Abstraction ability normal. MMSE on 10/24/19 30/30 Cranial Exam: Cranial nerves ll-Xll intact PERRLA Visual fields full to confrontation, extraocular movements intact, smooth pursuits, intact verticaI/horizontal saccades Facial sensation, strength symmetrical Tongue; palate midline Hearing intact b/l Shoulder shrug symmetric Finger tapping normal Cerebellar exam normal Motor Assessment: 5/5 in bilateral upper and lower extremities Normal tone in upper and lower extremities No tremors Upper and Lower extremity reflexes: Brachioradialis 2+ bilaterally Biceps 2+ bilaterally Triceps 2+ bilaterally Patella 2+ bilaterally Achilles 2+ bilaterally Babinski- Toes are downgoing on both sides Ankle Clonus- Is not present on either side Hoffmans absent Sensory Assessment: Sensation in bilateral upper and lower extremities is intact and symmetrical to light touch and pinprick. There is no allodynia or hyperalgesia Assessment/ Diagnosis: o F0781 Postooncussional syndrome ~ R110 Nausea o R1110 Vomiting, unspecified o 880.812A Abrasion, leftlowerleg http : H.76 1 02. 1 3 0 . 9: 1000’s61Vlethownload‘hask:getfile&docid:1 5 78 72280273 7&secure:. .. 6w’22s’2020 06/22/2020 12:19PM FAX 14086773101 MIND 8c BODY PAIN CLINIC .0015/0020 Encounter Note for Gordon, Elliot Page 4 0f 5 o 850.311A Abrasion of right elbow 800.91XA Abrasion of unspecified part of head G44‘309 Post-traumatic headache, unspecified, not intractable F4310 Post-traumatio stress disorder, unspecified Plan Notes: o This is a 14 year old male with no PMHX had MVA on 9/13/19. He was riding his bike at an intersection between California St‘ and Franklin when he was hit by a car, The impact caused him to fall onto the road and he suffered injuries to his face, right arm, and left knee. He was wearing a helmet and denies any LOC. He was taken to the ER at El Camino Hospital where multiple imaging studies were done. They were negative and he was discharged home later that night. He then followed up with his pediatrician within the next 3-4 days. He missed about 2 weeks of school due to the accident and is now catching up. He is back to his regular routine of school and afterschool activities. He is also back to riding his bike with safety gear on‘ o In terms of symptoms, he states his pain overall has improved since the incident. He suffered abrasions to his face, right arm, and left knee. These are healing and he continues to apply vitamin E oil to avoid scarring. He also has headaches about once per week that are generalized to the entire head, He feels dizzy sometimes when he moves abruptly upon waking up. Headaches usually occur between his 3rd and 4th period classes at school towards the morning and he feels nauseated and has to vomit. He feels better after vomiting. He denies any activities that may trigger/aggravate headache. He denies any light or sound sensitivity. He denies any vision or hearing changes. He is worried/anxious about catching up in school work as he does not want to held back. o Imaging: X-ray right shoulder on DOI showed no gross fracture or subluxation. X-ray left knee on DOI showed no gross fracture CT sinuses/maxilla on DOI showed no evidence of an acute fracture. CT head on DOI showed no acute intracranial hemorrhage or large vessel infarct. o Upon initial physical examination, patient is alert, oriented x 3, very pleasant. Cranial nerves || 7 XII are normal. Cerebellar exam normal, no evidence of pronator drift. Hoffman’s is negative bilaterally. DTRs +2 in BUE and BLE‘ Motor strength 5/5. Full ROM in RUE and LLE. Noted with well healed abrasionsto his right cheek, right arm, and left knee. o MMSE on 10/24/19: 30/30 - Detailed past medical, surgical, allergies, social, family history were documented in patient's intake questionnaire and personally reviewed by me. o The patient will benefit from integrative pain management including appropriate procedures/injections, physical rehabilitation, and medication optimization to address the chronic pain issues. - Based upon the history and physical exam, patient appears to have post concussion symptoms. Will start with conservative treatment to help decrease pain and improve function. Patient will benefitfrom the following: o 1. Brain MRI in the future ifsymptoms persist orvvorsen o 2. Zofran 2 mg 1 PO QD PRN for nausea o 3. May initiate Nortriptyline or Gabapentin if headaches persist/worsen o 4. May refer to CBT if patient experiences anxiety, depression, or any PTSD symptoms related to the Injury. - 11/21/19 - Elliot is here for follow up with his father present during visit. He is having increased headaches at this time. He states the headaches are constant and focused in the frontal lobe and radiates to the temples. He has nausea associated with the headache for which he is taking Zofran PRN with benefit. He notices that schoolwork/homework trigger the headache at times. Parents have been limiting digital screen time and ensuring he gets plenty of rest. However, he has been missing school due to the headache about 2-3 times per week‘ He has been struggling with keeping grades up and withdrew from honors classes. He also stopped playing sports after school for now. At this time, it is feasible to proceed with an MRI brain to thoroughly evaluate and initiate Nortriptyline 1O mg QHS to help manage the headache. He currently takes OTC Advil PRN for the pain. We anticipate with initiation of Nortriptyline, his headache frequency and intensity will be reduced allowing him to be more productive and attend school regularly. - 1/1 0/2020 - Elliot presents with his mother to review MRI findings. Summarized below: o MRI Brain 1/3/20 Impression: http://76. 102. 1 30.9: 1 000/5ervlet/Download?t3sngetfile&docid:1 578722802737&secure:. .. 6/22/2020 06/22/2020 12:20PM FAX 14086773101 MIND 8c BODY PAIN CLINIC @0016/0020 Encounter Note for Gordon. Elliot Page 5 0f 5 ° 1. Examination ofthe bifrontal regions is limited due to magnetic susceptibility artifact, likely from dental hardware. o 2. There are a few scattered predominantly subcortical white matter hyperintensities on T2 and FLAIR weighted imaging which are nonspecific. Given the patient's history: the differential diagnosis includes trauma/traumatic brain injury. Other etiologies such as demyelinating process and vasculitis should be ruled out Clinically. Axial FLAIR series 8, image 22. The arrows show bifrontal and left parietal subcortical white matter hyperintensities. o 3‘ Neuroquantitative analysis demonstrates that there is no evidence for atrophy of the medial temporal lobes. ~ The white matter changes reflected in the MRI are likely related to the trauma that he suffered due to the head injury. His headaches and nausea have improved but he still gets headaches about 1-2 times per week currently. He continues to use Zofran on as needed basis. He will monitor the headaches and let us know ifthey worsen. If headaches worsen, we discussed initiation of Gabapentin 100 mg PO QHS. He is agreeable to this. o Antiepileptic and psychiatric meds - Patient warned that these may cause increased suicidality. Patient agrees to contact me if starts experiencing increased depression or suicidal ideation. | informed patient that antiepileptio meds may be teratogenic and should be stopped if pregnant. The patient verbalized understanding. o PHQ 9 score on 10/24/19 was 6. There is mild indication of depression. The patient was educated that Chronic pain is often associated with depression or depression symptoms and will need to be monitored. Psychological assessment included risk of addictive disorders. o Psychological testing done, including psychodiagnostio assessment of emotionality: personality: intellectual abilities and psychopathology per hour of the physicians time, including face to face time administering test to the patient and time spent interpreting this test result and preparing the report. Total time spent 32 minutes. o This note has been electronically signed off by the following providers: Shalla Ahmed, AGNP, and Harpreet Singh.’ MD, QME on 1/1 0/2020. Followup: 4 weeks Signed 7777777777 [Cosigned Singh, Harpreet MD License A71 470] Ahmed, Shalla AGPCNP License: 95003528 http : 76 1 02. 13 0 . 9: l0005sen‘let«Download?task:getfile& docid:1 5 78 72280273 78; secure? .. 652232020 06/22/2020 12:23PM FAX 14086773101 MIND 8a BODY PAIN CLINIC .0020/0020 Fm w.9 Request for Taxpayer _ Gm Fommhe momma“, Identification Number and Certification requester. no no: Department nuns Treasury _ send to the IRS. Imam! Revenue Service D Go to wwars.govlFonnW9 for inmofiona and moMam lnfonnahun. ZBWnnmaldisregarmda ' namJldmenmfvomabove h]mmcg J) 603V PA! I Name (as shown on your income tax return). Name isrequked on thin fine: do not leave this line blank. HARPRiaT SINa-I: Mag, Inc aL/Nl/ luflowing avert Dams. D Infivéduallsolo pmpriatnr or D c Camfian seommfion singla-rnember LLC miner LLC that is nom‘ U Ofl'ler (see 'u-Btuclions) D 5 Check appropr’ntom tortednrd melassifieanon o! Ina person whose name is amend on lino 1. Check only on. o! ma D Limited I‘ahlity company. 31m tho wt dass'rfication (C=c corporation. Sus corporation. PnParmarshiplD Non: Check the appropriate box in me line above lor 1h: tax ciasnificalien a! tho sinqla-membnt owner. Do not check IJ.C If II'Ie LLc is clasdfied asas'ngle-memberuc mat is disregarded 1mm the owner uniess ma owner of the LLC '3 from 1M owner tor us. federal tax putposes. Olhemise. a single-memlasl' Llc that Is dlsragarded 1mm Ihe owns: should check tho appropriate box lot the lax dassifieafion of its owner. 4 Exemphna (codes apply orly Io certain animus. n01 MMduals: see Inshucllons on page 3}: U Pannmhip U Trusuemle Exempt payee code 0f any) Exemption from FATCA Iaponiw code (i1 any) wuss Iomummmmmm USJ 5 Adams (umber. street. end apt ov suite no.) Soc inmmcflcns. P0 80X BLOWOQ Prlnt or type. Sea Specific lnstructlons on page 3. 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FaunW-s mew. 10-2018) Hgaflh _ Diagnostics a A Sl'monMed Funk)- Patient Name: Gordon, Elliott Accession Number: 28308511 Patient ID: 4345502 Location: Health Diagnostics-Mountain View Gender: Male Exam Date: January 3, 2020 13:59 Date of Birth: February 8, 2005 Modality: MR Referring Physician: Zeng, Yan Report Status: Final BRAIN WIO (TBI PROTOCOL) INDICATION: Nausea and severe headaches since motor vehicle accident while biking on 09/1 3/1 9. TECHNIQUE: T1, T2, FLAIR, diffusion and susceptibility weighted images were obtained. GRE images were obtained. Neuroquantitative analysis was performed for evaluation of brain atrophy. FINDINGS: Examination of the bifrontal regions is limited due to magnetic susceptibility artifact, likely from dental hardware. SUPRATENTORIAL STRUCTURES: There are a few scattered predominantly subconical white matter hyperintensities on T2 and FLAIR weighted imaging which are nonspecific. Given the patient s history, the differential diagnosis includes trauma/traumatic brain injury. Other etiologies such as demyelinating process and vasculitis should be ruled out clinically. There is no mass, mass effect, hemorrhage or infarct. POSTERIOR FOSSA: The brainstem is normal in signal intensity. The cerebellum appears within normal limits. The cerebellar folia and sulci are unremarkable. The internal auditory canals appear within normal limits. The seventh and eighth cranial nerves are normal and there is no evidence for cerebellopontine angle mass. VENTRICULAR SYSTEM: The ventricles are normal in size and shape. There is no evidence for hydrocephalus and there is no evidence for transependymal flow of CSF. SKULL BASE AND OSSEOUS STRUCTURES: The orbits, paranasal sinuses and temporal bones are within normal limits. There is no evidence for abnormal mass or fluid collection associated with these structures. VASCULAR STRUCTURES: There is normal signal void within the major vessels of the circle of Willis. The superior sagittal sinus appears unremarkable on this examination. PITUITARY AND SELLA: There is no evidence for mass. DIFFUSION WEIGHTED IMAGING: There are no signal abnormalities to suggest an acute ischemic process. There is no evidence for acute small vessel ischemia. NEUROQUANT ANALYSIS: Analysis of brain volumes was performed. The left hippocampus measures 4.3 cm3 and the right hippocampus measures 4.1 cm3. These values are within the normative ranges for the patient's age. There is no evidence for atrophy of the medial temporal lobes. SUSCEPTIBILITY WEIGHTED IMAGING: Susceptibility weighted images demonstrates no Thank you for your kind referral. lfyou require further assistance, please contact our Radiologist Hotline at 855-RAD-TALK (855-723-8255) Report exported on Wed, Jan 8, 2020 12:51 :43 -07OO - Page 1 of 2 Hgaflh _ Diagnostics a A Sl'monMed Funk)- Patient Name: Gordon, Elliott Accession Number: 28308511 Patient ID: 4345502 Location: Health Diagnostics-Mountain View Gender: Male Exam Date: January 3, 2020 13:59 Date of Birth: February 8, 2005 Modality: MR Referring Physician: Zeng, Yan Report Status: Final areas of signal dropout to suggest residual blood products. IMPRESSION: 1. Examination of the bifrontal regions is limited due to magnetic susceptibility artifact, likely from dental hardware. 2. There are a few scattered predominantly subcortical white matter hyperintensities on T2 and FLAIR weighted imaging which are nonspecific. Given the patient s history, the differential diagnosis includes trauma/traumatic brain injury. Other etiologies such as demyelinating process and vasculitis should be ruled out clinically. Axial FLAIR series 8, image 22. The arrows show bifrontal and left parietal subcortical white matter hyperintensities. 3. Neuroquantitative analysis demonstrates that there is no evidence for atrophy of the medial temporal lobes. Reported by: Avery Knapp MD. Electronically signed by: Avery Knapp MD. on Jan 07, 2020 @ 09:44 Thank you for your kind referral. If you require further assistance, please contact our Radiologist Hotline at 855-RAD-TALK (855-723-8255) Report exported on Wed, Jan 8, 2020 12:51 :43 -0700 - Page 2 of 2 , , EL CAMINO HOSPITAL Gordon, Elliott Peter (3 El (ammo Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/201 9, D/C: 9/1 3/201 9 4302 Facesheet Patient Demographics Address Phone 460 FRANKLIN STREET 650-279-0859 (Home) MOUNTAIN VIEW CA 94041 Hospital Account Name Acct ID Class Status Primary Coverage Gordon, Elliott Peter 100070030 Emergency Billed BLUE CROSS 8 ANTHEM - BX/BS OUT OF STATE - BX EXCLUSIVE Guarantor Account (for Hospital Account #1 000700308) Relation to Name pt Service Area Active? Acct Type Gordon, Tracy Mother ECHSA Yes Personal/Family Address Phone 460 FRANKLIN ST 650~279-0859(H) MOUNTAIN VIEW, CA 94041-1 994 Coverage Information (for Hospital Account #1 000700308) F/O Payor/Plan Precert # BLUE CROSS ANTHEM/BXIBS OUT OF STATE - BX EXCLUSIVE Subscriber Subscriber # Gordon, Tracy EPAAN7466443 Address Phone PO BOX 60007 LOS ANGELES, CA 90060-0007 Admission Information Arrival Date/Time: 09/1 3/2019 1623 Admit Date/Time: 09/1 3/2019 1623 IP Adm. Date/Time: Admission Type: Urgent Point of Origin: Non-healthcare Admit Category: Facility Means of Arrival: Car Primary Service: Adt - Emergency Secondary Department Service: Transfer Source: Service Area: ECH SERVICE Unit: MV AREA EMERGENCY DEPT Admit Provider: Attending Linker, Alex Referring Provider: Henri, MD Provider: Discharge Information Discharge DatelTime Discharge Disposition Discharge Destination Discharge Provider Unit 09/1 3/2019 1821 Home Home None MV EMERGENCY DEPT Reason for Visit Pedi struck by vehicle 20 minutes PTA, helmted cyclist cycling across street, pt was struck by vehicle on right side, fell and twisted landing on right side, arrives with right facial swelling and abrasions and chin abrasions, left knee abrasion. right shoulder and upper arm. Reportedly vehicle was traveling at 20mph when pt was struck. Final Diagnoses Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 1 , . EL CAMINO HOSPITAL Gordon, Elliott Peter 6% El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/C: 9/13/2019 4302 Facesheet Final Diagnoses (continued) Codes Comments Bicycle rider struck in motor vehicle accident, initial encounter V19.9XXA Events ED Arrival at 911312019 1623 Unit: MV EMERGENCY DEPT Admission at 9I13I2019 1632 Unit: MV EMERGENCY DEPT Room: WR 01 Bed: WR 01 Patient dass: Emergency Service: ADT - Emergency Department ED Roomed at 9/1 3I2019 1632 Unit: MV EMERGENCY DEPT Transfer In at 9/1 312019 1634 uhit: Mv EMERGENCY DEPT Room: MVED17 Bed: 17 Patient class: Emergency Service: ADT - Emergency Department ED Transfer at 9I1 3I2019 1634 Unit: MV EMERGENCY DEPT Discharge at 911 3/2019 1821 Unit: MV EMERGENCY DEPT Room: MVED17 Bed: 17 Patient class: Emergency Service: ADT - Emergency Department Discharge at 9l1 3l2019 1821 Unit: MV EMERGENCY DEPT Allergies as of 9I13/2019 Reviewed by Hawkins. Sonya Man’e. RN on 9/1 3/2019 No Known Allergies (DrugIFoodlEnv) Immunizations None History Medical as of 9I13I2019 Medical last reviewed by Hawkins, Sonya Marie, RN on 9I1312019 Past Medical History: None Pertinent Negatives: None Surgical as of 9I1 3/2019 Surgical last reviewed by Hawkins, Sonya Marie, RN on 9113I2019 None Family as of 9l1 3/2019 Family never marked as reviewed None Family Status as of 9I1 312019 Family Status never marked as reviewed None Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 2 EL CAMINO HOSPITAL 2500 GRANT ROAD(:9 El (amino Health 4302 Inpatient Record Tobacco Use as of 9/1 3/2019 Tobacco Use never marked as reviewed ' Smoking Status . Smoking Start Date Never Assessed .5 _ Types 7 Comments - - Unknown Sm0king Quit Date Smokeless Tobacco Status Gordon, Elliott Peter MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/2019, D/C: 9/1 3/2019 PacksIDay Smokeless Tobacco Quit Date Years Used Source Alcohol Use as of 911 3I2019 Alcohol Use never marked as reviewed None Drug Use as of 911 3l2019 Drug Use never marked as reviewed None Sexual Activity as of 9/1 3I2019 Sexual Activity never marked as reviewed None Activities of Daily Living as of 9I1 3I2019 Activities of Dally lelng never marked as reviewed None Social Documentation as of 9I1312019 Social Documentation never marked as reviewed None Occupational as of 9I1 3I201 9 Occupational never marked as reviewed None Socioeconomic as of 9/1 3I2019 Socioeconomic never marked as reviewed ' ' 7 Number of Years ‘ Education Marital Status Spouse Name Chum" Education - Lave. Single - - - - Financial Resoui’ce Strain Food Insecurity: Worry Food Insecurity: Inability Preferred Language English Race White or Caucasian Ethnicity Not Hispanic or Lafino Transportation Needs: Medical Source ' Transportation Needs: Non- medical Birth as of 911 3I2019 Birth never marked as reviewed None ED Arrival Information Means of Arrival Car Expected Arrival Acuity - 9113/2019 16:23 2 Arrival Complaint Chief Complaint Complaint Comment 7 ‘ V By Service ADT - Emergency Department Escorted By Family Member Last Edited Time Relationship Admission Type Urgent ED Provider Viewed/Printed by Torres, Miguel Angel at 11/19/1 9 3:23 PM Page 3 (3% El Camino Health EL CAMINO HOSPITAL 2500 GRANT ROAD Gordon, Elliott Peter MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/2019, D/C: 9/1 3/2019 4302 Inpatient Record Chief Complaint (continued) j , 7 Last Edited r Complaint Comment By me Relationship ED Provider Pedi struck by 20 minutes PTA. helmted cyclist cycling across street, pt was Hawkins, 9i13l2019 4:32 None No vehicle [Other] struck by vehide on right side, feII and twisted landing on right Sonya Marie. PM side. arrives with right facial swelling and abrasions and chin RN abrasions, left knee abrasion. right shoulder and upper arm. Reportedly vehicle was traveling at 20mph when pt was stmck. Diagnoses Diagnosis Comment ' Added By Time Added Bicycle rider struck In motor vehicle Linker, Alex Henri. MD 9/1 3I2019 5:50 PM accident. Initial encounter WWW V , ““““ A, , _ fi‘ M, ,7 v _ -wwwm, , Facial abrasion. initial encounter. n 7 . .Liflkfi- AJQKNHQRMQV.’ . .7 . ,fillflzmééflm V. Abrasion of right shoulder, initial Llnker. Alex Henri, MD 9/13I2019 5:50 PM “SQQQJIJISJLWW W. v .. .H 4 r . , . . ‘ . .‘ WMwww.wmumw ._. w V Abrasion of right elbow, Initial Linker. Alex Henn’, MD 9/13/2019 5:51 PMWSWMWM __ WWW - , - - ,M.‘ -W ..-‘ . N- w ..-V.__,m---_--m. .M - Abrasion of left knee. initial Linker. Alex Henri. MD 9/1 312019 5:51 PM ,§_'199.Ul'397__,_‘._-_..V-w. _«._.k..__l.u .v H. - #M ,7 .A. . v. , .. , .V w H V .7 _ “MM“.WWWV“- .. ‘ Ebéwegvlleagmigmlmsiélsaeeyntgt . . _______ . kinky; Nfizsflgnfl-MQ 7 \ N79113JEQJ§V§LQLEMW 7 7. 7 7 H Contuslon of face. initial encounter Linker. Alex Henri. MD 9I1 312019 5:51 PM ED Disposition ED Disposition Condition User Comment Discharge Stable Linker, Alex Henri, MD Viewed/Printed by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 4 , , EL CAMINO HOSPITAL Gordon, Elliott Peter (,E El Cammo Health 2500 GRANT ROAD MRN: 0000354536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/c: 9/13/2019 4302 Inpatient Record ' ED Provider Notes - ED Notes ED Provider Notes by Linker, Alex Henri, MD at 9/1 3I2019 4:30 PM Author: Linker. Alex Henri. MD Service: Emergency Services Author Type: Physician Filed: 9/13/2019 6:55 PM Creation Time: 9/13/2019 4:30 PM Status: Signed Editor: Linker. Alex Henri, MD (Physician) Scribed for Dr. Alex Linker by Lindon Tran on 9/1 3/2019 at 4:30 PM. Scribe documentation reviewed by rne and is accurate. Dr. Alex Linker on 9/1 3/2019 at 6:48 PM Histog Chief complaint by ED Nursing Chief Complaint Patient presents with - Pedi struck by vehicle 20 minutes PTA, helmted cyclist cycling across street, pt was struck by vehicle on right side, fell and twisted landing on right side, arrives with right facial swelling and abrasions and chin abrasions, left knee abrasion, right shoulder and upper arm. Reportedly vehicle was traveling at 20mph when pt was struck. HPI 14 y.o. male who presents to the Emergency Department for right face, right arm, and left knee pain status post motor vehicle crash at 4:00 PM. Patient was a helmeted bicyclist crossing the street when he was hit by a vehicle from the right and landed on his right side. Mountain View Police and Fire Department arrived on scene and evaluated patient. They believed he would be okay but suggested he still visits the ED. Denies any loss of consciousness. Tetanus is up to date. History reviewed. No pertinent past medical history. History reviewed. No pertinent surgical history. Social History - Lives with parents - Student - Vaccinations up to date No Known Allergies (Drug/Food/Env) Home Medications Med List Status: In Progress Set By: Sonya Marie Hawkins, RN at 09/1 3/2019 4:31 PM No medications reported. Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 5 9 . EL CAMINO HOSPITAL Gordon, Elliott Peter c} El Camilla Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/c: 9/13/2019 4302 Inpatient Record r 77 w . ED Provider Notes - ED Notes (continued) ED Provider Notes by Linker, Alex Henri, MD at 9/1 3l2019 4:30 PM (continued) ROS 12 point review of systems performed, negative except as detailed in HPI. Physical Exam ED Triage Vitals [09/1 3/19 1629] Temp Pulse Resp BP Sp02 36.8 °C 80 14 116/78 99 % (98.2 °F) Temp src Source Patient BP Fi02 (%) Position Location -- Oximetry -- -- -- PHYSICAL EXAMINATION: | have reviewed the vital signs and nursing notes. Room Air Pulse Oximeter is 99%. This is normal. GENERAL: Alert. In no acute distress. GCS 4-6-5. HEAD: Normocephalic, atraumatic. No scalp hematoma. Abrasion to right side of face, cheek, and under chin. NECK: No midline tenderness or stepoff. No jugular venous distention. Trachea midline. No pulsatile mass. EYES: Pupils equal, round, reactive to light. Extraocular muscles intact. Acuity grossly intact. Conjunctivae normal. No hyphema. ENT: Airway patent. Dentition normal. Voice normal. Oropharynx clear. Facial bones stable without deformity or swelling. CARDIAC: Regular rate and rhythm without murmurs, rubs, or gallops. Pulses 2+ and equal throughout. Normal capillary refill. RESPIRATORY: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. No tenderness or crepitus of the chest wall. No ecchymoses noted. Nontender over sternum and ribs. GI: Soft, nontender, nondistended. No rebound, guarding, or rigidity. No organomegaly or mass. No ecchymoses noted. NO CVAT. Spine: No C spine, T spine, L/S spine vertebral body tenderness to palpation. MUSCULOSKELETAL: Full range of motion in all joints without pain. No limb deformities. No significant effusions noted. No tenderness in the long bones or compartments. Abrasion to right shoulder and left knee. BACK: No midline tenderness or stepoff. No ecchymoses or other signs of trauma. NEUROLOGIC: Cranial nerves ll-XH normal. Mental status normal. Motor, sensory, and deep tendon reflexes normal and symmetric. Cerebellar testing normal. SKIN: Warm, dry. No lacerations. No ecchymosis. Abrasions to face, right shoulder, left knee, right elbow Labs Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 6 , . EL CAMINo HOSPITAL Gordon, Elliott Peter (,9 El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/c: 9/13/2019 4302 Inpatient Record ED Provider Notes - ED Notes (Continued) ED Provider Notes by Linker, Alex Henri, MD at 9/13I2019 4:30 PM (continued) Labs Resulted Up to the Time of Admitted to the Floor - No data to displav X-Rayllmaging CT Sinuses/Maxilla or facial bones without IV Contrast Final Result CT Head or Brain without IV Contrast Final Result XR Knee 3 View Left Final Result XR Shoulder 2+ View Right ED Interpretation Xray of the right, shoulder Number of Views: 4 Indication: trauma Interpretation: by ALEX LINKER, MD showing proximal humerus fracture, no soft tissue swelling, no dislocation, no foreign body. Impression: Proximal humerus fracture. (pending Radiologist review) Authenticated by Alex H Linker MD at 5:13 PM Final Result fidiolw Interpretations: Xr Shoulder 2+ View Right Result Date: 9/1 3/201 9 Narrative: Examination:XR SHOULDER 2+ VIEW RIGHT Indication: Pain Comparison: None FINDINGS: No evidence of an acute fracture. The physes do not appear widened. No rib fracture or pneumothorax. IMPRESSION: No gross fracture or subluxation. Finalized by Marcos Alvarez, MD at 9/1 3/2019 5:50 PM Ct Head Or Brain Without Iv Contrast Result Date: 9/1 3/201 9 Narrative: PROCEDURE: CT HEAD W0 CONTRAST HISTORY: Altered mental status COMPARISON: None TECHNIQUE: 3 mm axial sections through the cranium were performed without contrast. Sagittal and coronal images were reconstructed and reviewed. CT dose reduction technique utilized with one or more of the following: Automated exposure control and/or adjustment of the mA and/or kV according to patient size and/or use of iterative reconstruction technique. FINDINGS: No acute extra-axial collection. No mass effect or midline shift. The calvarium is intact. The paranasal sinuses are clear. Soft tissue hematoma overlies the right orbit. IMPRESSION: No acute intracranial hemorrhage or large vessel infarct. This patient received a total of 2 Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 7 , , EL CAMINo HOSPITAL Gordon, Emott Peter (,E El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/c: 9/13/2019 4302 Inpatient Record ED Provider Notes - ED Notes (continued) ED Provider Notes by Linker, Alex Henri, MD at 9/1 3/2019 4:30 PM (continued) exposure event(s) during this CT examination. The CTDIvol and DLP radiation dose values for each exposure are: Exposure: 1; Series: 2; Anatomy: Head; Phantom: 16 cm; CTDlvol: 36; DLP: 606 Exposure: 2; Series: 2; Anatomy: Head; Phantom: 16 cm; CTDIvol: 24; DLP: 359 The following accession numbers are related to this dose report 4657996: 4657997 The dose indicators for CT are the volume Computed Tomography (CT) Dose Index (CTDlvol) and the Dose Length Product (DLP), and are measured in units of mGy and mGy-cm, respectively. These indicators are not patient dose, but values generated from the CT scanner acquisition factors. The report includes radiation exposure data for exposures received during this examination. If multiple reports are produced from this examination, the exposure data is duplicated in each report. The exposure data reported is indicative, but not determinative, of the radiation dose received by this patient. Finalized by Marcos Alvarez, MD at 9/1 3/2019 5:30 PM Ct Sinuses/maxilla Or Facial Bones Without Iv Contrast Result Date: 9/1 3/201 9 Narrative: PROCEDURE: CT SINUS FACIAL BONES W0 CONTRAST HISTORY: Headache status post trauma TECHNIQUE: A facial CT was performed utilizing contiguous 3 mm axial images with reformats in the coronal and sagittal planes. No intravenous contrast was administered. CT dose reduction technique utilized with one or more of the following: Automated exposure control andlor adjustment of the mA andlor kV according to patient size andlor use of iterative reconstruction technique. COMPARISON: None FINDINGS: The cervical spine is in anatomic alignment. No evidence of an acute fracture. The globes are intact. There is no evidence of a postseptal or intraconal hematoma. Soft tissue hematoma overlies the right orbit and right zygoma. Mucosal hypertrophy within the ethmoid air cells. The mastoid air cells are clear. The middle ears are patent. IMPRESSION: No evidence of an acute fracture. This patient received a total of 2 exposure event(s) during this CT examination. The CTDIvoI and DLP radiation dose values for each exposure are: Exposure: 2; Series: 2; Anatomy: Head; Phantom: 16 cm; CTDlvol: 24; DLP: 359 Exposure: 1; Series: 2; Anatomy: Head; Phantom: 16 cm; CTDIvoI: 36; DLP: 606 The following accession numbers are related to this dose report 4657997: 4657996 The dose indicators for CT are the volume Computed Tomography (CT) Dose Index (CTDlvol) and the Dose Length Product (DLP), and are measured in units of mGy and mGy-cm, respectively. These indicators are not patient dose, but values generated from the CT scanner acquisition factors. The report includes radiation exposure data for exposures received during this examination. If multiple reports are produced from this examination, the exposure data is duplicated in each report. The exposure data reported is indicative, but not determinative, of the radiation dose received by this patient. Finalized by Marcos Alvarez, MD at 9/13/2019 5:33 PM Xr Knee 3 View Left Result Date: 9/1 3/201 9 Narrative: Examination2XR KNEE 3 VIEW LEFT Indication: Pain Comparison: None FINDINGS: No evidence of an acute fracture. No malalignment. Small suprapatellarjoint effusion. IMPRESSION: No gross fracture. Finalized by Marcos Alvarez, MD at 9/1 3/2019 5:41 PM ED Course Medication Administration from 09/1 3/2019 1623 to 09/1 312019 1848 Rout Comment Date/Time Order Dose e Action Action by s Viewelerinted by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 8 , , EL CAMINO HOSPITAL Gordon, Elliott Peter CE El Camilla Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/C: 9/13/2019 4302 Inpatient Record ED Pravider Notes - ED Notes (continued) ED Provider Notes by Linker, Alex Henri, MD at 9I13I2019 4:30 PM (continued) Rout Comment Date/Time Order Dose e Action Action by S 09/1 3/2019 lidocaine HCI (UROJET) 2 10 Intra- Given John Cramer, RN 1721 % jelly in applicator 10 mL ureth mL ral ED Consult Log Date/Time Other User 09/1 3/19 1746 Call Requested radiologist LT 09/1 3/1 9 1747 Called LT 09/13/19 1748 Returned Phone Call Discussed xray results with LT radiologist, who believes there is no fracture. MDM Patient is a 14-year-old male brought to the emergency room by ambulance after he was struck by a car riding his bicycle. He was wearing a helmet. He did not lose consciousness. He actually feels relatively well apart from having a abrasions. No significant headache nausea or vomiting. He is neurologically intact. Cervical spine cleared by nexus criteria. CT scan of head and face show no acute fractures. He is tender in the right shoulder obtained an x-ray which l initially thought might show a fracture per Radiology feels does not. Tenderness likely secondary to the abrasions. He had additional raisins which were cleaned and dressed. No lacerations. Patient was re- evaluated several times on secondary and tertiary exam with no additional injuries identified. Tetanus is up-to-date. Final diagnoses: Bicycle rider struck in motor vehicle accident, initial encounter Facial abrasion, initial encounter Abrasion of right shoulder, initial encounter Abrasion of right elbow, initial encounter Abrasion of left knee, initial encounter Closed head injury, initial encounter Contusion of face, initial encounter There are no discharge medications for this patient. Viewelerinted by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 9 EL CAMINO HOSPITAL Gordon, Elliott Peterfl o CE El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/2019, D/C: 9/1 3/2019 4302 Inpatient Record ED Provider Notes - ED Notes (continued) ED Provider Notes by Linker, Alex Henri, MD at 911 3/2019 4:30 PM (continued) Electronically Signed by Linker, Alex Henri. MD on 9/13/2019 6:55 PM ED Provider Quick Note - ED Notes ED Provider Quick Note by Linker, AIex Henri, MD at 9I1 3I2019 6:21 PM Service: Emergency Services Author Type: PhysicianAuthor: Linker, Alex Henri, MD Creation Time: 9/1 5/2019 5:07 PM Status: SignedFiled: 9115/2019 5:07 PM Editor: Linker. Alex Henri. MD (Physician) l called in follow up and his mother reports that he is doing well. Electronically Signed by Linker, Alex Henri. MD on 9115/2019 5:07 PM Viewed/Printed by Torres, Miguel Angel at 11/1 9/1 9 3:23 PM Page 10 , . EL CAMINO HOSPITAL Gordon, Elliott Peter (,9 El Camilla Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/C: 9113/2019 4302 Inpatient Record Discharge Instructions - Encounter Notes Discharge Instructions signed by Xvalidation, Doc, MD at 9I14I2019 10:31 AM Author: Xvalidatian, Doc. MD Sewice: - Author Type: Physician Filed: 9/14/2019 10:31 AM Creation Time: 9/14/2019 10:31 AM Status: Signed Editor. Xvalidation, Doc. MD (Physician) Scan on 9114/2019 10:31 AM by Xvalidation. Doc. MD: 1 Electronically Signed by Xvalidation, Doc. MD on 9/14/2019 10:31 AM General Information Date: 9/13/2019 Time: Status: Posted Location: ECH RIS MV CT APPOINTMENT LOG Room: Service: LOCATION Patient class: Case classification: Diagnosis Information No post-op diagnosis codes associated with the log. Case Tracking Events Event ' 7 , f Timeln JnRoom , . , ,_ .,_V V 7, W A 7, Moggeggifigi‘gan M _. ‘. . 7 floggggg§gd§thafipd.u. ‘ , _ , . . ,, H . , . , W V _, . , , Out of Room Questionnaire Data None Brief Op Notes No notes found. OR Nursing Notes No notes found. Implants No active impiants to display in this view. General Information Date: 9/1 3/2019 Time: Status: Posted Location: ECH RIS MV CT APPOINTMENT LOG Room: Service: LOCATION Patient class: Case classification: Diagnosis Information No post-op diagnosis codes associated with the log. Case Tracking Events Event : > Time In TMQQé.@§IL$E<§91§§E.f§ié-if 7 a " ' ’ “““ . M992r33§.§9§asi9n§nd u Out of Room Questionnaire Data None Brief Op Notes No notes found. Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 11 EL CAMINO HOSPITAL Gordon, Elliott Peter0 o (,9 El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/2019, D/c: 9/13/2019 4302 Inpatient Record Brief Op Notes (continued) OR Nursing Notes No notes found. Implants No active lmpIants to display in this view. Viewed/Printed by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 12 , . EL CAMINo HOSPITAL Gordon, Elliott Peter (g El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/c: 9/13/2019 4302 Inpatient Record Imaging - Other Orders CT Head or Braln without IV Contrast [1 5597543] Eiectronically signed by: Linker, Alex Henri. MD on 09l13l19 1630 Status: Completed Ordering user: Linker, Alex Henri. MD 09/1 3/19 1630 Ordering provider: Linker. Alex Henn‘, MD Authorized by: Linker. Alex Henri. MD Frequency: Once 09/13/19 1631 - 1 occurrence Indications comment: ALOC Questionnaire Question 7 ' Answer Radiologist may modify the order per protocol to meet the clinical needs of the Yes patient? CT SinuseslMaxilla or facial bones without IV Contrast [1 5597546] Electronically signed by: Linker, Alex Henri, MD on 09l13l19 1630 Status: Completed Ordering user: Linker. Alex Henri. MD 09/13/19 1630 Orden‘ng provider: Linker. Alex Henri. MD Authorized by: Linker. Alex Henri. MD Frequency: Once 09/1 3I19 1631 - 1 occurrence Indications comment: Pain Questionnaire _Q_uestion ' r An’swe'r Radiologlst may modify the order per protoco! to meet the clinical needs of the Yes patient? Order comments: Patient presents with: Pedi sttuck by vehicle: 20 minutes PTA. heimted cyclist cycling across street, pt was struck by vehicle on light side. fell and twisted landing on right side, arrives with right facial swelling and abrasions and chin abrasions. left knee abrasion, right shoulder and upper arm. XR Shoulder 2+ View Right [1 5597547] Electronically signed by: Linker, Alex Henri, MD on 09l13l19 1630 Status: Completed Ordering user: Linker. Alex Henri. MD 09/13/19 1630 Ordering provider: Linker, Alex Henri. MD Authorized by: Llnker, Alex Henri, MD Frequency: Once 09/13/19 1631 - 1 occurrence Indications comment: TraumaIPain Order comments: Patient presents with: Pedi struck by vehicle: 20 minutes PTA, helmted cyclist cycling across street. pt was struck by vehicle on right side. fell and twisted landing on n'ght side, arrives with right facial swelling and abrasions and chin abrasions. left knee abrasion. right shoulder and upper arm. XR Knee 3 View Left [1 5597548] Electronically signed by: Linker, Alex Henri, MD on 09/1 3/19 1630 Status: Completed Ordering user: Linker, Alex Henri, MD 09/1 3119 1630 Ordering provider: Linker. Alex Henri. MD Authorized by: Linker. Alex Henri. MD Frequency: Once 09l1 3/19 1631 -1 occurrence Indications comment: Trauma/Pain Order comments: Patient presents with: Pedi struck by vehicle: 20 minutes PTA. heimted cyclist cycling across street. pt was stmck by vehicle on right side. fell and twisted landing on right side. am'ves with n‘ght facial swelling and abrasions and chin abrasions, left knee abrasion. fight shoulder and upper arm. Medications - Other Orders Iidocaine HCI (UROJET) 2 % jelly in applicator 10 mL [1 5597555] Electronically signed by: Linker, Alex Henri, MD on 09113119 1729 Status: Completed Mode: Ordering in Verbal with readback mode Communicated by: Cramer. John, RN Ordering user: Cramer. John. RN 09I13I19 1720 Ordering provider: Linker, Alex Henri, MD Authorized by: Linker. Alex Henri. MD Frequency: Once 09l13/19 1725 - 1 occurrence Encounter-Level ESignatures: No documentation. All Results - Results CT Head or Braln without IV Contrast [1 5597549] Resulted: 09/1 3/19 1730. Result status: Final result Ordering provider: Linker, Alex Henri, MD 09I13I19 1630 Order status: Compieted Resulted by: Alvarez. Marcos N. MD Performed: 09I1 3119 1709 - 09l1 3/19 1718 Accession number. 4657996 Resulting lab: P8360 Narrative: PROCEDURE: CT HEAD W0 CONTRAST Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 13 p . EL CAMINO HOSPITAL Gordon, Elliott Peter (,9 El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/c: 9/13/2019 4302 Inpatient Record All Results - Results (continued) HISTORY: Altered mental status COMPARISON: None TECHNIQUE: 3 mm axial sections through the cranium were performed without contrast. Sagittal and coronal images were reconstructed and reviewed. CT dose reduction technique utilized with one or more of the following: Automated exposure control andlor adjustment of the mA andlor kV according to patient size andlor use of iterative reconstruction technique. FINDINGS: No acute extra-axial collection. No mass effect or midline shift. The calvarium is intact. The paranasa! sinuses are clear. Soft tissue hematoma overlies the right orbit. IMPRESSION: No acute intracranial hemorrhage or large vessel infarct. This pafient received a total of 2 exposure event(s) during this CT examination. The CTDlvol and DLP radiation dose values for each exposure are: Exposure: 1; Seriesz2: Anatomy: Head: Phantom: 16 cm: CTDIvol:36; DLP:606 Exposurez2; Seriesz2; Anatomy Head; Phantom: 16 cm: CTDIvolz24; DLP:359 The following accession numbers are related to this dose report 4657996: 4657997 The dose indicators for CT are the volume Computed Tomography (CT) Dose Index (CTDIvol) and the Dose Length Product (DLP). and are measured in units of mGy and mGy-cm, respectiveiy. These indicators are no! patient dOSe. but values generated from the CT scanner acquisition factors. The report includes radiation exposure data for exposures received during this examlnation. If multiple reports are produced from this examination. the exposure data is duplicated in each report. The exposure data reported is indicative. but not determinative. of the radiation dose recelved by this patient. Finalized by Marcos Alvarez, MD at 9/1 3/2019 5:30 PM Testing Performed By Lab - Abbreviatlon Name Director Address Valid Date Range 131 - P8360 P8360 Edwina Sequeira. M.S., 815 Pollard Rd (LGH137) 02/1 1/15 0901 - Present CLS Los Gatos CA 95032 Interpretation Summary PROCEDURE: CT HEAD WO CONTRAST HISTORY: Altered mental status COMPARISON: None TECHNIQUE: 3 mm axial sections through the cranium were performed without contrast. Sagittal and coronal images were reconstructed and reviewed. CT dose reduction technique utilized with one or more of the following: Automated exposure control andlor adjustment of the mA andlor kV according to patient size andlor use of iterative reconstruction technique. FINDINGS: No acute extra-axial collection. No mass effect or midline shift. The calvarium is intact. The paranasal sinuses are clear. Soft tissue hematoma overlies the right orbit. IMPRESSION: Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 14 , , EL CAMINO HOSPITAL Gordon, Elliott Peter 6% El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/c: 9/1 3/2019 4302 Inpatient Record All Results - Results (continued) No acute intracranial hemorrhage or large vessel infarct. This patient received a total of 2 exposure event(s) during this CT examination. The CTDlvol and DLP radiation dose values for each exposure are: Exposure: 1; Series:2; Anatomy: Head; Phantom: 16cm; CTDlvol: 36; DLP: 606 Exposure22; Series:2; Anatomy: Head; Phantom: 16cm; CTDlvol:24; DLP: 359 The following accession numbers are related to this dose report 4657996: 4657997 The dose indicators for CT are the volume Computed Tomography (CT) Dose Index (CTDlvol) and the Dose Length Product (DLP), and are measured in units of mGy and mGy-cm, respectively. These indicators are not patient dose, but values generated from the CT scanner acquisition factors. The report includes radiation exposure data for exposures received during this examination. If multiple reports are produced from this examination, the exposure data is duplicated in each report. The exposure data reported is indicative, but not determinative, of the radiation dose received by this patient. Finalized by Marcos Alvarez, MD at 9/13/2019 5:30 PM Signed Electronically signed by Alvarez. Marcos N, MD on 9/13/19 at 1730 PDT CT SlnuseslMaxilla or facial bones without IV Contrast [1 5597552] Resulted: 09/1 3119 1733, Resuit status: Final result Ordering provider. Linker, Alex Henri, MD 09/1 3/19 1630 Order status: Compieted Resulted by: Alvarez. Marcos N, MD Performed: 09/1 3I19 1709 - 09I1 3I19 1720 Accession number: 4657997 Resulting lab: P8360 Narrative: PROCEDURE: CT SINUS FACIAL BONES W0 CONTRAST HISTORY: Headache status post trauma TECHNIQUE: A facial CT was performed utilizing contiguous 3 mm axial images with refonnats in the coronal and sagitta! planes. No intravenous contrast was administered. CT dose reduction technique utilized with one or more of the following: Automated exposure control andlor adjustment of the mA andlor kV according to patient size andlor use of iterative reconstruction technique. COMPARISON: None FINDINGS: The cetvical spine is in anatomic alignment. No evidence of an acute fracture. The globes are intact. There is no evidence of a postseptal or intraconal hematoma. Soft tissue hematoma overlies the right orbit and right zygoma. Mucosal hypertrophy within the ethmoid air cells. The mastoid air cells are clear. The middle ears are patent IMPRESSION: No evidence of an acute fracture. Viewed/Printed by Torres, Miguel Angel at 11/19/1 9 3:23 PM Page 15 , , EL CAMINO HOSPITAL Gordon, Elliott Peter (,3 El Camilla Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/c: 9/13/2019 4302 Inpatient Record All Results - Results (continued) This patient received a total of 2 exposure event(s) during this CT examination. The CTDlvol and DLP radiation dose values for each exposure are: Exposure: 2; Series: 2; Anatomy: Head; Phantom: 16cm; CTDlvol: 24; DLP: 359 Exposure: 1: Serieszz; AnatomyzHead: Phantom: 16cm; CTDlvolz36; DLP:606 The following accession numbers are related to this dose report 4657997: 4657996 The dose indimtors for CT are the volume Computed Tomography (CT) Dose Index (CTDIvoI) and the Dose Length Product (DLP), and are measured in units of mGy and mGy-cm. respectively. These indicators are not patient dose. but values generaied from the CT scanner acquisition factors. The report includes radiation exposure data for exposures received during this examination. If multipie reports are produced from this examination. the exposure data is duplicated in each report. The exposure data reported is indicative. but not determinative. of the radiation dose received by this patient. Finalized by Marcos Alvarez. MD at 9/1 3/2019 5:33 PM Testing Performed By Lab - Abbreviation Name Director Address Valid Date Range 131 - P8360 P8360 Edwina Sequeira, M.S.. 815 Pollard Rd (LGH137) 02/1 1/15 0901 - Present CLS Los Gatos CA 95032 Interpretation Summary PROCEDURE: CT SINUS FACIAL BONES WO CONTRAST HISTORY: Headache status post trauma TECHNIQUE: A facial CT was performed utilizing contiguous 3 mm axial images with reformats in the coronal and sagittal planes. No intravenous contrast was administered. CT dose reduction technique utilized with one or more of the following: Automated exposure control and/or adjustment of the mA and/or kV according to patient size and/or use of iterative reconstruction technique. COMPARISON: None FINDINGS: The cervical spine is in anatomic alignment. No evidence of an acute fracture. The globes are intact. There is no evidence of a postseptal or intraconal hematoma. Soft tissue hematoma overlies the right orbit and right zygoma. Mucosal hypertrophy within the ethmoid air cells. The mastoid air cells are clear. The middle ears are patent. IMPRESSION: No evidence of an acute fracture. This patient received a total of 2 exposure event(s) during this CT examination. The CTDlvol and DLP radiation dose values for each exposure are: Exposurez2; Series:2; Anatomy: Head; Phantom: 160m; CTDlvol224; DLP:359 Exposure: 1; Series:2; Anatomy: Head; Phantom: 160m; CTDIvoI: 36; DLP2606 Viewed/Printed by Torres, Miguel Angel at 1 1/19/19 3:23 PM Page 16 9 , EL CAMINO HOSPITAL Gordon, Elliott Peter (g El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/C: 9/13/2019 4302 Inpatient Record All Results - Results (continued) The following accession numbers are related to this dose report 4657997: 4657996 The dose indicators for CT are the volume Computed Tomography (CT) Dose Index (CTDlvol) and the Dose Length Product (DLP), and are measured in units of mGy and mGy-cm, respectively. These indicators are not patient dose, but values generated from the CT scanner acquisition factors. The report includes radiation exposure data for exposures received during this examination. If multiple reports are produced from this examination, the exposure data is duplicated in each report. The exposure data reported is indicative, but not determinative, of the radiation dose received by this patient. Finalized by Marcos Alvarez, MD at 9/13/2019 5:33 PM Signed Electronically signed by Alvarez, Marcos N. MD on 9/1 3/19 at 1733 PDT XR Shoulder 2+ View Right [1 5597553] Resulted: 09/13/19 1750. Result status: Final result Ordering provider: Linker. Alex Henri. MD 09/1 3/19 1630 Order status: Completed Resulted by: Alvarez. Marcos N. MD Performed: 09/13/19 1630 - 09I1 3/19 1700 Accession number. 4657974 Resulting lab: P8360 Narrative: Examination:XR SHOULDER 2+ VIEW RIGHT Indication: Pain Comparison: None FINDINGS: No evidence of an acute fracmre. The physes do not appear widened. No tib fracture or pneumothorax. IMPRESSION: No gross fracture or subluxation. Finalized by Marcos Alvarez. MD at 9/1 3/2019 5:50 PM Testing Performed By Lab -*Abbreviation Name Diredor Address Valid Date Range 131 - P8360 P8360 Edwina Sequeira. M.S.. 815 Pollard Rd (LGH137) 02/1 1I15 0901 - Present CLS Los Gatos CA 95032 Interpretation Summary Examination:XR SHOULDER 2+ VIEW RIGHT Indication: Pain Comparison: None FINDINGS: No evidence of an acute fracture. The physes do not appear widened. No rib fracture or pneumothorax. Viewed/Printed by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 17 , . EL CAMINo HOSPITAL Gordon, Elliott Peter (,3 El (ammo Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/C: 9/13/2019 4302 Inpatient Record All Results - Results (continued) IMPRESSION: No gross fracture or subluxation. Finalized by Marcos Alvarez, MD at 9/13/2019 5:50 PM Signed Electronically signed by Alvarez, Marcos N. MD on 9/13/19 at 1750 PDT XR Knee 3 View Left [1 5597554] Resulted: 09/1 3/19 1741. Result status: Final result Ordering provider. Linker. Alex Henri. MD 09/13/19 1630 Order status: Completed Resulted by: Alvarez. Marcos N, MD Performed: 09/1 3/19 1635 - 09/13/19 1714 Accession number: 4657975 Resulting lab: P8360 Narrative: Examination:XR KNEE 3 VIEW LEFT Indication: Pain Comparison: None FINDINGS: No evidence of an acute fracture. No malalignment. Small suprapatellarjoint effusion. IMPRESSION: No gross fracture. Finalized by Marcos Alvarez, MD at 9/1 3/2019 5:41 PM Testlng Perforated By ‘ Lab - Abbreviation Name Director r Address Valid Date Range 131 - P6360 P8360 Edwina Sequeira, M.S.. 815 Pollard Rd (LGH137) 02/1 1/15 0901 - Present CLS Los Gatos CA 95032 Interpretation Summary ExaminationIXR KNEE 3 VIEW LEFT Indication: Pain Comparison: None FINDINGS: No evidence of an acute fracture. No malalignment. Small suprapatellar joint effusion. IMPRESSION: No gross fracture. Finalized by Marcos Alvarez, MD at 9/1 3/2019 5:41 PM Signed E!ectronically signed by Alvarez, Marcos N, MD an 9113/19 at 1741 PDT Viewed/Printed by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 18 EL CAMINO HOSPITAL Gordon, Elliott Peterf o(g El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/C: 9/1 3/2019 4302 Inpatient Record All Results - Results (continued) All Results - Results Implants No active implants to dispiay in this view. Encounter Messages No messages in this encounter Viewed/Printed by Torres, Miguel Angel at 11/1 9/1 9 3:23 PM Page 1 9 EL CAMINO HOSPITAL Gordon, Elliott PeterI o (,9 El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/2019, D/c: 9/1 3/2019 4302 Inpatient Record Encounter-Level Documents - 09H 3/2019: Scan on 9/14/2019 10:31 AM by Xvalidation. Doc, MD: (below) cnption‘Male a_o‘B- 21812005 t .. rtmeylvgimm w‘ggean DEPT» r; Elliott Peter Gordon» pa WisosiszossH. i ,g-H. ;. 911312019 mazivm. 594% ,MR‘N‘:iofifioam’s’é’w " «at : El Camino Health Discharge Instructions Signature Page I have received and understand the discharge instructions. Patienthuardian Signature:@" Relatlonship to'Patient: WM . r'" Date: (Time: Clinician(Printed Name): A I 6%!“WMMClinician S'gnatu e: /V ’ Date: H1 >2”? C ?Ime: “‘70 Gordon, Elliott Peter (MRN: 0000854536) CSN:1605152036 Printed al 9113I19 5:51 PM Page 1 of1 Viewed/Printed by Torres, Miguel Angel at 11/1 9/1 9 3:23 PM Page 20 , , EL CAMlNo HOSPITAL Gordon, Elliott Peter (E El Cammo Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/c: 9/13/2019 4302 Inpatient Record Scan on 9/1 3/2019 4:52 PM by Ramusovic. Ema__J (below) l omam-oueauh mafik‘gaawga1man's» zsoocmummmm. ammoam olsmcnou‘momum: ___ ELcm DDSPHN. Conditions of AdmissionIService 1. General Medical and Surgical Consent: The undersigned consents to hospital services. including telehealth services. that may be performed during this hospitalization or on an outpatient basis. including emergency treatment or services. which may include but are not limited to laboratory procedures. x-ray examinations. medical or surgical treatment or procedures. anesthesia. or hospital sewices rendered the patient under genera! and special instructions of the patient's physician or surgeon. The undersigned agrees to photographic documentation. production of recordings. films, or other images to assist in their treatment or for the hospital's operations. such as internal training activities and quality assurance review. The undersigned authorizes El Camino Health to use andlor dispose, at its discretion any blood. body fluid. limb, organ or other tissue removed or obtained during an operation, procedure or treatment. including use in existing or future research conducted by El Camino Health or third parties if allowed under legal requiremenm and El Camino Health policy. In addition to caring for patients. El Camino Health participates in educational affiliations to provide training to healthcare . EMERGENCY DEPARTMENT P I ~ ' 7h?”Agreement to Paragraph 1: (BEFORE SCREENING EXAM) Patient or Rgsiysnsible Person Signature Daternmé qua”V 2. Nursing Care: This hospital provides only geneta! duty nursing care unless. upon orders of the patient’s physician the patient is provided more intensive care. If the patient's condition is such as to need the service of a special duty nurse. it is agreed that such must be arranged by the patient or hislher legal representative. The hospital shall in no way be responsible for failure to provide the same and is hereby released from any and all liability arising from the fact that said patient is not provided with such additional care. 3. Physicians Are Independent Contractors: All physicians and surgeons furnishing services to the patient. including the radiologist, pathologist. anesthesiologist and the like. are independent contractors d are not employees or agents of the hospital. Some of these physicians will bill separately their‘services. I understand thatl am under the care of the patient's attending physician and that ician is responsible for obtaining informed consent as needed for my care. Patient Initials: bles: l understand that it is encouraged to leave personal items at home. The hospital m ms a fireproof safe for [he safekeeping of money and vaiuables, and the hospital shall not be liable for the loss or damage to any money. jewelry. documents. eyeglasses. dentures. hearing aids, cell phones. laptops. other personal electronic devices or other articles of unusual value that are not placed in the safe. Hospital liabiiity for any loss of personal property deposited with the hospital for safekeeping is limited by law to five hundted dollars ($500.00) unless a written receipt for a greater amount has been obtained from the hospital by the patient Financia! Agreement: The undersigned agrees. whether he/she signs as agent or as patient. that in consideration of the service to be tendered to the patient. helshe hereby individually obligates himself/herself lo pay the account of the hospital in accordance with the regular rakes and terms of the hospital. Shouid the account be referred to an attorney or collection agency for collections. the 5-" A copy o! this document should be given to (ha patient andany otherperson who fiiflns this document. lllllllIlllllllllllllllll 8039 Rev. 07/26/2018 WHITE - MEDICAL RECORDS CANARY - PATIENT’S COPY Page 1 of 2 Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 21 , , EL CAMINO HOSPITAL Gordon, Elliott Peter (g El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/201 9, D/c: 9/1 3/201 9 4302 Inpatient Record Gordy Ema P tar c a cammo Hospitar mfiaasgegéksfi saw”)'l‘ Noi'lfll 0' Sllltol Vllll' 2500 Grant Road Mounmin View, CA 940404378 Tel. (650) 940-7000 815 Pollard Road. L08 Saws. CA 95032-1438 Tel; (408) 3788131 undersigned shall pay actual attorney's fees and collection expenses. All delinquent accounts shall bear interest at the legal rate. By providing a telephone numberto the hospital or your referring physician. you consent to receive autodialed and prerecorded calls and text messages from El Camino Health. its vendors, and collection agencies relating to your account or relationship with the hospital. such as for treatment, biiling, collections and eligibility for government health care programs. You may opt out of automated calls at any lime by email lo gatient.accounts@elcaminohosQitamrg. 6. Assignment of Insurance Benefits: The undersigned authorizes, whether helshe signs as agent or as patient. direct payment to the hospital of any insurance benefit otherwise payable to the undersigned for services rendered at a rate not to exceed hospitals usual and customary charges. It is agreed that payment to the hospital. pursuant to this authorization. by an insurance companyIHealth Care Service Plan shall discharge that insurance company/health care service plan of any and all obligations under a policy to the extent of such payment. It is understood by the undersigned that helshe is financially responsible for charges not covered by this assignment. 7. Health Plan Obligation: It is the undersigned's responsibility to know and verify if benefits are covered in the insurance plan. The hospital maintains a list of health plans with which it contracts. A list of such plans is available upon request from the financial office. The hospital has no contract. express or implied. with any plan that does not appear on the list. The undersigned agrees that helshe is individually obligated to pay the full charges of all services rendered to himlher by the hospital if he/she be!ongs to a plan that does not appear on the above mentioned list 8. Advanced Directives: D I have an Advance Healthcare Directive. D is named as my surrogate decision maker and is responsible for roviding a copy of my Advance Directive lo the hospital. E I do not have an Advance Healthcare Directive. l am aware that l can ask for the Advance Directive information pamphlet. Your RI ht to Make Decisions About Medical Trea ent. U Patient declined to provide information. The undersigned certifies that helshe has read both pages of the Terms and Conditions of Service. has received a copy of it, and is the patient or is duly authorized by or on behalf of theW and accept its terms. 4/4/7 1/A I 2:.%& SIGNAWWLegaI RepresentativW LP4W Date Tim Indicate RELATIONSHIP to Patient Print Many J If this document was translated: SIGNATURE OR NAME OF LANGUAGE LINE Date Time Language r {3 J [1/ (Msfl mate Wutness Signature U/’L La. Date Time A copy of this document should be given to me patient and any other person who si ns thls document. 8039 Rev. 07/26/2018 WHITE - MEDICAL RECORDS CANARY - PATIENT'S COPY mimllm'lmmmmml Page 2 of 2 Imaging - Clinical Orders CT Head or Brain without IV Contrast [1 5597543] Electronicaily signed by: Linker, Alex Henri, MD on 09113I19 1630 Status: Completed Ordering user: Linker. Alex Henri, MD 09/13/19 1630 Ordering provider: Linker, Alex Henri, MD Authorized by: Linker, Alex Henri. MD Frequency: Once 09/13/19 1631 - 1 occurrence Indications comment: ALOC Questionnaire Viewed/Printed by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 22 , , EL CAMINO HOSPITAL Gordon, Elliott Peter (,) El caman Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/C: 9/13/2019 4302 Inpatient Record Imaging - Clinical Orders (continued) CT Head or Brain without IV Contrast [1 5597543] (continued) Question Answer Radiologist may modify the order per protocol to meet lhe clinical needs of the Yes patient? CT SinusesIMaxllla or facial bones without IV Contrast [1 5597546] Electronically signed by: Linker, Alex Henri, MD on 09/13/19 1630 Status; completed Ordering user: Linker. Alex Henri, MD 09/13/19 1630 Ordering provider: Linker, Alex Henri, MD Authorized by: Linker, Alex Henri, MD Frequency: Once 09/13/19 1631 - 1 occurrence Indications comment: Pain Questionnaire Question Answer Radiologist may modify the order per protocol lo meet the clinical needs of the Yes patient? Order comments: Patient presents with: Pedi struck by vehicle: 20 minutes PTA. helmted cyclist cycling across street. pt was struck by vehicle on right side. fell and twisted landing on right side, arrives with right facial swelling and abrasions and chin abrasions. left knee abrasion. right shoulder and upper arm. XR Shoulder 2+ View Right [15597547] Electronically signed by: Linker, Alex Henri. MD on 09/13/19 1630 Status: Completed Ordering user: Linker. Alex Henri. MD 09/13/19 1630 Ordering provider: Linker. Alex Henri. MD Authorized by: Linker. Alex Henn’. MD Frequency: Once 09/13/19 1631 - 1 occurrence Indications comment: Trauma/Pain Order comments: Pa‘ient presents with: Pedi struck by vehicle: 20 minutes PTA. helmted cyclist cycling across street, pt was struck by vehicle on right side. fell and twisted landing on right side. arrives with right facial swelling and abrasions and chin abrasions, left knee abrasion. right shoulder and upper arm. XR Knee 3 View Left [1 5597548] Electronically signed by: Linker, Alex Henri, MD on 09/1 3/19 1630 Status: Completed Ordering user: Linker, Alex Henri, MD 09/13/19 1630 Ordering provider: Linker. Alex Henri, MD Authorized by: Linker, Alex Henri, MD Frequency: Once 09/13/19 1631 - 1 occurrence Indications comment: Trauma/Pain Order comments: Patient presents with: Pedi struck by vehicle: 20 minutes PTA. helmted cyclist cycling across street, pt was struck by vehicle on right side. fell and twisted landing on right side, arrives with right facial swelling and abrasions and chin abrasions, left knee abrasion. right shoulder and upper arm. All Meds and Administrations lidocaine HCI (UROJET) 2 % jelly in applicator 10 mL [15597555] Ordering Provider: Linker. Alex Henri, MD Status: Completed (Past End Date/Tlme) Ordered On: 09/13/19 1720 Starts/Ends: 09/13/19 1725 - 09/13/19 1721 Dose (Remaining/Total): 10 mL (0/1) Route: lnlra-urethral Frequency: Once Rate/Duration: -- / -- Admin Instructions: Prior to Foley catheter insertion Tlmestamps Action Dose Route Other Information 09/13/19 1721 Given 10 mL Intra-urethral Performed by: Cramer. John. RN Medication Administration Report for Gordon. Elliott Peter as of 09/04/19 through 09/13/19 Legend: Given Hold Not Given Due Canceled Entry Other Actions Time Time (Time) Time lime Time-Action [Discontinued] | Completed | | Future | | MAR Hold. I £7 L'lnkedl‘vsz, Medications 09/04 09/05 09/06 I 09107 I 09/08 09/09 09l10 09I11 09I12 09I13 Completed Medications Viewed/Printed by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 23 EL CAMINO HOSPITAL Gordon, Elliott PeterI o cg El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019. D/c: 9/13/2019 4302 Inpatient Record Medication Administration Report (continued) for Gordon. Elliott Peter as of 09/04/19 through 09/13/19 Medications 09/04 09/05 09/06 09107 09/08 09/09 09/10 09/11 09/12 09/13 lidocaine HCI(UROJET)2%jeIIyin applicator yr 7 7 17211 10 mL Dose: 10mL Freq: Once Route: iurt Start: 09/1 3/19 1725 End: 09/13/19 1721 Admin Instructions: Prior to Foley catheter insenion Administration Detail Eef Action Time |Dose |Rate IRoute Site Duratio Comments I Reason 'User n 1 Given 09113I19 1725(8) 10 mL qlntra- Cramer, John 0911 3/1 9 1721 (a) urethral (19/13/12 1722(r) (s - time All Orders lidocaine HCI (UROJET) 2 % jelly In appllcator 10 mL [1 5597555] Electronically signed by: Linker. Alex Henri, MD on 09113I19 1729 Status: Completed Mode: Ordering in Verbal with readback mode Communicated by: Cramer. John. RN Ordering user: Cramer. John. RN 09l13/19 1720 Ordering provider: Linker, Alex Henn‘, MD Authorized by: Linker. Alex Henri, MD Frequency: Once 09/1 3I19 1725 - 1 occurrence Order Item Modification History: lidocaine HCI (UROJET) 2 % jelly in applicator 10 mL [1 5597555] Change #1 - Rx Autovefify by Cramer. John. RN at 911 3I2019 5:20 PM Item Description. a , ' Old Value ‘ New Value ,.19.”--"QQflLAwaflUWMQBWEBW.W V. , , 1 , PACS_P8360_ESCRIP_I MEDX_MACH7_CHANG E [1 25] Viewed/Printed by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 24 , , EL CAMINO HOSPITAL Gordon, Elliott Peter (,3 El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/2019, D/C: 9/1 3/201 9 4302 Inpatient Record All Orders (continued) Order Item Modification History: CT Head or Brain without IV Contrast [1 5597549] (continued) 1050 RESULTING LAB "":NE'VSiLEEWW ”""""'éi56“\?éihé">" All Administrations of CT Head or Brain without IV Contrast © The administrations shown are only for this specific order and not for bther orders for the same medication that may be In this encounter. No Administrations Recorded Dysphagia Screen [1 5597544] Electronically signed by: Linker, Alex Henri. MD on 09l13l19 1630 Status: Discontinued Ordering user. Linker. Alex Henri, MD 09/13/19 1630 Ordering ptovider: Linker, Alex Henri, MD Authorized by: Linker. Alex Henri, MD Frequency: Once 09/13/19 1631 -1 occurrence Discontinued by: Discharge Provider, Automatic 09/1 3/19 2221 [Patient Discharge] All Administrations of Dysphagia Screen © The administijations shown are only for this specific order and not for other orders for the same medicatiori that may he In this enéounter. No Administrations Recorded Keep patient NPO [1 5597545] Electronically signed by: Linker, Alex Henri, MD on 09113I19 1630 Status: Discontinued Ordering user: Linker, Alex Henri. MD 09/13/19 1630 Ordering provider: Linker. Alex Henri. MD Authorized by: Linker, Alex Henri. MD Frequency: Until Discontinued 09I1 3I19 1631 - Until Specified Discontinued by: Discharge Provider. Automatic 09/1 3I19 2221 [Patient Discharge] All Admlnlstrations of Keep patient NPO © The administrations shown are dnly for this specific ordef and not forr'outher orders for the same medication tha‘ may be In this encbunter. No Administrations Recorded CT SinuseslMaxilla or facial bones without IV Contrast [1 5597546] Electronically signed by: Linker, Alex Henri, MD on 09I13I19 1630 Status: Completed Ordering user: Linker. Alex Henn‘. MD 09l13/19 1630 Ordering provider: Linker. Alex Henri. MD Authorized by: Linker. Alex Henri. MD Frequency: Once 09/1 3I19 1631 - 1 occurrence Indications comment: Pain Questionnaire flesflon , Answer Radiologist may modify the order per protocol to meet the clinical needs of the Yes patient? Order comments: Patient presents with: Pedi struck by vehicle: 20 minutes PTA, helmted cyclist cycling across street. pt was struck by vehicle on right side, fell and twisted landing on tight side. arrives with right facial swelling and abrasions and chin abrasions. left knee abrasion. right shoulder and upper arm. Order Item Modification History: CT SinuseslMaxilla or facial bones without IV Contrast [1 5597552] Change #1 - Order Transmittal by Linker, Alex Henri, MD at 9/1 3I2019 4:30 PM Item Descriptlon 7 ' Old Value : New Value 70 RESULTING AGENCY PACS_P8360_ESCRIP_I MEDX_MACH7_CHANG WW...‘,_H..,-_.~.m... . . V ,, ,. 7 Eliza“, 1050 RESULTING LAB All Administrations of CT SinusesIMaxilla or facial bones without IV Contrast © The administrations shown are only for this specific ovder and not for other orders for the same medication that may be in this encounter. No Administrations Recorded XR Shoulder 2+ View Right [1 5597547] Viewed/Printed by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 25 , , EL CAMINo HOSPITAL Gordon, Elliott Peter (3 El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/C: 9/13/2019 4302 Inpatient Record All Orders (continued) XR Shoulder 2+ View Right [1 5597547] (continued) Electronically signed by: Linker, Alex Henri. MD on 09113I19 1630 Status: Completed Ordering user: Linker, Aiex Henri. MD 09/13/19 1630 Ordering provider: Linker, Alex Henri, MD Authorized by: Linker, Alex Henri. MD Frequency: Once 09/1 3/19 1631 - 1 occurrence Indications comment: TraumalPain Order comments: Patient presents with: Pedi struck by vehicle: 20 minutes PTA. helmted cyclist cycling across street. pt was struck by vehicle on n'ght side, fell and twisted landing on right side, am‘ves with n'ght facial swelling and abrasions and chin abrasions, left knee abrasion. n'ght shoulder and upper arm. Order Item Modification History: XR Shoulder 2+ View Right [1 5597553] Change #1 - Order Transmittal by Linker, Alex Henri, MD at 9I1 3I2019 4:30 PM Item f Description r fl Old Value New Value 70 RESULTING AGENCY PACS_PS360_ESCRIP_I MEDX_MACH7_CHANG Eliza, .. - "i636" ”M’Rm'ééiilflfifié'flfi" '7 “Efié‘i’lé‘liié‘s ' \ " All Administrations of XR Shoulder 2+ View Right © The administrations shown are only for this specific order and not for other orders for the same medication that may be in this encounter. No Administrations Recorded XR Knee 3 View Left [1 5597548] Electronically signed by: Linker. Alex Henri, MD on 09I13I19 1630 Status: Completed Ordering user: Linker. Alex Henri. MD 09/13/19 1630 Ordering provider: Linker, Alex Henri. MD Authorized by: Linker. Alex Henn‘, MD Frequency: Once 09/13/19 1631 - 1 occurrence Indications comment: TraumalPain Order comments: Patient presents with: Pedi struck by vehicle: 20 minutes PTA. helmted cyclist cyding across stteet. pt was struck by vehicle on right side. fell and twisted landing on right side. arrives with right facial swelling and abrasions and chin abrasions, left knee abrasion, right shoulder and upper arm. Order Item Modification History: XR Knee 3 View Left [1 5597554] Change #1 - Order Transmittal by Linker, Alex Henri. MD at 9I13I2019 4:30 PM Item Description Old Value New Value 7O RESULTING AGENCY PACS_P8360_ESCRIP_I MEDX_MACH7_CHANG”WWW, fl ,, , ‘ ,-W ‘ _ E‘Ugélm V v - ,,,,,, 1050 RESULTING LAB All Administrations of XR Knee 3 View Left © The administrations shown are only for this specific order and hot for other orders for the same medication that may be in this encounter. No Administtations Recorded CT Head or Brain without IV Contrast [1 5597543] Electronically signed by: Linker, Alex Henri, MD on 0911 3/19 1630 Status: Completed Ordering user: Linker. Alex Henri. MD 09/13/19 1630 Ordering provider: Linker, Alex Henri. MD Authorized by: Linker, Alex Henri, MD Frequency: Once 09/1 3/19 1631 - 1 occurrence Indications comment: ALOC Questionnaire _Q_I_sestion Answer Radiologist may modify the order per protoco! to meet the clinical needs of the Yes patient? All Administrations of CT Head or Brain without IV Contrast © The administrations shown are only for this specific order and nbt for other orders for the same medication that may be In this encoumer. No Administrations Recorded Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 26 EL CAMINO HOSPITAL Gordon, Elliott PeterI o (,E El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/201 9, D/C: 9/1 3/201 9 4302 Inpatient Record All Orders (continued) Dysphagia Screen [15597544] Electronically signed by: Linker, Alex Henri, MD on 09/13119 1630 Status: Discontinued Ordering user: Linker, Alex Henri, MD 09/1 3119 1630 Ordering provider: Linker. Alex Henn’. MD Authorized by: Linker. Alex Henri. MD Frequency: Once 09/1 3/19 1631 - 1 occurrence Discontinued by: Discharge Provider. Automatic 09/13/19 2221 [Patient Discharge] All Administrations of Dysphagla Screen ® The administrations shown are only for this specific order and not for Other orders for the same medication that may be in this encounter. No Administtations Recorded Keep patient NPO [1 5597545] Electronically signed by: Linker, Alex Henri, MD on 09I13H9 1630 Status: Discontinued Ordering user. Linker, Alex Henn‘. MD 09/13/19 1630 Ordering provider: Linker. Alex Henri. MD Authorized by: Linker. Alex Henn', MD Frequency: Until Discontinued 09/13/19 1631 - Until Specified Discontinued by: Discharge Provider, Automatic 09/13/19 2221 [Patient Discharge] All Administrations of Keep patient NPO © Tfié administrations shown are only f0}- this specific order aha not for othér orders for the same medication that may be in thlé enchuhter. No Administrations Recorded CT SinusesIMaxilla or facial bones without IV Contrast [1 5597546] Electronically signed by: Linker, Alex Henri, MD on 09(13I19 1630 Status: Completed Ordering user: Linker. Alex Henn‘, MD 09/13/19 1630 Ordering provider: Linker. Alex Henri. MD Authorized by: Linker. Alex Henri. MD Frequency: Once 09/1 3/19 1631 -1 occurrence Indications comment: Pain Questionnaire _Question Answer Radioiogist may modify the order per protoco! to meet the clinical needs of the Yes patient? Order commems: Patient presents with: Pedi struck by vehicle: 20 minutes PTA, helmXed cyclist cycling across street. pt was struck by vehicle on right side. fell and twisted landing on right side. am‘ves with right facial swelling and abrasions and chin abrasions. left knee abrasion, tight shouider and upper arm. All Administrations of CT SinuseslMaxilla or facial bones without IV Contrast © Thé administrations shown are only for this specific order and not for other orders for the same medication that may be in this encounter. No Administrations Recorded XR Shoulder 2+ View Right [1 5597547] Electronically signed by: Linker, Alex Henri, MD on 09I13I19 1630 Status: Completed Ordering user: Linker, Alex Henri, MD 09/1 3/19 1630 Ordering provider: Linker. Alex Henri, MD Authorized by: Linker. Alex Henri. MD Frequency: Once 09I1 3/19 1631 -1 occurrence Indications comment: TraumalPain Order comments: Patient presents with: Pedi stmck by vehicle: 20 minutes PTA, helmted cyclist cycling across street, pt was struck by vehicle on right side. fell and twisted landing on right side, arrives with right facial swelling and abrasions and chln abrasions, left knee abrasion, fight shouIder and upper arm. All Administrations of XR Shoulder 2+ View Right © The administrations shdwh are only for this specific order and not for other orders for the same medication that may be in this encounter. No Administrations Recorded XR Knee 3 View Left [15597548] Electronically signed by: Linker, Alex Henri, MD on 09113l19 1630 Status: Completed Ordering user: Linker. Alex Henn‘, MD 09l1 3/19 1630 Ordering provider: Linker, Alex Henri, MD Authorized by: Linker. Alex Hemi. MD Frequency: Once 09I1 3/19 1631 -1 occurrence Indications comment: TraumaIPain Order comments: Patient presents with: Pedi struck by vehide: 20 minutes PTA. helmted cyclist cycling across street. pt was stmck by vehicle on right side. fell and twisted landing on right side, arrives with n'ght facial swelling and abrasions and chin abrasions, left knee abrasion, right shoulder and upper arm. Viewelerinted by Torres, Miguel Angel at 11/19/19 3:23 PM Page 27 EL CAMINO HOSPITAL Gordon, Elliott PeterF o V (,E El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/c: 9/13/2019 4302 Inpatient Record All Orders (continued) All Administrations ofXR Knee 3 View Left © Th6 adihinisfréflohs shown are only fof {his specific order and néi for other orders f0} the same medication that may be in thls enéouhter. No Administrations Recorded Vitals Most recent update: 9/1 3/2019 4:30 PM BP Pulse Temp Resp Ht 116/78 (85 %. z = 1.03/ 80 36.8 °c (98.2 °F) 14 152.4 cm (5') (3 %. z= 4.84» 96 %, z = 1.74)‘ w: Spoz BM: 46.7 kg (20 %. z= - 99% 20.12 kglm= (58 %. z= 0.21 )1 0.84” *BP percentiles are based on the 2017 AAP Clinical Practice Guideline for boys tGrowth percemiles are based on CDC (Boys. 2-20 Years) data Flowsheets (all recorded) ' Abuse Indicators RoW’Name 09M 3I19 1649 09113119 1631 Screening Do you feel safe at UTA(commentbox) -JC Ptnotalone ~SH ,'39!!19.3m-m,_ “H-“g w _ ,. Do you feelsafein UTA(commentbox) -JC Ptnotalone -SH .‘Ywélélloflfilpflww WW, ,, --_ . _ r . r r ,, . v , , k- AbuselNeglecWiolenc No suspected abuse, No suspected abuse. e- ‘ ,. h . qngaieggginglgngg,:99 , ,nsgleqtg‘grnglgngfifl . . , , , . . ,7 ,7 Recorded by [JC] Cramer. John, RN [SH] Hawkins. Sonya 09/13/19 1649 Man'e. RN 09/1 3119 1631 Acuitleestinatlon Row Name 09/13119 1632 Acuitleestination “Béfigntagaitxmqfl 2§Hm\ 7 , ,. a ., V , , A ‘ ‘ A , 7 K . ‘ ,7 ED Destination Main from Waiting Room -IEEQSQQHJPJEEM-.. “Iflagfigqmplfitfi r$H ‘ . . H ‘ ,. ,, , 7 7 ,- , Was this patient part' No -SH of a mass casualty iuflgmz_____ . , _ , ‘7 A . . ,, , ,7 . 7. 7 , 7 ,, .7 , , ,7 , 7 , Recorded by [SH] Hawkins, Sonya Marie, RN 09/13/19 1632 AUDlT-C Row Name ' 09I13I19 1631 Alcohol Use Disorders Identification Test - ConSumption (AUDIT-C) How often do you O -SH haveadrink containing alcohol in ,_,!he..P§.§.t_Y§,aI? , How many drinks do 0 -SH you have on a typical day when you were drinking in the past ,_ YEEIEM.” H ‘ . ,, H . How often have you 0 -SH had six or more drinks on one occasion in the £§§L¥9§fiw ,, . .‘ .V Iggélfiggllfi Score. ,Qfi:§tl K Recorded by [SH] Hawkins, Sonya Marie, RN 09/13/19 1631 Viewed/Printed by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 28 (2% El (amino Health 2500 GRANT ROAD EL CAMINO HOSPITAL Gordon, Elliott Peter MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/2019, D/C: 9/1 3/2019 AUDlT-c (continued) 4302 Inpatient Record Flowsheets (all recorded) (continued) Columbia Sulcide Severity Rating Scale (C-SSRS Short Version) Row Name 09l13l19 1649 Columbia Suicide Severity Rating Scale 09M3I19 1631 “L_Nshto be Deadmw I No -JCv n V H _ fl _,-_ U ~ ‘ > 2. Are you having any No dc Pt not alone -SH thoughts of hurting ,_yourse|forothers? fl 7. ‘ _ - ,A .. 6. Suicide Behavior No -JC - Qqeiion n ,. .x V. , w , Recorded by [JC] Cramer, John, RN [SH] Hawkins, Sonya 09/1 3119 1649 Marie, RN 09/13/19 1631 Consults Row Name 09/13I19 1748 09113I19 1747 09/13119 1746 Consults Other Returned Phone Call Called -LT Call Requested Discussed xray results radiologist [2] -LT with radiologist, who believes there is no H ,. 7 Easmrg 111.:1-1 ,, V Recorded by [LT] Tran. Lindon [LT] Tran. Lindon [LT] Tran. Lindon Custom Formula Data 09/13/19 1749 09/1 3/19 1749 09/1 3l1 9 1749 Row Name 09113119 1630 09M3I19 1629 OTHER Hidden M u a U 7i;§!-!7 v h _ 7 r- ‘ fl 7 Weigh! Change (Q) V_ 9321 gm”-SH 7 7-: 7 7 wgigbiifllbémm... 103|b__s_ -S.H.___. A .2: _ _ BSA (Calculated- sq 1 .4 sq meters -SH - Binh Weight above ~SH - 7 Comparison- BETIRED , M h .. . ‘ N f Avg Weight Gain Last 9321 g -SH - 7 Days (168 Hrs) - .RETIRED _7 _ ‘ V 7 A LengthChange W r Qecméshfl 7 ‘ - Weight m (lb) to have 127.7 -SH - “BM|= 25 .M W.._ ‘ V ,IBW_I_k_q (Calculated) 50 -SH W :l BMI (Calculated from 20.1 -SH - "daily weight) w ‘ I IBWjHarnwiMMethod) u H 48. 1_8 kg -SH - V_Totalfl__.Daily Dose H 1869 -SH - ‘BasalDose I r 9§§ -§H_ 7 V H W-_ A_Nutritional Dose A _ _§“1*2~_-§_H - ”Iotal.Daily. pose; ‘wgwfiH - _ Basal Dose _ 791 JSH :- _NutntxonalDose 7 r ‘ A gggmfiflw 7-," VIsLtfialyéiIVDQSek, . .2§;§§--§H : ,BasalDose M r illgggwfiH _:-_ fl V 'NutrmonalDose ‘ / . §_.,§.9N;_S__l-l_ -- '[ota_l Daijy_Dqse V 2_8_.9~3.7-SH “-7, 7 _B_a_sang__se w ”_7_1.4_.9.2“-_S*H 7 t V _ Nutrmonal Do_se_ _ ‘ iéigzu-"SH - fl ’ Scheduled Regular 1.75 -SH - H Insulin Dos_e V U b Scheduled Regular 2.34 -SH - 10§Eli11995£, _ _.__,.._ , _ Standard Regular 2.92 ~SH - Insulin Dose Viewed/Printed by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 29 EL CAMINO HOSPITAL Gordon, Elliott Peter0 o (,§ El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 218/2005. Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019. D/c: 9/1 3/2019 4302 Inpatient Record Flowsheets (all recorded) (continued) Custom Formula Data (continued) Ré‘w' Name 09/13/19 1630 ' 09113119 1629'"- ‘éefiéafiiéa iié'guié} 3.5' '-sH -- ,‘Jnigliwsééw. . W ,. M- V 7 ,7 , 7 V ., . . Recorded by [SH] Hawkins. Sonya [SH] Hawkins. Sonya Marie, RN‘ 09/13/19 1630 Man'e. RN 09/1 3/19 1630 Row Name 09/13/19 1630 VitalSigns ...B.M,L.(9§19sal.a!9q)w,.,. ”?.ELLSH .‘ ‘ . ,. v . Recorded by [SH] Hawkins. Sonya Marie, RN 09/13/19 1630 Row Name 09113I19 1630 Birth Anthropometrics Birth Weight (First 37400 -SH Birth Length (First 152.4 -SH .flWflg‘mlwwmw ., V ‘ . . ‘v , . p . . 7., . x ., , ,, , .7 M Recorded by [SH] Hawkins, Sonya Marie! RN 09/13/19 1630 Row Name 09l13l19 1630 Estimated Energy Needs Mifflin- St.Jeor 1355 -SH Equation (Overweight .QLQbségffliéflté)_,,._V,___.__-,._.,,W, 7 Recorded by [SH] Hawkins. Sonya Marie, RN 09/13/19 1630 Row Name‘ 09/13119 1630 Adult IBWNT Calculations IBWIkngalculated) 50 -SH_W"W V 7 7 I A fl ‘ H W, V .1 7‘ 7 V ‘ A M LowRangthGmL/kg ,300mUk9,_-§|:L,,.w _ 7 ,W Adult Moderate Range 400 lekg -SH\MmL/kqw_ ,, , .7 , V ,, , A 7 , 7777777 AduItHigh Range Vt 500 mLJkg -SH ,lQmLflsgm.” “7, H H V, _ H 7. .V ,V V .. , , H ,, Recorded by [SH] Hawkins, Sonya ' Marie! RN 09/13/19 1630 Row Name 09I13I19 1631 Alcohol Use Disorders Identification Test - Consumption (AUDlT-C) UI<3£§1ALJQEI£§99I9V 7 77,9 :§!:I.. . .V .. ..IQ£§!ALJQ!T:QS.C£I§. .9,:§H , , . V _ ‘ . .§E.9Le,-._-hw-w .fi r ”77.90131 r , _ ‘ _ 7 ,zfliwgfi er§ttfl , . , v .égfiemfigrfi 9_-§tL ., 7 Recorded by [SH] Hawkins. Sonya Marie, RN 09/13/19 1631 Row'Name 09M3I19 1649 Columbia Suicide Severity Rating Scale C-SSRS Risk Level Minimal Assumed RiskH” W.,,,.V..7:J§‘.r ‘ < Recorded by [JC] Cramer. John, RN 09/13/19 1649 Departure Condition Row Name 09/13l19 1820 Departure Condition I__l_)~e_padure Comm ~ Good -JC_ r ,.M@1filx.§t. Dgnattura Amhulatqry .-J,C Discharge Alert -JC Assessment! V.E£°.‘=.we‘1‘i£§5.,w.-w...w - . Discharge Instructions Printed discharge care Provided: instructions;Medication reconciliation Viewelerinted by Torres, Miguel Angel at 11/19/19 3:23 PM Page 30 (3; El Camino Health 2500 GRANT ROAD 4302 Inpatient Record EL CAMINO HOSPITAL Gordon, Elliott Peter MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/2019. D/C: 9/1 3/2019 Flowsheets (all recorded) (continued) Departure Condition (continued) Row Name ' 09/13/19 1820 ""i'fis'txiiéfibniWfié‘rf'té"séé'k” V " W medical care;Laboratory/EKG findings;Patient instructed not to drive self home,How to manage “pain at home_ -JC Discharge Insiructions Patient. Father;Mother ‘ Received Bv: W ,. -JC Teaching Method! Verbal Instruction;Given ,-R__§§P.9fl5.§’_____ __-,,,VVW."_“9.'1!113_L93§1:J_QV ,, ,, ,V 7 Departure Mode 7 r With family member -JC N V V V Recorded by [JC] Cramer John RN 09/1 311 9 1821 ED Primary Assessments Row Name 09(13I19 1647 Neurological ENQLJIQAMQLL ‘. .. V WPI- -JC Recorded by [JC] Cramer, John RN 09/13/19 1649 Row Name 09113119 1647 Giasgow Coma Scale Eye Opening 4_ _ 4 -JCV v V 7 7 _ _ 7 A _ «BestVerbal Re_s_p9_nse _V__5__-_.j_C. fl v A v - _ _ ~ $ ‘ V A BestMotor Response‘ n6 -JC _ _ 7 w v V i Glasgow Coma Scale 15 -JC Score. 7. . . Recorded by [JC] Cramer. John, RN 09/1 3/19 1649 Row Name 09113119 1647 HEENT ,BEENIMQEL , X, :49. 4 Head and Face ndeme§s night qhe‘erk _-.JC, Swelling;TraumafInjury.Te infirm- 7 ,mtchi-ig V , , “Iggggg Pink & moist -JC .¥9199-. ._ . QQMEnT-JQ Mucous Membrane(s) ng‘sjriq 7 ,_T£§!h A , anagthACA ‘‘‘‘‘ Neck No rigidity;Symmetrical.No t i 7 _ 7 V 7 7 tendeme§§_abrasion -JC Recorded by [JC] Cramer John. RN 0911 3/19 1649 Row Name 09M 3I19 1647 Musculoskeletal Musculoskeletal X -JC MEL.) 7 p A. , RUE Limited movementlnjuryltrauma abrasion to upper arm A ‘ and elbow -JC 71,.qu V 7 Full movement -JC H 7 W RLE ‘ ‘ a Fullmovement -JC a ,..':.L.E , Ful} movement -JC v Recorded by [JC] Cramer. John RN 09/13/19 1649 ED Quick Updates Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 31 (:9 El Camino Health ED Quick Updates (continued) EL CAMINO HOSPITAL 2500 GRANT ROAD 4302 Inpatient Record Flowsheets (all recorded) (continued) Gordon, Elliott Peter MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/201 9, D/C: 9/1 3/201 9 " Rdwnain'e‘ ‘ 09113119 1653 09113119 1634 ' ‘ ‘ ‘ Quick Updates Quick Updates Returned from Xraszo - Quick Updates - Free - Per Dr Linker. no c-collar Leastw 7. , 7 7 ,anggegwfili ‘ Recorded by [JC] Cramer. John. RN [SH] Hawkins. Sonya 09/1 3/1 9 1658 First Provider Evaluation Marie. RN 09/1 3/19 1634 Row Name 09113119 1628 First Provider Evaluation Time File First Provider File -AL .E‘Lélgélbflfiffle, . mm- - w ,- ,, , Recorded by [AL] Linker. Alex Henri. MD 09/1 3/19 1632 Follow Up Row Name ‘ 09/15/19 1707 ED Follow Up .‘BQQQEGEIQHQ‘MERQH ”XgfirzALw 7 ,, .._E9!JQW_HQI§§9'!§Q V, ,,X.e.§_:A£-W _ _ ,_ V , Recorded by [AL] Linker. Alex Henri, MD 09/15/19 1707 Height and Weight Row Name 09I13119 1630 Height and Weight £9199: m, -. n , . ”moanétT-fi, _, _ V v , , HfléiBDLMémQQV . . §.t3;t§§.:.3.li- m , , , , - flsigmm V H , Ailiafifi _ u ,V Recorded by [SH] Hawkins. Sonya 7 Made, VRVN 09I13l19 1630 Row Name 09I13l19 1630 Drug Calculation Weight Drug Calcuiation 46.7 kg -SH -WWQLQDLW , H 4. - A U , Recorded by [SH] Hawkins. Sonya Marie, RN 09/13/19 1630 LACE+ Score r rRo’w’Name 09113I19 1821 OTHER \VLAQELSWQQEQ , I 2.3.39 ,. .‘ . , .A .A , Recorded by [JC] Cramer. John. RN Sepsis Screening 09/1 3/1 9 1821 Row Name 09H3I19 1631 Sepsis Screening .Argtiggrs. 9:916233. V, N9 _-.§!7!.. . ‘ . Is there a suspected No -SH infection or is the patient .rimflanQEQmPIQEDEQQ? - . , Is the palient's mental No ~SH ”Mééflefig? w, A ‘ V. ,, Recorded by [SH] Hawkins, Sonya Viewed/Printed by Torres, Miguel Angel at 11/1 9/1 9 3:23 PM Page 32 (SE El Camino Health Sepsis Screening (continued) EL CAMINO HOSPITAL 2500 GRANT ROAD 4302 Inpatient Record Gordon, Elliott Peter MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/2019, D/C: 9/1 3/201 9 Flowsheets (all recorded) (continued) ”“R'ofw Name 09113719 1631 ‘ ‘_W , ManeRN 09/13/1916” . Vitals Row Name 09/13119 1629 Pain Assessment Pain Assessment Yes -SH BEEEELQQSL. ‘ M- , w a _ Recorded by [SH] Hawkins, Sonya Marie. RN 09/13/19 1630 Vitals Row Name 09l13l19 1629 \fltalSigns -Ismgfl, V H - 3.6-8°C(9§ 2“TF).,-§|i , , , « , “£959“ ,_ §0 -SH r... ,,,,,, V , A, - Sourceuw W _ Oximetry -SH _ ¥ Raga” lim-ét! BP 1_16I_78 -SH 69.03%. V §§3Zq -.SH ,. Recorded by [SH] Hawkins. Sonya Marie, RN 09/13/19 1630 Row Name 09/13I19 1629 Oxygen Therapy gxmapgyisgw A ,7 N0ne WM" ‘ ‘ 1 Other 09/1 3/19 1748 09I13/19 1749 - Discussed xray results with radiologist who LT k .. ,, , ‘ Pfllflfilbflfi.!§flQ.IE§9t9Ee.,, . ‘ 2 .thgr. ‘ Q&UfillQJZAQ , 09/13/19 1749 V QQIJ,.B€9I.J.§§19£1.radiologist _ LT 2 Other 0911 3/19 1746 09l1 3119 1749 Call Requested LT User Key (r) = Recorded By. (t) = Taken By, (c) = Cosigned By , Initials Name Effective Dates Provider Type DisclpIine Ala". ‘ ,. Linker. Alex Henri MD. V9.5._I91!1..9_ : . .thsman V, _ ,E.hY§i9ian . m_Sfl > Hawkins Sonya Mane, RN > 1_1_I‘14l18_- 7 iReqlstered Nur§e_ Ngrsfle 7 7 7 Ll.“ v_ Tran, Lindon ‘ 02/05/19 - Scribe ‘ - 7 V 7 H JC Cramer. John. RN 06/13/19 - Registered Nurse Nurse Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 33 , , EL CAMINO HOSPITAL Gordon, Elliott Peter (,E El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/201 9, D/c: 9/1 3/201 9 4302 Inpatient Record After Visit Summary After Visit Summary printed by Linker, Alex Henri, MD on 9/13/2019 5:51 PM Viewed/Printed by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 34 (SP El Camino Health Call Information EL CAMINO HOSPITAL Gordon, Elliott Peter 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/2019, D/C: 9/1 3/2019 4302 Telephone Report Department Center 9/1 3/2019 4:32 PM Mv Emergency Dept MV Reason for Call History User Date & Time Reason for Call Hawkins, Sonya 09/1 3/2019 04:32 PM Pedi struck by vehicle Marie, RN Comment: 20 minutes PTA, helmted cyclist cycling across street, pt was struck by vehicle on right side, fell and twisted landing on right side, arrives with right facial swelling and abrasions and chin abrasions, left knee abrasion, right shoulder and upper arm. Reportedly vehicle was traveling at 20mph when pt was struck. User Date & Time Reason for Call Hawkins, Sonya Marie, RN Call Documentation No notes of this type exist for this encounter. Care Advice Given No Care Advice given for this encounter. Code Timeline 09/13/2019 04:29 PM Pedi struck by vehicle Comment: 20 minutes PTA, helmted cyclist cycling across street, pt was struck by vehicle on right side, fell and twisted landing on right side, arrives with right facial swelling and abrasions and chin abrasions, left knee abrasion, right shoulder and upper arm. No data selected in time range Patient Care Timeline (911 3I201 9 16:23 to 9I1 3I201 9 18:21) 9I13I2019 Event Details User 16:23 Patient arrived in ED Lacanlale. Madyn M i's'fééfid " " " ” ’EfiQ‘r‘g’éhEii’éiiééfihiér" ‘Lé’céfiiél'e.’iu§ri§i{ih created 16255251 ” ”'Kiri‘G'alndér‘iibiéihi' ‘fii‘tby't'he' car' “1655251” fiéiiéfiéfiv‘é‘fiziéb” ‘ ” ‘ ‘ Léeéhiéie,'ifiéfiyfi M‘ 1356 "’i-‘iFsYFébQi'cié'r ’L‘inEéfiAiék fie’hh‘filb" Evaluation of Patient i’éé’é' ”"fifi's'i'fiééiiidér ' ’fii'rs't‘fir‘bwd’ekéJaI'fi'aiién fimé" ' ‘Ei‘riik’éfiléié Hé'iiiififi" Evaluation A7,. , , » .. fligfifit,P'TQViFjefEYa'99fi90 Time? File, ,. 7W 16:29 Vitals Reassessment Vitals Timer Hawkins, Sonya Man'e. RN - ,, A ,. . HBQSIQGWQIEIIWF Yes. -Q . 16:29 Vitals Pain Assessment Hawkins, Sonya Pain Assessment Performed: Yes Marie. RN Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 35 (:9 El Camino Health EL CAMINO HOSPITAL 2500 GRANT ROAD Gordon, Elliott Peter MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/2019, D/C: 9/1 3/2019 4302 Inpatient Record Patient Care Timeline (9I1 3I2019 16:23 to 9/1 3I2019 18:21) (continued) 9I13I2019 r Eventm“ D_etalls_ __ K w ‘ ‘ 7 - ”User A r v 16:29 Vitals Vital Signs Hawkins. Sonya Marie. RN Te_mp: _36__8__°_C _(_98._2?E)_ ‘ H > r Pulse: 80 Source Oxnmetry Eegp: 14: BP: 116/78 Sp02: 99 % Oxygen Therapy Oxygen Device: None (Room air) Pain Assessment , , ,,W,MW- MM WE?" Asses§me"E ° 1° ”flPérifl‘SuQWQQ A4 .V “mmmmmu d -, u 16:29 Custom Formula Data Other flowsheet entries Hawkins, Sonya Marie. RN , ‘ H ‘ ,. $996.9: .4 V. 16:29:46 Assign Attending Alex Henri Linker, MD assugned as Attending Linker, Alex Henri. MD '1'6"?2‘é?&‘é""" " “A‘é‘éi‘gn Ehysi'éfa‘n”” ‘ ‘ ‘ ’ ’ "‘[i'nTé'rI’RiéYfiéfihTi/IB“ ?éiéééfi" " ' ‘T‘Ei‘g‘é‘e‘EEo'Ei'Ei’a’g‘éfia‘h’ ' "“Fl‘a’vikfiws'fs'ébya‘ Man'e. RN ‘1'6‘?2‘é2§’1‘ ' " '"ffi’a'é‘of ‘s'ia‘iiéii " ' ’ ’ ' H'a'Jinns Sonya Marie RN “1.5255357 A ‘ I h ‘l‘CWfi-lgf‘b‘éififlfil-a'ifit‘é‘ M ' ‘ ' + Pedi struck by vehicle (20 mlnutes PTA helmted cyclist cycling aciHssTstreet ptwas struck by H55vi I lBW/kg (CaIculated) 50 BMI _(Qaicglhaleq from daily weight). 20. 1 V r V_IBW (H_amwi Methgd) 48 18 kg ' Total_ _D_a_il_y _Do§e_: 18.69 §§§§[va5_8. 9.3_5 __u“MWMW Iota! Daijy Dose 14.92 §§§§’P.°Se. 7 91m ,N‘JEE'EEQC'al D0595 ._g .34 EteLPefly99§e 2.3.36. V §a§§199§95 J1 68 “Nutritional Dgse: _3.89 H I T__ota__l Daily _Do_se:_ 2_8.03 Bas_a| Dose: 1_4.02 I r “NutritionaIDose 467 thedulefingggular Insulin Dose“ 1 ZS Schedu‘|_e_dv_R_egular |n_su|in D539: 2.34 I ‘ fl 7 V ‘ ‘ Standard Regularlnsulm Dose: 2.92 Scheduled Regularlnsuhn Dpse: 3.5 fl H 16:30:55 CT Ordered CT SINUS FACIAL BONES W0 CONTRAST CT HEAD W0 CONTRAST Linker, Alex Henri. MD Viewed/Printed by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 36 (3% El Camino Health EL CAMINO HOSPITAL 2500 GRANT ROAD Gordon, Elliott Peter MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/1 3/2019, D/C: 9/1 3/2019 4302 Inpatient Record Patient Care Timeline (9M 3/2019 16:23 to 9/1 312019 18:21) (continued) , 9I13I2019‘ _ ' ” MEYentm a v A V Details ‘ fi v A v Uggr -16.30.55 XR Ordered XR KNEE 3 VIEW LEFT. XR SHOULDER 2+ VIEW RIGHT Linker Alex Henri, MD 1835633 ' " ”EEJSE;EEESA‘ ‘ ' CT fié'a'dBF 'B‘Féiéi'fiiiiafit'iVfidfii‘raTéi E“By§bh“a“g"i'5‘§é¥ééfii ’R‘éép'fiau’éfi‘t‘fi'fi'o’ cf M ”Uhk‘éflie? i-‘I’e‘fi‘ri' M15 ' SinuseslMaxilla or facial bones without IV Contrast ; XR Shoulder 2+ View Right ; XR Knee 3 \fiew Lefl '1“6“:§6?§8“ “ ' ' " ‘ ‘ Zfié'r'gTégfiéQEWe'a‘ ' ' “ " ‘ ‘ ”H‘aVvkfifi‘éEo‘fijé“ Man'e. RN 16331 " "' "“fréOSi §aré’efiih’g"‘ ' ‘Hio‘e’yaa Béén ’ih‘bbfiiééifiiz’h 'so‘ni‘e‘dhé Whisks; Jakifib’fim‘sfii‘e’ {66 y‘o‘fi ‘h‘avééh; bfihé " 'Ré‘éian‘sfédhya” following symptoms? Muscle paln; Bruising or bleeding ; Have you traveled internationally in Marie. RN the last month? No T551" "“ "‘Kfifiiflé" " ‘ ' '” '"“Ki"éa'fiéfij’s'é'6&3EEEEQ'iE’éH‘EfiéEtEBH‘fé’s't’i‘ééfi‘s‘dfififiahiflfi‘fiiiéi‘ ' "’fia'wii'r'ié]$695 " " ‘ " ' Marie. RN How often do you have a drink containing How many drinks do you have on a typical alcohol in the past year): Never day when you were drinking in the past,W H ”a 129111. 1.9,! 2 _‘ ‘. .. ‘ _ ,_ How often have you had six or more drinks Total AUDlT-C Score: 0 W r- M h WWW “W _ ‘7 r V, on one occ_asi_on in t_he past year?: Never W . ‘ .W _ A r q 7 ~ ‘ 16:31 Abuse lndicatom Screening Hawkins, Sonya Marie. RN Do you feel safe at home?: Pt not alone Do you feel safe in your relationships?: Pt 7 Wm. \ A, M -. V, - , 0,91 §J9£§ m AbuselNeglecWiolence: No suspected ”WW V r v r_ m_wwwm u . 7 _ abuse. ngggecg or yi9l_ence_ ~ ‘ 7 M mwumu _. H I 16:31 Sepsis Screening Sepsis Screening Hawkins. Sonya Man‘e, RN Are rigors presenl?: No ls there a suspected infection or is the . P??.ifim.immgnwgmflmmifiglVN9. ‘ , w w W ls the patuent's mentai status altered? No ~ ‘ A7 _ A mm» V a m 16:31 Columbia Suicide Columbia Suicide Severity Rating Scale Hawkins. Sonya Severity Rating Scale Marie. RN (C'SSRS Short vers'on) 2. Are you having any thoughts of hurting mm > 7 W _ H 7 mm yourself or_others?: Pt notMalone n hW w a ”m“MM_W H 16:31 Custom Formula Data Alcohol Use Disorders Identification Test- Consumption (AUDlT-C) Hawkins, Sonya Man'e. RN _ _TotalmAUDJT-C Scotet 0 Scoggogw m v7 fl W gag Boy; §coig: _0 3rd wa Score 0 ______ W WWW“WWW W n r_ _T_ota| AUDIT_-C Score: 0 N r_mWWW 16.31 :02 Home Medications Hawkins. Sonya Reviewed Marie. RN 1351265 ' i-IEEJfiEfiEfiEJ“ ‘ ” " "s”ééiiah’é' r’éfiéfii’e‘a I’Meai'éal'l. ”Siiréfdé'l " HéWfiifié’."’s"o}iyé W . M- , V V, fl - v.-‘M_a.ri§. RN . W, A 16:32 Triage Completed Hawkins. Sonya Marie RN $6535 ' ' " ' A&EiiyifiéEt’zfiéiIBH' ' ' 'A’c’hit‘fib'é’éii’hé‘tién ’ " "Hawai‘édhya ' ' Marie. RN PatnentAggltx r___ ‘ ED_ Destination: Main from V_V_a_itlng Room_ _ Tn'age Complete: Triage complete Was this patient part of a mass casualtyWM _ “WWW“--W fl. 7. ..___w.__,_ M _ , ingigentz- N9 _._ 7 A ,__ ,A A 16:32:21 Chief Complaints Pedi struck by vehicle Hawkins, Sonya Updated (20 minutes PTA, helmted cyclist cycling across street. pt was struck by vehicle on right Marie. RN side. fell and twisted landing on right side, arrives with right facial swelling and abrasions and chin abrasions, left knee abrasion, right shoulder and upper arm. Reportedly vehicle was traveling at 20mph when pt was struck. ) 36:323‘2'6‘ ' Acuity 2'éei'e’ét’e‘d H‘a'wsilh's', édnyé Marie, RN i'éié‘éf’dé ' " " ' é’a'flér’n E&éifiéfiifi’éb ' 'TB Fc'i‘c‘ihiWé '01’ ' "Hafik’i'ri‘é.“s’d'fiyé ‘ ' ‘ H,.,-W.W -u A . _, ‘ . w . . M?.rig BM- H .. w w 16:32:42 Patlent roamed in ED Hawkins. Sonya Marie. RN i655; ‘ ” ' "ED dfiiéii Ufiéétég ' db'ié'k’tibé‘l'a’t’e‘é Héiikifié Sonya ' Marie. RN Quick Updates- Free Text: Per Dr Linker. .. . n9 mi'arneqdefi, . n 16:34:20 Patient transferred From room WR O1 to room MVED17 Hawkins. Sonya Marie. RN Viewelerinted by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 37 (i; El (amino Health EL CAMINO HOSPITAL 2500 GRANT ROAD Gordon, Elliott Peter 4302 Inpatient Record Patient Care Timeline (9/1 3I2019 16:23 to 9/1 3/2019 18:21) (continued) ”9M 312019 $3356” ‘ ‘ 7673635 “- 1‘674‘émm' ' ‘ 13:33“ W d 363E” M i‘éiS’fiXO‘W ' i‘éié'fzz‘s ' "' i's'fi'ié'r W53 v ~ ??E'OAQifi'zW" " ' " ' ‘ ‘ ifdéf‘z‘é” ” ” " ?ibéfig " ‘ TiffiEEEWW” ’ ‘1'7'3’1'451'3 ' Viii's'fi?" ' fiz‘é'o’ib'i " " V‘ 17156361 ' Patient transferred KEQQfi‘fiii'rEe‘ ' " ' V ‘EmQE'KéEBECvTe‘JEéJ V ‘éfifiififiry’ ‘ ' Assessments Vflifiéé‘lfiaiééi‘ohr‘s‘ " ’Eéifiifiifi'a”s‘fia}ié Severity Rating Scale (C-SSRS Short Version) Efiéia'rfifioiifiiié 65h ‘ ‘fiégi’éfiéfldfi’EEfiii'e'ie'd' irfié'gifi‘gmeié‘fii “Siéfiéd ' " 'iifié‘g'ifiaéiéfiéié‘r‘téa ' 'Ebflfiifiékfiijbiéié's" iifi'éé‘i'r’ié Eié'a’ifi "E'Fiéi’ed‘ 'IEh'a'éing éiéifi‘é'tafr'fe'd i'fii'é'éihg' éxéiii $53136 Siééil‘biéi’i'ih'ifiaiy ’ Result ED Preliminary Read 16139139 'Eiééifi E5838 655$ 'P'Ia'c‘é'd" éidéEs'AékhofiiéE'géd Details r r N "5&3 ‘kfiéé‘é‘iiiéifi ‘E‘e‘fl‘ "'"Jbiififiéa‘r‘fi'éfi"fifi"éééigfiéa‘éé'fi'ééi's'ié'iéii‘N‘Ix‘réé ‘ ' Hgfiiifié §5ri§§ MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/C: 9/1 3/2019 User Marie. RN ”"é'r'é'ifi'éfi'iéfifififiw fiéW'L "6fii‘e'a'é’éfé‘ié’ifi‘ih‘ifiEfifiVE&"fifl‘a's'f 3‘ fifiifié'g'ié'ééfi‘e‘fi‘f 'k'éep patient N156; CT SinuseslMaxilIa or facial bones without IV Contrast ; XR Shoulder 2+ Wew Right : XR Knee 3 View Left fl’éfi'f‘oiégic‘ai W ' Neuro (WDL): VWthin Defined Limits Glasgow Coma Scale Best Verbal Response: Oriented Glasgow Coma Scale Score: 15 Eye Opening: _Spontaneous _. Best Motor Response: Obeys commands HEENT HEENT(WDL): Exceptionsto WDL Head and Face: Swel!ing:Traumafinjury; M p Tenderness (right cheek) M 7 . __ Igflgue Pinkamoist ‘ l ' Mucous Membrane(s) Moist Neck. No rigidity; Symmetrical: No tenderness (abrasion) ‘ firba’i’ifiia’ét” " ‘VOIcer Deep ‘ Teeth: Intact Musculoskeletal RUE: Limited movement; Injuryltrauma , A .(EP."E§‘2'J.E°.HPP£EET! EDQEEQW) BLE-EUJ!!DQV§!D9§§ , , ., Musculoskeletal (WDL). Exceptions to WDL liLUE fgllflpgement n A L_LE: FulI movement Screening Do you feel safe at home?: UTA (comment Do you feel safe in your relationships?: 7,9,9’Smew- 7-. "mm -- .m Wm--.“ .h v. .HTAIPQTEQEPQX) AbuseINeglecWiolence: No suspected aguse. neglect. or violence 7 Columbia Suicide Severity Rating Scale» ‘ ‘ I 1. Wish to be Dead: No 2. Are you having any thoughts of hurting 199$?“ 91’ 9£h§F§3£ N9 6. Suicide Behavaor Question N'o V Columbia Suicide Severity Rating Scale V .QrsfaBS Risk 1-919.“ Minimal Assamed Risk. “A A. iii ’éiwdfil’d'ér‘i'sé mew iifghi’ 'dfi'i'ck'fiidéié's‘" ' Quick Update_s M Returned from Xray; To CT 7 ‘n‘wwV . XR Shoulder 2+ \fiew Right CT Heéd bf BEE: Witfié‘u‘iniéohiési V " ’ ' 6'? "Si'hfiseélMéiil'lé 6f’féci’a'l' béfiéé Witiiéu't' iV'C‘bfitééé‘t' Zfiiéiihiifié'fy ié‘sdftiié 'é'i-ibULfi'Efiél ViéWfiiéHf ' ' XfiéhdfiifiékéfliiéifiRighf ' ” ‘ Xé'khéé‘a’Vi'eWLéft i'idbc'ai‘ne’iélél '(URO'JET‘) 2 5/5 ieiiy ih abbfiéétdr id nil; NEW - 'lidbcé'ifie' i-id (Ufiéjéf) zékieiiyifi Vap'piific’a’tdf‘ib mL , _(BXCJ') 7V réramer, 131713. RN ' C‘ré’rfié’h JBEEJEN” ” ‘ 'ér'é‘mé‘rfiéfifi‘. 'fiii' ' ' ‘ éiééfié}: J‘oh'n'fiiN'“ ” ‘ " C?EhieE'Jo'hfiffiii’ ' ' ' ééifiliédwéféfié? Hill, Yi-Hui. RT (RKCTL Hlll YI-Hui RT (8)191) ,, Cramer. John. RN Lé'é, i-Ti’iéy'i ‘fifiiij’ " Ngh‘ye‘h’ fihuSrig‘fi? (BXCT) Nguyen. Phuong. RT Linker. Alex Henri, MD ' Li‘nik'e'E Kié'i: 'Hé'riii',"Mb V [éé. ‘FIHeVJ. R‘T (iii Lihkéé; Aléx'llié’hfi; 'M‘D ' bréihéi. 'Jéfihféfi‘ ' ” Viewed/Printed by Torres, Miguel Angel at 11/19/19 3:23 PM Page 38 (2% El Camino Health EL CAMINO HOSPITAL Gordon, Elliott Peter 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/C: 9/13/2019 4302 Inpatient Record Patient Care Timeline (9I1 3/2019 16:23 to 9/1 3/2019 18:21) (continued) 911312019 -17 20:20 i752? i 7":‘2m2'i61' 175614" ' ' ???“é‘i‘iéiém " ’ 17:31:16 ‘ V Res_ulted Event lmiglngwExam Ended ’Méafééifdfi"éi}iéfi”’ ‘ ‘ 'ifiéfiifi'fié’isfi Eh'éiéd' " E??iéé’é’éI-EFa'ih W ' " ’ without IV Contrast Imaging Fih'al Result ”E‘i’AFfrTaTRHe‘s‘dit“ ' ' Detail_s v W W; W ‘WWUsef W1 MW” CT Head or Brain without IV Contrast Nguyen, Phuong. RT V(R)(CT) ”IE63E:’a‘ifié1-’Id'20§63éfi5%]369'653§fi£éi6¥16 ifiL'l'ijéééi"1"o’“i§iiL£ fiébié: "ih‘t'réifiFé‘iHréii’ Cramer, John. RN’ Scheduled Time: 1725 i755}? I v -CT SlnusesIMaxilla cl; facial bones without IV -7, ,, , , ‘antflnquResultegflv 17:34:47 Imaging Final Result 1754547 " ‘ ‘c'fiiifi‘ai'fié‘s'uii iiiii‘iiéé "“ifi’ikfiééfii/"i’éWfléfi " H V 7, Resulted ‘ 17:42:37 Imaging Final Result 171535? " {?Eié ‘ 173565 ??Eié" T7748" 7’ W” T7745 ” " i‘fiéz'sg ' '1'"?§48255" " fifibzi'f ' " 'i'iféiffi ' WEE???" 37351316” ‘17:"5'1'546 ' ‘ ‘ ""Sii-éfii‘r'iéifiééhi‘t' ' "éifiéE‘ééi‘i'Fédfiéé‘tédv‘ ‘ ' 7 " ' 7' ' "6i}ié? 531i ’r'é'd'iiéé‘t'é‘d' ‘ “cmd'fisfiiié “615% ébfiéfiii ééiiéé ' “'Eéh'éijl‘t'é‘ " ‘ ‘ BEES; ?e'ifiii'éa’pfifié' AgaleM Consults “ 'BEcFSFgZBifiiésiiibn §eiected Disposition Selected ' §§§fi$fiié§£é¥ihéfi " Right Resulted Imaging Final Result ' "Xi‘ayiii‘r‘i’aifi‘ééfiif "AVE Ffihiéii' V ' K05 'ééifiiéé ‘ "61"éi'hhéééifléi’i‘ll’éfi'rfiééi‘Béfiég'fiiihauiiVéBEiEiEsi ' ' ' " ‘ ' ' th}e"h“’§fiiiéfi§ffif” 7 -7..,A,VA_,,,A_WU(81(CI),____, mu-" Collected 9I1312019 17:16 Last updated: 9I13I2019 17:31 Status: Final result Interface, Radiology Resultsln ‘ ”éfliééd affir‘é’ifi‘fifififii’l‘ééhfiééi“ ‘ ' " " "ifiié'r'rEé'e‘ffiTa’a'iéiEéyw ,.,,‘_Www.-.“WWW,,_-_. , 7 7 . .. ,A .Bgalitusm‘-ww. (Final result) CT HEAD W0 CONTRAST Interface. Radiology M N - ,7 ,_ ‘ . Resultsln. M Collected: 911 312019 17:16 Last updated: 9l1 3l2019 17:34 Status: Final result Interface. Radiology Resultsln '6f’éifidé’e‘é’N5ifiiEEE‘EéEéiE'ofié‘sWiifiautN b‘br’it’r'a'st ' ' ' ’ ' ‘ "ihfe’rfa‘é'e‘ 'fiéfiidié‘g‘i » _ ‘ ., , V V . _._Be__su|18.|11____‘_.‘ (Final result) CT SINUS FACIAL BONES W0 CONTRAST Interface. Radiology fl u , . V Resultsln ’C’oiieét'e‘d'i '9i13'l'26'1‘9 16:51 La'éi'dpa’a't'ed: 911312019 17:42 Status: Final result Interface 'Radioiogy W fl 7 W ‘7 WW‘ 7 R_esuL_ts_ln N“__m‘ _")~(‘R“I‘(_t{ée’3 View Left fl v Interface, RadiologyM. wwwm ‘ ,, ,, , . H ‘ H , , ‘ Re§u|1§Ln W (Final result) XR KNEE 3 VIEW LEFI' Interface Radiology u .Rgsylfiulnw Tran.Lindon 'anci'iaibéi’s’i' " ' ' " ’ ’ ’ " "T‘rEdIiIiHéEfiww 'é‘éhéhfié” ' " ' " " ' ' ' ‘ ' "" “ftériliriafifi” , .93h9r3. Gall Reguggeid, (radiglmist) . .m 7 .V ,. ._ Tran, Lindon ‘é‘éfi‘édifs " " ' ” ‘ " ‘ ‘ ’ ‘ ‘ ‘ ‘ "“T'?5ii'.’i‘.’ifi&dh . 0.1!19'3 95.9951. , ,, V 4 Discussed xray results with radiologist who believes there Is no fracture. Tran. Lindon ”Eo’n‘éfiits " ' ” ‘ ' ' ' ' “ ‘ ' ‘ ‘ " " ' "”fiéfi‘flihaéii”"W"" Other: Returned Phone Call (Discussed xray results with radiologist who believes t_here Is no ftactute. ) ED Disposition set to Discharge I 7 A 7 H ‘ V [ififiéfirfli‘é figfififfifi " ‘fihi'efi Klék‘fiéfifi’. Mb Collected: 9I1 3I2019 16:31 Last updated: 9I1 3I2019 17:51 Status: Final result lntezface. Radiology ,V -MM -, , ., ,. A, . ., , , , A , n _ , Results In mm H XR Shoulder 2+ \fiew Right Interface. Radiology M n . ‘ , V, M . . ,..R,§§E!L§Jfl. (Final result) XR SHOULDER 2+ VIEW RIGHT Interface. Radiology R_e§ult§ In Linker. Alex Henri, MD Blank Page Linker. Alex Henri, MD Discharge Signature Page ED After Visit Summary Viewed/Printed by Torres, Miguel Angel at 11/1 9/19 3:23 PM Page 39 EL CAMINO HOSPITAL Gordon, Elliott PeterI o (,9 El Camlno Health 2500 GRANT ROAD MRN: 0000854536, DOB: 2/8/2005, Sex: M MOUNTAIN VIEW CA 94040- Adm: 9/13/2019, D/C: 9/13/2019 4302 Inpatient Record Patient Care Timeline (9I1 3/2019 16:23 to 9/13I2019 18:21) (continued) $131.20.” A Eve"; L Details ‘ dwgmlksg: _V 18:20 Departure Condition Departure Condition Cramer, John. RN Departure Condition: Good H H Mobility atDeparture. Ambulatory Discharge Assessment I Procedures Alert Discharge Instructions Provided: Printed discharge care instructions; Medication reconciliation instruction; When to seek medical care: LaboratoryIEKG findings; Patient instructed not to drive self home: How to manage pain at home. _ Bfiéfiéfie"|n§ifdéfiér¥§ééé§9é§§9z§V V ~ ‘ Teaching Metholeesponse:. Verbal “Pane"t Féthefi. M91591"MW . u . ..!Q§W9?!9019i"€0 Wfittfiflmflfiflflw A MA," ,WVDGPa'Ture M°de Wth‘ami'y meme’ 7. ,- V H -w 18:21 Patient discharged Cramer, John, RN {8721" ”“U‘ééiééa‘Fe‘w ' ‘ "Bifié‘rfiEw‘éfi’e’éi'éfit‘r-ré; ' ' " ' ' ‘ ' " ”C?afi‘éffjafifil'fifi .LAGE: §?9F95 7.23 , , 55253333 “"M‘P‘éht‘i‘éfit‘iiééfiir‘ééé‘ " ' ' ' ' ” ‘ ' ‘ ' ” ‘ ‘ " '”“"“é'ré‘rfie‘EfiHfififfifi “1‘8”:§T:é§ww "”“éfirééfifié'é‘éifiiTe‘ié” ' H ' ' ‘l ” " H ' fl ' 'é'r‘a’rh‘e'fi'iiiiifi'ffifim END OF REPORT Viewed/Printed by Torres, Miguel Angel at 11/1 9/1 9 3:23 PM Page 40 AFTER VlSlT SUMMARY (i) El Camino Health Elliott P. Gordon MRN: 0000854535 fl 9/13/2019 Q MV EMERGENCY DEPT 650-940-7055 Instructions g Read the attached information1. Minor Head Injury Discharge Instructions (English) 2. Skin Abrasions (English) Follow up with JANE AUH, MD'In 3 days (around 9/1 6/201 9) Specialty: Pediatrics Contact: 701 E EL CAMflNO REAL Mountain View CA 94040 650-934-7956 What's Next You currently have no upcoming appointments scheduled. Please take this medication list with you to your next doctor visit. It is important to update your medication list whenever medications are discontinued, doses are changed, or new medications (including over the counter products) are added. It is also a good idea to carry current medication information at all times in the event of an emergency. Your Medication List You have not been prescribed any medications. Other Info from Your Visit Your” Allergies Date Reviewed: 9/13/2019 No active allergies 4» Your Vital Signs Were Most recent update: 9/13/2019 4:30 PM BP Pulse Temp Resp Height 116/78 80 36.8 ”C (98.2 14 152.4 cm (5') “F) Weight Sp02 BMI 46.7 kg 99% 20.12 kg/m’ Eflliott P. Gordon (MRN: 0000854536) - Printed at 9/13/19 5:51 PM Today's Visit You were seen by ALEX LINKER, MD Reason for Visit Pgdi struck by vehicle Diagnoses - Bicy_c|e rfider struck In motor vehicle accident, initial encounter - Facial abrasion, initial encounter - Abrasion of right shoulder, initial encounter ° Abrasion of right elbow, initial encounter - Abrasion of ?eft knee, initial encounter - Closed head injury, initial encounter - Contusion of face, initial encounter m Imaging Tests CT Head or Brain without IV Contrast CT Sinuses/Maxilla or facial bones without |V Contrast XR Knee 3 View Left XR Shoulder 2+ View Right é Medications Given Iidocaine HCI (UROJET) Last given at 5.21 PM Your End of Visit Vitals @ glood BMIressure 116/78 20'1 2 Eb Weight Q] Height 5| Temperature Pulse 98.2 °F KOO 103 lb g Re4$piration Oxygen Saturation Page 1 of13 H AFTER VISIT SUMMARY 5%“ 3"“9’Hea'm Elliott P. Gordon m 9/15/2019 9:00 AM Q 701 Mt View Pediatrics 650-934-7956 Instructions from vi Ding, MD Come back if there are signs of skin infection- streaking, spreading redness, oozing/ drainage from your wounds. Come back if there are worsening headache, Shep disturbance or other concerning symptoms Today's Visit You saw Yi Ding, MD on Monday September 16, 2019. Blood Pressure m Weight 104/65 104 lb 13.6 oz (23rd percentile) Temperature (Tympanic) 93 °F KW 2956 Percentiles calculated using: CDC (Boys, 2-20 Years) What's Next You currently have no upcoming appointments scheduled. My Health Online View this After Visit Summary and more online at https://mho.sutterhealth.org. Elliott P. Gordon - Printed at 9/16/19 9:37 AM Page 1 of 2 % IN RE ELLIOTT PETER GORDON CASE NO.: 20CV36747O MC-350 ATTACHMENT 100 TERMS OF SETTLEMENT (Settlement Agreement Attached) SETTLEMENT AGREEMENT AND RELEASE OF ALL CLAIMS PARTIES. This Settlement Agreement and Release (hereinafter “Agreement”) is deemed made December 23, 2020 in the City of Long Beach, County of Los Angeles, State of California. This Agreement is entered into by and between: A. Claimant, ELLIOTT PETER GORDON (hereinafter collectively referred t0 as “Claimant”); and B. Defendants, SOPH, INC. dba PAPA JOHN’S PIZZA and SANH CUONG LAM (hereinafter referred to as “Defendants”) The entities named in this Section are hereinafter collectively referred t0 as the “Parties.” RECITALS A. Claimant made a claim t0 Defendants’ insurer, The Princeton Excess and Surplus Lines Insurance Company, arising out of certain alleged acts or omissions by Defendants (hereinafter “Subject Claim”). In the Subject Claim, Claimant sought to recover for personal injuries allegedly sustained 0n or around September 13, 2019, in a motor vehicle accident that occurred at the intersection 0f California Street and Franklin Street in the City of Mountain View, County 0f Santa Clara, State of California (hereinafter “Incident”). B. The Parties desire to enter into this Agreement in order to provide for certain payments in full settlement and discharge of all claims which are, or might have been, the subject matter 0f the Subject Claim, upon the terms and conditions set forth below. M RELEASE AND DISCHARGE 1.1 In consideration of the payment set forth in Section 3.0 below, Claimant hereby completely release and forever discharge Defendants and Princeton Excess and Surplus Lines Insurance Company (hereinafter “Released Parties”) from any and all past, present, 0r future claims, demands, obligations, actions, causes 0f actions, wrongful death claims, rights, damages, costs, losses of services, expenses and compensation of every nature whatsoever, based on tort, contract, or other theory of recovery, which Claimant now have, or which may hereinafter accrue or otherwise be acquired on account of, or may in any way grow out 0f, 01‘ which are the subject of the Subject Claim, including, without limitation, any and all known or unknown claims for bodily and personal injury to Claimant, or any future wrongful death claim of Claimant’s representatives or heirs, that may have resulted or may result from the alleged acts or omissions of the Released Parties. / / / Settlement Agreement and Release ELLIOTT GORDON v. SOPH, INC. dba PAPA JOHN’S PIZZA, et a1. _ 1 _ 1.2 This release and discharge shall also apply to Released Pamies’ past, present, and future officers, directors, stockholders, employees, agents, insurers, adjusters, attorneys, servants, representatives, franchisors, management firms, parent companies, subsidiaries, affiliates, partners, predecessors, and successors in interest, and assigns and all other persons, firms or corporations with whom any of the former have been, are now, or may, hereinafter be affiliated (hereinafter “Affiliates”). 1.3 This release, on the part of the Claimant, shall be a fully binding and complete settlement among the Claimant and Released Parties, and their heirs, assigns and successors. 1.4 Claimant acknowledges and agrees that the release and discharge set forth above is a full and complete general release. Claimant expressly waives and assumes the risk of any and all claims for damages which exist as of this date, but of which Claimant does not know or suspect to exist, Whether through ignorance, oversight, error, negligence, or otherwise, and which, if known, would materially affect Claimant’s decision to enter into this Agreement. Accordingly, Claimant does hereby expressly waive and relinquish any and all rights and benefits which each may otherwise have pursuant to California Qflfl Q9919, Section 1542, which provides that: “A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS THAT THE CREDITOR OR RELEASING PARTY DOES NOT KNOW OR SUSPECT TO EXIST 1N HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE AND THAT, IF KNOWN BY HIM OR HER WOULD HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR OR RELEASED PARTY.” Claimant further agrees that they have accepted payment of the sum specified herein as a complete compromise of matters involving disputed issues of law and fact. Claimant assumes the risk that the facts 0r law may be other than Claimant believes. It is understood and agreed to by the Parties that this settlement is a compromise of doubtful and disputed claims, and the payments are not t0 be construed as an admission of liability on the pan of the Released Parties, by‘ whom liability is expressly denied. Claimant acknowledges that they may hereafter discover facts different from, or in addition to those which they now know 0r believe to be true, with respect t0 the Incident or other things which are the subject of this Agreement, and Claimant hereby expressly agree t0 assume the risk 0f possible discovery of additional 01‘ different facts, and agree that this Agreement shall be and remain effective in all respects regardless of such additional 01‘ different facts. /// /// Settlement Agreement and Release ELLIOTT GORDON v. SOPH, INC. dba PAPA JOHN’S PIZZA, et a1. _ 2 _ 1.5 Claimant hereby warrants that he has satisfied, or will satisfy upon receipt 0f settlement funds, any and all outstanding liens of any kind arising from the Incident, including, without limitation, any and all medical liens; attorney liens; and workers’ compensation liens. Claimant further agrees, upon execution of this Agreement and receipt of the settlement funds described in Section 2.0, t0 defend, indemnify and hold harmless Released Parties and their Affiliates from any subrogation, demand, claim, lawsuit, and/or causes of action asserted by any lienholder relative to the Subject Claim, should Claimant fail to satisfy any and all outstanding liens. 1.6 Claimant hereby stipulates and agrees to not sue any other entity, party or person for damages arising out of or related in any way to the Incident or the circumstances alleged in the Subject Claim. _2_;Q CONDITIONS PRECEDENT 2.1 Except, but only except, as they may be waived as specifically provided herein, this Agreement is contingent upon the delivery of payment by or on behalf of Defendants to counsel of record for Claimant within thirty (30) days 0f the delivery of the following documents to counsel of record for Defendants: (1) the original executed Agreement and (2) prior t0 any payment being made to the minor, Elliott Gordon, a signed order from the Court approving the minor’s motion, petition, 0r application for minor’s compromise. 2.2 Payment by or on behalf of Defendants Will be made payable to “Tracy Gordon as guardian ad litem for Elliott Gordon and Adamson Ahdoot LLP” in the form of one or more negotiable checks in the total sum of Two Hundred Thousand United States Dollars ($200,000.00). §_._Q CONSIDERATION 3.1 Defendants agree t0 provide Claimant the following as consideration for the settlement of any and all Claims including the Subject Claim and for the Release provided in Section 1.0: payment of money in the total sum 0f Two Hundred Thousand United States Dollars ($200,000.00) t0 Claimant, Elliott Gordon in accordance with provisions of Section 2.0 above. 3.2 As further consideration of this Agreement, counsel for Claimant will file a motion, petition, or application for minor’s compromise. Such motion, petition, or application will be approved by the Court and counsel for Claimant will provide the Court’s order 0f approval to counsel for Defendants prior to any payments being made for the benefit of Claimant, Elliott Gordon. 3.3 Claimant hereby acknowledges and agree that all settlement payments will be sent to the Adamson Ahdoot, Claimant’s attorneys of record, for deposit into Claimant’s attorney’s client trust account before fumher disbursement to Claimant and that this Settlement Agreement and Release ELLIOTT GORDON v. SOPH, INC. dba PAPA JOHN’S PIZZA, et a]. __ 3 _ provision satisfies the notice requirements of California Business & Professions Code section 6149.5 fl MEDICARE CONDITIONAL PAYMENTS This Claims Settlement Allocation Agreement is intended to be, and is, a part of the settlement of Claimant’s claim for certain injuries against Released Parties. 4.1 The Parties have considered Medicare’s interests in this settlement and have determined that an allocation for future Medicare covered expenses is not required pursuant t0 the policy and procedure established by the Centers for Medicare and Medicaid Services (hereinafter “CMS”) Memoranda to protect Medicare’s interests, as required by the Medicare Secondary Payer Statute, and for reasons set forth below. 4.2 Based upon reports of Claimant’s current health care providers, there are n0 future Medicare covered treatments or prescriptions prescribed or reasonably expected related t0 the injuries in this claim; therefore, n0 allocation is required or being established. 4.3 Claimant specifically warrant and represent that they are not now and never have been a Medicare beneficialy or recipient. Claimant further warrant and represent that none of Claimant’s medical bills for treatment for injuries attributed to the Incident have been or will be submitted to CMS (Medicare) for payment. 4.4 Claimant has not applied for Social Security Disability Insurance (“SSDI”) and are not classified by Medicare as having a “reasonable expectation 0f Medicare enrollment within 30 months.” Claimant has not applied, and has n0 plans to apply for SSDI. It is not anticipated 01‘ foreseeable that Claimant will become eligible for Medicare in the near future. Therefore, no funds are being set aside for Claimant’s future Medicare-covered treatment. 4.5 Claimant understand that should CMS (Medicare) find that the non~allocation was insufficient and that Medicare’s interests were not adequately protected, CMS (Medicare) may require Claimant to expend up t0 the entire settlement amount on Medicare covered expenses related to the injury before Medicare will provide coverage for the injury. Claimant voluntarily accept this risk and waive any and all claims of any nature and/or damages against the Released Parties and their Affiliates should Medicare take such action, including, but not limited to a Private Cause 0f Action against the Released Parties’ carrier under the Medicare Secondary Payer Act (MSP) pursuant t0 42 USC §1395YCb)(3)(A)~ 4.6 Claimant has been apprised 0f his right to seek assistance from legal counsel 0f their choosing 01‘ directly from the Social Security Administration or other governmental agencies regarding the impact this Settlement Agreement may have on Claimant’s current 01‘ future entitlement to Social Security or other governmental benefits. Settlement Agreement and Release ELLIOTT GORDON v. SOPH. INC. dba PAPA JOHN’S PIZZA, et al. _4_ 4.7 Claimant fumher agrees to waive any and all future actions against the Released Parties and its Affiliates, including but not limited to any private cause of action for damages pursuant to 42 U.S.C. § 1395y(b)(3)(A) et seq. 4.8 In addition to and without limiting any other language in the Agreement, Claimant agrees to indemnify and hold harmless Released Parties and Affiliates from any and all Medicare Claims that have been or may in the future be related to, arise out of 01‘ are in connection with the Incident. This indemnification obligation includes all damages and costs incurred by Released Palfies and Affiliates, including but not limited to attorney’s fees, fines and penalties, multipliers, costs, interest, expenses and judgments, incurred by 0r imposed against Released Parties and Affiliates. 4.9 In agreeing to the Agreement, Released Parties are relying 0n the representations and warranties of Claimant regarding Claimant’s Medicare status. If the above representations are not correct, it is acknowledged and agreed that Claimant is in material breach 0f this Agreement, and Released Parties shall receive complete repayment of the Settlement Funds described in Section 3.0. In addition, Claimant shall indemnify Released Parties and their Affiliates for any damages, legal fees and costs or expenses for their failure to adhere to the representations and warranties contained herein. fl ATTORNEYS FEES 5.1 Each party hereto shall bear all attorneys fees and costs arising from the actions of its own counsel in connection with the Subject Claim, the Agreement, and the matters and documents referred to herein, and all related matters. 5.2 Notwithstanding Paragraph 5.1, in any Motion to Enforce Settlement Agreement, Breach 0f Contract, 01‘ any other action 0f any kind relating to this Agreement, the prevailing party shall be entitled t0 collect reasonable attorney’s fees and costs from the non-prevailing party in addition to any other recovery to Which the prevailing party is entitled. Q9 REPRESENTATION OF COMPREHENSION OF DOCUMENTS In entering into this Agreement, Claimant has relied upon the advice of his attorneys, who are the attorneys of his own choice concerning the legal and tax consequences of this Agreement; that the terms of this Agreement have been completely read and explained to Claimant by his attorneys; and that the terms of this Agreement are fully understood and voluntarily accepted by Claimant. / / / / / / / / / / / / Settlement Agreement and Release ELLIOTT GORDON v. SOPH. INC. dba PAPA JOHN’S PIZZA. et al. _5__ 1.2 WARRANTY OF CAPACITY TO EXECUTE AGREEMENT Claimant represents and warrants that no other person or entity has, or has had, any interest in the claims, demands, obligations, or causes of action referred to in this Agreement, except as otherwise set forth herein; that Claimant has the sole right and exclusive authority to execute this Agreement and receive the sums specific in it, and that Claimant has not sold, assigned, transferred, conveyed, or otherwise disposed 0f any 0f the claims, demands, obligations, or causes 0f action referred to in this Agreement. fl GOVERNING LAW This Agreement shall be construed and interpreted in accordance with the laws 0f the State of California. fl ADDITIONAL DOCUMENTS All Parties agree to cooperate fully and execute any and all supplementary documents and to take all additional actions which may be necessary or appropriate t0 give full force and effect to the basic terms and intent of this Agreement. 10.0 ENTIRE AGREEMENT AND SUCCESSORS IN INTEREST This Agreement contains the entire agreement between the Claimant and the Released Parties with regard to the matters set fomh in it and shall be binding upon and inure to the benefit of the executors, administrators, personal representatives, heirs, successors and assigns 0f each. 11_.0 NO ADMISSION OF LIABILITY The settlement effected by this Agreement pertains to disputed claims and is the result of compromise. As such, it does. not constitute and shall not be deemed an admission of liability by Released Parties. 12.0 EFFECTIVENESS This Agreement shall become effective immediately following execution by Claimant. /// /// /// /// Settlement Agreement and Release ELLIOTT GORDON v. SOPH, INC. dba PAPA JOHN’S PIZZA, et a1. _ 6 _ 13.0 CONTINUING JURISDICTION The Parties agree that the Court in the Subject Claim shall continue to have jurisdiction t0 enforce the terms of this Agreement pursuant to California Code of Civil Procedure section 664.6 and the Parties request the Court t0 retain jurisdiction over this action and these Parties for said purpose. 14.O CONSTRUCTION Each party has cooperated in the drafting and preparation 0f this Agreement. Hence, in any construction to be made of this Agreement, the same shall not be construed against any party. H 5OO SEVERANCE If any provision of this Agreement is held to be illegal or invalid by a court of competent jurisdiction, such provision shall be deemed to be severed and deleted; neither such provision, nor its severance and deletion, shall affect the validity of the remaining provisions of this Agreement. 16.O INTEGRATION This Agreement, after full execution and delivery, memorializes and constitutes the entire agreement and understanding between the parties and supersedes and replaces all prior negotiations, proposed agreements and agreements, whether written 0r unwritten. Claimant acknowledges that no other party, nor any agent 0r attorney of any other party, has made any promise, representation, or warranty whatsoever respecting this Agreement. CAUTION : THIS IS A RELEASE . . . READ BEFORE SIGNING PARTY SIGNATORIES X Elliott Gordon Claimant, ELLIOTT GORDON I have read and I understand the above Agreement DATED: Settlement Agreement and Release ELLIOTT GORDON v. SOPH, INC. dba PAPA JOHN’S PIZZA. et a1. _7_ DATED: X Tracy Gordon TRACY GORDON as Guardian ad Litem for Claimant, ELLIOTT GORDON I have read and I understand the above Agreement APPROVED AS TO FORM: Dated: ADAMSON I AHDOOT Attorneys for Claimant, ELLIOTT GORDON Signature: 5 0 ”/9 Tracy Go don (Jan 20, 2021 21:19 PST) Email: tracycgordon@gmail.com Settlement Agreement and Release ELLIOTT GORDON v. SOPH. INC. dba PAPA JOHN’S PIZZA, et al. _g_ DATED: X TRACY GORDON as Guardian ad Litem for Claimant, ELLIOTT GORDON I have read and I understand the above Agreement APPROVED AS TO FORM: Datedsz/zm ADAMSON | AHDOOT Attorneys for Claimant, ELLIOTT GORDON Settlement Agreement and Release ELLIOTT GORDON v. SOPH, INC. dba PAPA JOHN’S PIZZA, et a]. _ 8 _ 2021 .O’l E19 Settiement Agmt and Release -- Gordon Final Audit Report 2021-01-21 Created: 2021-01-20 By: Maria Gonzalez (maria@aa-llp.com) Status: Signed Transaction ID: CBJCHBCAABAAIK|AP850trgz4MfH49LRvyNszngvaN "2021 .01 .19 Settlement Agmt and Release - Gordon" History ’% Document created by Maria Gonzalez (maria@aa-I|p.com) 2021-01-20 ~ 11:12:52 PM GMT- 1P address: 74.87.39.4 ‘33; Document emailed to Tracy Gordon (tracycgordon@gmail.com) for signature 2021-01-20 - 11:13:18 PM GMT 5% Email viewed by Tracy Gordon (tracycgordon@gmail.com) 2021-01-21 - 4:29:47 AM GMT- IP address: 66.249.80.177 fig Document e-signed by Tracy Gordon (tracycgordon@gmail.com) Signature Date: 2021-01-21 - 5:19:07 AM GMT - Time Source: server- IP address: 108.65.79.167 ® Agreement completed. 2021~01~21 - 5:19:07 AM GMT I Adobe Sign IN RE ELLIOTT PETER GORDON CASE NO.: 20CV36747O MC-350 ATTACHMENT 13a DECLARATION REGARDING FEES AND COST 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Arash Nematollahi Esq. (State Bar N0. 225306) ADAMSON|AHDOOT 1150 S. Robertson Blvd. Los Angeles, California 90035 T: 310.888.0024 F: 888.895.4665 E: arash@aa-llp.com Attorneys for Plaintiff, ELLIOTT PETER GORDON, a minor by his Guardian ad Litem Tracy Gordon SUPERIOR COURT OF THE STATE OF CALIFORNIA FOR THE COUNTY OF SANTA CLARA - DOWNTOWN ELLIOTT PETER GORDON, a minor by his Case No.1 20CV367470 Guardian ad Litem Tracy Gordon DECLARATION OF ARASH Plaintiff, NEMATOLLAHI, ESQ. (Attachment 13a) vs. SANH CUONG LAM, an individual; SOPH, INC., dba PAPA JOHN’S PIZZA, a corporation; PAPA JOHN’S USA, INC., dba PJ USA, INC., a corporation; and DOES 1-100, inclusive; Complaint filed: 06/19/2020 Defendants. Trial date : None set DECLARATION OF ARASH NEMATOLLAHI, ESQ. I, Arash Nematollahi, hereby declare as follows: 1. I am an attorney licensed to practice in the State of California, and I am an attorney 0f record for ELLIOTT PETER GORDON, a minor, in this matter. The following are facts Within my personal knowledge and, if called as a Witness, I could and would testify competently thereto. /// DECLARATION OF ARASH NEMATOLLAHI, ESQ. 1 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 2. The total amount for Which attorney’s fees are requested is $50,000.00 (25% of settlement amount, reduced from the 40% [$80,000] per retainer agreement) plus $5,890.20 for incurred costs. Petitioner/Claimant and Attorney have an agreement for services provided in connection With the claim and are as follows: (a) Initial investigation with Petitioner; (b) Representation letter t0 defendant and to insurance company; (c) Numerous conferences With insurance company; (d) Numerous conferences with Petitioner to discuss the case; (e) Filing 0f litigation in this case (instant action); (f) Numerous conferences With defense counsel; (g) Negotiating settlement 0f case; (h) Negotiating all liens with medical providers; and (i) Preparing Petition t0 Approve Compromise 0f Disputed Claim 0f Minor. 3. A copy of the Attorney-Client Retainer Agreement and Designation of Representation are attached herein. I declare under penalty 0f perjury under the laws of the State of California that the foregoing is true and correct. Executed this 3rd day of February 2021, at Los Angeles, California. Declarant ARASH NEMATOLLAHI DECLARATION OF ARASH NEMATOLLAHI, ESQ. 2 adamson ahdoot 1150 south robertson bouievard los angeies. ca 90035 t310.888.oo24 f888-895-4665 adamson ahdoot www.aa-Hp.com ATTORNEY-CLIENT CONTINGENCY FEE AGREEMENT 1. Parties. This agreement is made by and between ("Client”), and the law offices of Adamson | Ahdoot LLP ("Attorney"). 2. Scope of Services. Attorney shall provide legal services to Client as follows: representation of Client‘s Legal services for related or unrelated matters are not contemplated by this contract and shall be subject to separate negotiations and agreement, and shall not affect or alter the rights of Attorney and Client under this Agreement. 3. Client's Duties. This office shall make no settlement of Client’s case without Client’s complete approval. Client agrees, however, that Attorney has made no promises or guarantees to Ciient regarding the outcome of this case. Client agrees, at all times throughout Attorney's representation of Client, to: keep Attorney advised of Client's current address and phone number; to be honest and truthful to Attorney with respect to all matters involving Client's claim or the subject matter of the representation of Client by Attorney; and to fuily and truthfully advise Attorney of all potentially relevant or material facts involving Client's claim or the subject matter of the representation of Client by Attorney 4. Legal Fees, Costs, and Billing Practices. Attorney will only be compensated for legal services rendered if a recovery is obtained for Client. NO RECOVERY NO FEE In the event Ciient receives a recovery in this matter by way of a settlement, judgment, or verdict, or by any other means, Attorney shall be entifled to a contingency fee in the higher amount of (i) or (iii) below: (i) One Third (1/3") of the amount of the Gross Recovery if resolved prior to filing a lawsuit I arbitration, or Forty (40%) of the amount of the Gross Recovery if resolved after a lawsuit is filed in court or demand for arbitration, or Forty Five Percent (45%) of the Gross Recovery if resoived at or after the first dav of trial or arbitration ; or (ii) The amount awarded by the court for attorneYs fees. Gross Recovery shall include the amount of attorney's fees and costs awarded by a judge or arbitrator. Costs, disbursements, and expenses as described in Paragraph 5 below shall not be deducted from the Recovery in order to compute the attorney's portion of the contingency fee. Any third-party fees and all costs and expenses W11! be reimbursed to Attorney or paid to the third-party, if not previously paid, out of your portion of the Gross Recovery. Sanctions awards are not part of recovery. _ Q 5. Costs and Expenses. ln addition to the Attorney's fees stated above, Client agrees to pay all costs - Including, but not limited to. court filing costs, deposition reporter costs, Xeroxing, messenger services, expert witness fees, and process server costs. Through our experience, Costs and Expenses usually amount to $300.00 inmam. Costs and fees will be higher if a case is litigated and shall be itemized. This amount is to be deducted from the gross recovery at the conclusion of this matter. The costs and expenses required in prosecuting the case (above $300.00) may be either advanced by the client or by the Attorney. The client may choose either option. If the client e|ects to advance the money for costs and expenses, the client must pay each cost and expense as it is incurred. If the client elects to have the Attorney _advance the money for costs and expenses, the moneym be borrowed by the Firm from a third party lender and with an upterest rate which will be disclosed to the Client, statements are available upon request and piaintiff may pre-pay at any time. At the conclusion of the case, all such monies, including principal, interest and costs related to such advances shall be reimbursed to the law firm by the client from the recovery proceeds. 6. Attorney Discharge and Withdrawal. Client shall have the right to discharge Attorney at any time upon written notice to Attorney. Such discharge shall not affect Client’s obligation to reimburse Attorney for costs incurred prior to such discharge. In addition, Attorney shall be entitled to his full contingency fee if he has fully performed his obligations under this Agreement (except for any incidental obligation he has been prevented from performing) and has obtained a recovery for Client either by way of award, verdict, judgment, settlement, or compromise (whether or not actually paid. Attorney may withdraw as Client's Attorney for good cause. 7. Bonafide Offer of Settlement. If a bonafide offer of settlement is made, which in the opinion of Attorney shoutd be accepted, Client will have the right to insist that the matter proceed to trial, but in the event, and only in that event, Client shall advance all court costs, including expen fees, incurred or to be incurred from and after the date Client is advised of the settlement offer and of Attorney's opinion that it should be accepted. 8. Appellate Engagement. If an appeal is agreed upon or if the opposing party appeals, a separate written agreement, to be negotiated between Attorney and Client. shall provide for additional fees and costs. 9. Contingent Fee Disclaimer. Attorney has advised CIient that the foregoing contingent fee is a negotiated agreement and not set by law. 10. Attorney Lien. Attorney is hereby given a lien on said claim or cause of action. on any sum recovered by way of settlement, and 0n any judgment that may be recovered by way of suit thereon, for the sum and share hereinabove mentioned as his fee and any costs or advances made by Attorney to or on behalf of Client; and it is further agreed that Attorney shall have all general and special liens permitted by the common law, statutory law, and the Code of Ethics. 11. Attorney's Entitlement to Fees for Collection. It is agreed that in the event Attorney initiates legal proceedings in order to collect the Attorney's fees, costs, and advances provided for herein, Attorney shall be entitled to recover, in addition to court costs, reasonabie attorney's fees therefore. 12. Power of Attorney. Attorney is given a limited power of attorney to endorse Client's name on any draft or check for payment of settlement, judgment, or verdict presented by or on behalf of any defendant, and to deposit said funds into Attorney's Client Trust Account and thereafter disburse same in accordance with this Agreement. 13. Change, Modification, andlor Waiver of Agreement. There can be no change, modification, or waiver of any of the provisions of this Agreement unless the change is in writing and signed by both Client and Attorney. Any attempted change, modification, or waiver that is not in writing and signed by both Client and Attorney shall have no effect whatsoever. 14‘ Attomey-Client Dispute. Attorney and Client agree that in the event of any dispute under this agreement, they shall submit such dispute to non-binding mediation before resorting to litigation, and shall use their best efforts to resolve any such dispute through mediation. 15. File Retention. Adamson Ahdoot LLP maintains a paperless office. All documents are scanned and shredded upon receipt. Attorney retains original documents only where required. Unless otherwise notified by client, Attorney will shred and dispose of any originals thirty (30) days after the conciusion of the matter. Attorney will retain a digital copy of your file for two (2) years after the conclusion of your matter. Cl_ient Acknowledgmeqt. client acknowledges that he has read and fully understands all of the terms and conditions 0f thus Agreement before sugmng it, and has received a copy of this Agreement upon execution thereof. This Agreement represents the full and complete agreement between Client and Attorney, and supersedes any prior, simultaneous, or subsequent oral Irepresentation made by either party to the other. This Agreement is meant to be a totafly integrated contract that can be modrfied only in a writing signed by both parties. ACCEPTED AND AGREED TO THIS ON W ‘ i 2 g! 1(Date) . Signatfir EmoH“ 0W4 Pn‘nt Nam'e adamson ahdoot 1150 south robertson bouievard los angeles, ca 90035 t310.888.0024 f888.895.4665 adarhsoh ahdoot www.aa-Ilp.com DESIGNATION OF REPRESENTATION As required per California Code of Regulations, Title 10, Chapter 5, Subchapter 7.5 Unfair Claim Settlement Practice Regulations, Section 2695.2(0), I am informing you that I designate Adams I Ahdoot LLP as my legal representative in my pending liability case. Signature: Print: El UOEQSUW IN RE ELLIOTT PETER GORDON CASE NO.: 20CV36747O MC-350 ATTACHMENT 13b Expenses Date 02/02/2021 11/02/201 9 11/03/201 9 1 1/1 4/201 9 12/06/201 9 12/1 1/201 9 12/20/201 9 01/09/2020 01/1 0/2020 01/25/2020 04/29/2020 05/09/2020 05/1 9/2020 06/1 8/2020 06/20/2020 06/24/2020 06/24/2020 06/30/2020 07/09/2020 08/1 8/2020 10/07/2020 10/1 7/2020 10/22/2020 11/1 8/2020 IN RE ELLIOTT PETER GORDON CASE NO.: 20CV367470 Expenses Name Amount Admin Fee 150.00 TLO 44.99 Datalink Services, Inc. 4.75 Elliot Gordon 175.00 Prestige Research Solutions, LLC 599.00 El Camino Hospital 8.00 ChartSwap 14.10 ChartSwap 14.10 Boster, Kobayashi & Associates, Inc. 3,000.00 ChartSwap 25.00 One Legal LLC 0.00 One Legal LLC 15.67 One Legal LLC 65.00 On-Call 44.06 One Legal LLC 9.95 One Legal LLC 465.11 ChartSwap 14.10 One Legal LLC 77.73 Ultimate Invoice Finance, Ltd. 73.50 Sutter Health 15.00 Berto Legal 699.92 On-Call 209.39 Courtcall 94.00 On-Call 71.83 5,890.20 5,890.20 5,890.20 IN RE ELLIOTT PETER GORDON CASE NO.: 20CV36747O MC-350 ATTACHMENT 14 DOCTOR’S STATEMENTS 06/22/2020 12:20PM FAX 14086773101 MIND & BODY PAIN CLINIC [E0017/0020 Gordon, Elliot A L HEALTH INSURANCE CLAIM FORM ;u E APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCCl D2J‘12 ' g \ \ v 1. MED CARE MEDICAID TRICARE CHAMPVA GR-‘JUP FECA OTHER 13. INSURE 3 I D. NUMBER {For Program in Item 1) A HEALTH PLAN BLKLUN‘” Medicare #1 Mediwid #1 D xleDJDm D {Mamba IDm (lbw (IDm L i en LPATIENTb NAME (Lasl Hams, FHst Nanm. dedlc Initiah 3. PATIENTS BIRTH DATE 4. INSURED‘S NAME (LastNams, Fxrst Name, Mlddl: lnmalj DD YY Gordon, Elliot IM v ‘ J ‘ aa izms M- FD Gordon, Elliot 5. PATIENTS ADDRESS {No.. SlrE-el] j. PATiENT REILATIONSHIP TO INSURED 7. INSURED'S ADDRESS (NCL, SLreel‘ 45C] Franklin St Self. Spousem ChiIdE] onhefl 460 Flanklin St GUY STATE s_RESERVEDFoRNUCCUSE cnv STATE Mountain View CA Mountain View CA ZIP CODE TELEPHONE (Imlude Araa Code) ZIP CODE TELEPHONE (Include Ar ea Cnde] 94041 {) 94041 U SJ. OTHER INSURED‘S NAME 1Lasl, erSt, Middle Initial'w 10. IS PATIENTS CONDITION RELATED TO: a. OTHER INSURED‘S POLICY DR GROUP NUMBER II. INSURED'S POLICY GROUP DR FECANUMBER a. EMPLOYMENT? {Current ar Prewnusw D YES b. RESERVED FOR NLICC SE a. INSURED'S DATE OF BIRTH SEX MM ‘ DD ‘ ‘r’Y 02‘03‘2035 FEE b. AUTO AchDENTv PLAcasmtew D NO E. RESERVED FDR NUCC USE b. aTHER'cLAIM ID (Des‘gnared by Nucc) C. OTHER ACCIDEN‘W D YES ‘ 5. INSURANCE PLAN NAME DR PROGRAM NAME Lién d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designmed by NLJCC] d. IS THERE ANOTHER HEALTH BENEFIT PLAN? E] YES. No ”yes, complete items 9, Ba and 8d. READ BACKOF FORM BEFORE COMPLETING 8; SIGNING THIS FOPDL 12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE Iauthanzr. th: release {any medical or other mfomwalion nwassary tn process this claim. lal-s: quuest payment of government benefits eithEI m myself or tn the party who 13. INSURED'E OF: AUTHORIZED PERSONS SIGNATUREI authoriz: paymant 3f madical benefit: In th: und ..igned physician m’ supplier for services described below. a p15 assignment Laluw. SIGNED s I GNATURE 0N FILE DATE 1 0 2 8 2 u 1 9 SIGNED sIWATURE 0N F I LE 14. DATE OF CURRENT ILLNESS INJURY, m’ PREGNANCY 1-5. Omar Date 16.DATES PATIENT UNABLE TD WORK IN CURRENT OCCUPATION ‘LMFW‘ ‘ ‘ MM DD W MM ‘ DD YV MM‘ DD ‘ Y v’ 09‘13‘19 QUALJ431 QUALJMQ 09 15 ‘13 FROM ‘ ‘ T0 ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 173. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD WK MM DD ‘r’Y ‘ > 7 i > 7 7 7 iiiiiiiiiiiiiiiiiiiiiiiiii ‘ ‘ ‘ ‘ ‘ 17b. NPI FROM ‘ ‘ TC} ‘ ‘ I \ \ I '13, ADDITIONAL CLAIM INFORMATION (DESIgHath by‘ NUCC) 2‘3. OUTSIDE LAB” $ CHARGES YES 944309 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJUR‘V L'Rclat: A-L Iuscmicu I‘ll: L'mlow (24B) ICD Ind. :0 F4310 55L] 1 133A 22. RESUBMISSION CODE ORIGINAL REF. NO. A. a F0781 a a a 58C812A a 50091XA Q P110 H E1110 BJVERNNHOm3”DNNWmER I. F 3 3 l J. K. L. 24. A. DATEQS] OF SERVICE B. C. D. PROCEDURES, SERVICES, DR SUPPLIES E. F. 5-” H; I. J. From To PLACE OF {Erplain UnusualCircumstances‘ DIAGNOSIS 03;” EFF“? ID. RENDERING 1 MM DD ‘r"r MM DD YY SERVICE EMG CPTI‘HCPCS MODIFIER POINTER $CHARGES UNHS SE" DUAL. PROVIDERIDF! 2 1J‘44‘ 15 [10‘2'1‘ 13| 11 | \ 55:45 \ ‘ ‘ ‘ |AECD‘ 15w.uu\ 1‘ 3 1d‘24‘ 13 \1o‘24‘ 1: | 11 | \ 99j54 \ ‘ ‘ ‘ | AELL \ 5uu.uq 1 \ 4 131241 19 [10124 191 11 | \ 96130 [591 1 1 | I \ 500.00] 1‘ ‘ ‘ ‘ ---------------------- 5 l I l \ \ 1 1 1 l \ \ [ NW e \ l l \ \ ‘ : ‘ | \ \ \ NPI w 3 I 9 I 25. FEDERAL TAXI D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 7. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. Rsvd fur NUCC use 453715345 [j (Fmgovt (.Iaxms see back“ YES NO $“SUU.UU {r} 3 1 . SIGNATURE OF PHYSICIAN QR SUPPLIER INCLUDING DEGREES DR CREDENTIALS (I [emfy that Iha statements an 1MB r&vsrsa apply ID this bIII and are made a pan Iher 50f.) 32. SERVICE FACILITY LOCATION NFDRMATION Hind and Body Pain Clinic 33. BILLING PROVIDER INFO & PH# {4 U 8) 5 5 9 62 3 l Mind and Body Pain Clini: 2515 Samaritan Drive PD Box j20909 Slngh, MD, Harpreet San Jose, CA 951244108 Los Gates, CA 950320115 SIGNED 05"21”- -0 DATE 5- 1311265390 b- l 3- 1.811365 9,0 [b- NLJCC Instruction Manual available at: www.nuccm'g APPROVED DMB-0938-1 I97 FORM 1500 (02-12) NOHVWHOdNIGEHnSNIUNViNEin WHOdNIHEHddnSEKJNVKNSAHd NUUV 06/22/2020 12:21PM FAX 14086773101 MIND 8c BODY PAIN CLINIC @0018/0020 > > <- HEIHHVO NOILVWHOdNI GEHHSNI UNV J_Nfllin WHOdNI HEI'IddnS HO NVIOISAHd NUIiV Gordon , E]. l Lot L HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) D2J‘12 ' 1. MED CARE MEDEAID TRICARE CHAMPVA GR-‘DUP FECA OTHER 13. INSURE 3 I D. NUMBER «‘For Program in Item 1) HEALTH PLAN BLKLUN‘” Medicare #1 EMediwid #1 D xleDJDm D {Mamba IDm Dumfl D (IDm L i en LPATIENTb NAME (Lasl Hams, FHst Nanm. dedlc Initiah 3. PATIENTS BIRTH DATE 4. INSURED‘S NAME (LastNams, Fxrst Name, Mlddl: lnmalj I M DD Y)’ Gordon, Elliot ' J 1 aa :2005 M. F D Garden, Elliot 5. PATIENTS ADDRESS {No.. SlrE-el] j. PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (Nm, SUSEI] 45C] Franklin St Self. Spousem ChiIdE] onhefl 460 Flanklin St CITV STATE S. RESERVED FOR NUCC USE CITY STATE Mountain \‘iew CA Mountain View CA ZIP CODE TELEPHONE (Imlude Araa Code) ZIP CODE TELEPHONE (Include Ar ea Cnde] 94041 {) 94041 {J S. OTHER INSURED‘S NAME 1Lasl, erSt, Middle Initial'w TD. IS PATIENTS CONDITION RELATED TO: II. INSURED'S POLICY GROUP DR FECA NUMBER a. OTHER INSURED‘S POLICY DR GROUP NUMBER a. EMPLOYMENT7 {Current 5r Pr'ewDus\ a. INSURED'S DATE OF BIRTH SEX MM DD ‘r’Y EYES .No 02‘03‘2035 FD b. RESERVED FOR NLICC SE b. AUTO ACCIDENT7 b. OTHER CLAIM ID (DBS‘gnated by NUCC] PLAcasmtew ‘D NO ‘ E. RESERVED FDR NUCC USE C. OTHER ACCIDENT7 5. INSURANCE PLAN NAME DR PROGRAM NAME D YES Li en d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designmed by NUCC] d. IS THERE ANOTHER HEALTH BENEFIT PLAN? D YES ND ”yes, complete items 9, Ba and 8d. READ BACK OF FORM BEFORE COMPLETING 8; SIGNING THIS FOPDL 13. INSURED'S OF: AUTHORIZED PERSONS SIGNATUREI 12. PATIENTS OR AUTHORIZED PERSONS SIGNATURE Iauthanzr. th: release {any medical or other mfomwalion authoriz: paymant 3f madical benefit: In th: und ..igned nwassary tn process this claim. lal-s: quuest paymem of government benefits eithEI to myself or tn the party who physician m’ supplier for services described below. a p15 assignment Laluw. SIGNED s I GNATURE 0N FILE DATE 1 0 2 8 2 u 1 9 SIGNED sIWATURE 0N F I LE 14. DATE OF CURRENT ILLNESS INJURY, m’ PREGNANCY 1-5. Omar Date 16.DATES PATIENT UNABLE TD WORK IN CURRENT OCCUPATION A ‘LMPX‘ ‘ ‘ MM DD W MM ‘ DD YV MM‘ DD ‘ Y V’ 09‘13‘19 QUALJ431 QUALABB 09 13 ‘13 FROM ‘ ‘ T0 ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ ‘ 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 173. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES MM DD rr/ MM DD ‘r’Y ‘ » r 7 » 7 7 7 77777777777777777777777777 ‘ ‘ ‘ ‘ ‘ 17b. NPI FROM ‘ ‘ To ‘ ‘ . ‘ . ‘ . '13, ADDITIONAL CLAIM INFORMATION (DESIgHatcd by‘ NUCC) 2‘3. OUTSIDE LAB” $ CHARGES YES l 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJUR‘V Relate A-L Iuscmicu Inn: L'mlow (24B) ICD Ind. :3 I 22. RESUBMISSION ‘ ‘ CODE ORIGINAL REF. NO. A. 3-1430: B FU781 c, F431U D_ SE‘UllKA E, :5 8 C 8 1 2A F_ .50 U 9 1 :»:A Q P 1 1 (J H_ E 1 1 1 0 23- PRIOR AUTHORIZATION “UMBER |. J. K. L. 24. .‘\. DATEQS] OF SERVICE B. C. D. PROCEDURES, SERVICES, DR SUPPLIES E. F. G-F H; I. J. From To PLACE OF {Erplain Unusual Circumstances‘ DIAGNOSIS 03;” EFF“? ID. RENDERING 1 MM DD \r’Y MM DD YY SERVICE EMG CPTI‘HCPCS MODIFIER POINTER $CHARGES UNHS SE" DUAL. PROVIDER ID F! ‘ ‘ ‘ ‘ ‘ ‘ ‘ __ _ _ N211‘21‘ 19 [11‘21‘ 19| 11 | \ 55:15 \ ‘ ‘ ‘ |AECD‘ aw.uu\ 1‘ ‘ ‘ ‘ ‘ 7_ ‘ ‘ ‘ fl _ , _ A I 3 11‘21‘ 13 ‘11‘21‘ 19| 11 | \ 99354 \ ‘ ‘ ‘ |AEL-L\ 5«_m.uu\ 1 \ 4 l l l \ l 2 : 1 | \ l \ NP' ‘ ‘ ‘ ---------------------- 5 l I l \ \ 1 1 1 l \ \ [ NP' 6 \ l l \ \ ‘ : ‘ | \ \ \ NP' ‘ 1 1 1 l Np. 25. FEDERAL TAXI D. NUMBER SSN EIN 26. PATIENTS ACCOUNT NO. 7. ACCEPT ASSIGNMENT? 28. TOTAL CHARGE 29. AMOUNT PAID 30. Rsvd [m NUCC use (Fm govt (.Iaxms see back“ 4537153445 D YES ND $1300.00 ; 3 1 . SIGNATURE OF PHYSICIAN DR SUPPLIER 32_ SERVICE FACILITY LOCATION NFDRMATION 33_ BILLING PROVIDER INFO & PH}? r _1 U 8) 5 6 9 6 2 R l INCLUDING DEGREES DR CREDENTIALS ‘ ‘ h (I [emfy that Iha statements an 1MB r&vsrsa app'fm'h's b'"a"d are ""5“ a ”5“”‘5’90ft‘ Hind and Ecdy Pain Clinic Mind and Body Pain Clini : 2515 Samaritan Drive PD Box j20909 Slngh, MD, Harpreet San Jose, CA 951244108 Los Gates, CA 950320115 SIGNED 05"21”- -0 DATE 5- 1311265390 b- l 3- 1.811365 9,0 [‘3- V NLJCC Instruction Manual available at: www.nucCarg APPROVED DMB-0938-1 197 FORM 1500 (02-12) 06/22/2020 12:22PM FAX W? 14086773101 MIND & BODY PAIN CLINIC Gordon , Ell Lot ?owwz . HEALTH INSURANCE CLAIM FORM APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 ' 1. MED CARE MEDICAID TRICARE CHAMPVA GROUP FECA OTHER 1a. INSURED'S ID. NUMBER (For Program in nan: 1) HEALTH PLAN N .‘Madicare #1 Medicaid m D (IDWDJDFF) E(Mambel' ID#) (IBM L l E n Gordon, Elliot 2. PATIENTS NAME (Last Narms, Fxrsl Name. Middle hitiall 3. PATIENT'S BIRTH DATE MM DD YY c2 138:2005 Ml 4‘ INSURED'S NAME (LastNama, First Name, Middl: lnmall Gordon, Elliot 5. PATIENT'S ADDRESS {Non Slreel] a. PATiENT REILATIONSHIP TO INSURED 7. INSURED'S ADDRESS (Nun SLraal] 460 Franklin St Self. Spousem cniIdD Othefl 460 Franklin st CITv STATE 3. RESERVED FOR Nucc USE cnv STATE Mountain View CA Mountain View CA ZIP CODE TELEPHONE (hclude Araa Code) ZIP CODE TELEPHONE (Include Araa Cada] 94041 <1) 94041 {J 8. OTHER INSURED‘S NAME (Lest, First, Middle Initial) 1D. IS PATIENTS CONDITION RELATED TO: a. OTHER INSURED‘S POLICY DR GROUP NUMBER a. EMPLOYMENT? (Current or Prevmusj NOE] YES b. RESERVED FDR NUCC USE b. AUTO ACCIDENT? PLACE(StaleI c. RESERVED FDR NUCC USE D No C. OTHER ACCIDENT? D YES No 11. INSURED'S POLICY GROUP DR FECA NUMBER a. INSURED'S DATE OF BIRTH MM I DD ‘ ‘r’Y 02'0312035 l M- F D b. OTHER'CLAIM ID (Des‘gnamd by NUCC] G. INSUR‘ANCE PLAN NAME OR PROGRAM NAME Lien d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES {Designmed by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN? D YES No Ifyes, complete items 9, Ba and 8d. accapts assign ment below. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 12_ PATIENTS OR AUTHORIZED PERSON‘S SIGNATURE Iauthariza III: ralaasa uf any medical ar alhar infarmalion necessary tn process this shim. I als: request payment of government benefits either tn myself nr ln the pany who 13, INSURED'S OP. AUTHORIZED PERSON'S SIGNATUREI authoriz: paymam of medical benefits ta the undersigned physician m'supplier far services dessribed below. HGWD SIGNATURE 0N FILE DME 10/28/2019 NGED SIGNATURE 0N FILE 14. DATE OF CURRENT ILLNESS INJURY, Dr PREGNANCY 15. Other Date 16DATES PATIENT UNABLE TD WORK IN CURRENT OCCUPATION (LMPL V ‘ ‘ _ I r ’ MM DD I W MM ‘ Y MM‘ DD‘ Y'r’ 09'15‘19 mmu4s1 ouNg4j9 u9 13.19 WUM ‘ . T0 ‘ . . ‘ ‘ . . ‘ . ‘ . 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SER ICES MM DD x”! MM DD W 1 '1 ?b‘. {P} """"""""""""" FROM 1 1 To 1 j we. AbDITloNAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB') $ CHARGES ‘ YES l 21, DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Ruble A-L lu service Iin: bcluw (24E!) ICD Ind. .1’ ‘ 22. RESUBMISSION . ‘ CODE ORIGINAL REF. NO. k G44309 a F0781 g F4310 a sscllxg a 58C812A a 50091XA Q R110 H R1110 ZiPRDRAW“Dm3”DNNWBER l. J. K. L. 24. A. DATE\S) 0F SERVICE B. C. D. PROCEDURES, SERVICES, UR SUPPLIES E. F. Ggfl fl- I. J. From To PLACE 0F (Explain Unusual Circumstances) DIAGNOSIS ”3;" EFF"? ID. RENDERING MM DD YY MM DD YY SERVICE EMG CPTHHCPCS MODIFIER POINTER $CHARGES UNHS SE? QUAL. PROVIDER ID # A71470 A ' ‘ ,. I AI ,. I I x \ ‘ d_fi ‘A‘ ___ _’___’_._k_________ ulllo‘ 2U [01.1u- 2u | 11 | | 99215 l I ‘ ‘ | ABCD | auu.uq 1 | Mm 154b225823 A7147 . ‘ . . . ‘ ‘ 7,, 77777777777777777 01.10‘ 20 [01.10- 20 | 11 | \ 99354 \ . ‘ ‘ | ABCD \ 500.0q 1 \ Mm 13 6223323 l l l l l E i i | l l l 'N'Pi """"""""" . ‘ ‘ ___ _________________ l l l l l : 1 1 l l l l N“ l l l \ \ E 3 i | \ l \ I """"""""" ‘ i l l | ‘N'pi """"""""" 25. HzLJtRAL TAX I D. NUMBER SSN EIN '27. AchPT ASSIGNMENT? (Fur govt claws see hack] 26. PATIENT'S ACCOUNT NO. 28. TOTAL CHARGE ZS. AMOUNT PAID 30. Raid [DI NUCC use INCLUDING DEGREES DR CREDENTIALS {I cemfy thal the statements cm Ihe reverse apply tn Ihis bill and are made a pan thereaf.) [\lind and Body Pain Clinic 453715346 D. IVES END $1500.00 $ E; 1 . SIGNATURE OF PHYSICIAN DR SUPPLIER 32_ SERVICE FACILITY LOCATION NFORMATION 33_ BILLING PROVIDER INFO 5 FH# ( 4 U 8) 6 6 9 62 8 l Mind and Body Pain Clinic 2515 Samaritan Drive PD Box 320909 Slngh, MD, Harpree San Jose, CA 951244108 Los Gatos, CA 950320115 SIGNED 03/21/2020 DATE 3- 18112155390 b- l 3- 1811255390 [”- NUCC Inslruction Manual available a1: www.nucc.org APPROVED OMB-DS38-1 197 FORM 1500 (DZ-IZ) .0019/0020 > > <- HHIHHVO NOILVINHOdNI GHHHSNI GNV iNEIin >< WHOdNI HEI'IddnS HO NVIOISAHd N0|J_V V 1/8/2020 tos.simonmed.com/atty_|ien_invoice.aspx?Accession=28308511 BILL TO FROM {Emfiem wk??? WERN: «figéwfig‘é? @éfi gmgfikiifi fitmg‘z Mamnmm Efégw {EA §§£§€1§¢$§ fiémefifié‘imfi imagéng, im: W} $m€ 2%?fifi Q&Eim ”W ?§?§2€§~?£§~§§ 5303’” é-ieaith Diagzwstigs r Fv’iou=’itaéri View MR) 3T 74355? BRASN V‘J/C) (TEI PROTOCQL} $3,651.52 5312:: (-9 :1 2-6;? t ii”? a 'iia-s; {8,52 O L3. Ca A :‘a'aefl‘i $0: ?fiifi: fig fig tos.simonmed.com/atty_|ien_invoice.aspx?Accession=28308511 1/1 M APPROVED BY NATIONAL UNiFORM CLAIM COMMITTEE (NUCC) 02/12 •IPICA ^ ^ -^(Medicare^) [_J (MedicaW) \ j (7DM)oDffJ [I (Mmfer/D^ [_| (!Dff) J26.826Q5_^ ATTV ADAMSON AHDOOT 1150 S ROBERTSON BLVD LOS ANGELES CA 10035-1404 t:i®LUNGS1^ (For Program in item 1) 2. PATIENT'S NAME (Lasi Name, First Name, Middle Initial) 5. PATIENT'S (No., Street) 460 ST MM I DD i YV MOUNTAIN_VIEW^ I CA ZIP CODE I TELEPHONE (Inchjde Area Code) ATTY 439L_ 14. DATE OF CURRENT ILLNESS. INJURY, or PREGNANCY (LMF NED __SIGNATURE--OM-E1LE 6M32619 I 17. OF PROVIDER OR OTHER SOURCE IDN !YAN 19. ADDITIONAL CLAIM INFORMATION (Des TBI MRI 21. OR NATURE OF ILLNESS OR iNJUR A. ^M^l_. B. iRSl . |Ol632620lOlM2620lU \m^32^2QlQ1^32^20lll 3695,iQQ!1.0 3500.i0011.0i INH 11255594289 (For govt. claims, see back IXJYES LJNO 31. SIGNATURE OF PHYSICIAN OR SUPPLIER I INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse Q.JQQL7191.JOO. HD MOUNTAIN VIEW .BILUNG PROVIDER INFO & PH. (g66) 2 82 - 7905 | HEALTH OF CALIFON _01112A_ NL^-^ Instruction at: •www.nucc.org 113241-80 105 SOUTH 110 I PO BOX 207465 MQ.lMTAIM_M^_C^__Ma4D-4317_i-DAL.LAS^_TX^_25-12fi-74fi5- •_1Q32461134^__^^^^^^^^^^^^^^^^ 653 197 1500 (02-12) Jan.21.2020 9:29AM No.6797 P. 4/5 TYPE OF BILL DATE OF BILL (2) El Camino Health Man payment (o; E: oamuno HospitalP,O. Box 390342500 Grant Road Mountain ._' San Franmsco, CA Emergency 01/17/20 1View. CA 94040 4376 9413979034 Federal I. D. No. 94-3167314 PATIENT NAME HOSPITAL E ADMISSION DISCHARGE DAYSACCOUNT DATE DATE Gordon Emupeter 1000700305 :E 09/13/19 09/13/19-INSURANCE COMPANY NAME SUBSCRIBER ID GROUP NUMBER Blue Cross Anthem - Bx/bs Out Of Stale - Bx Exclusive EPAAN7466443 003330125ECAG010 Charles IRGV (:Odo Procedure Description Aniount Code 09/1 3/19 D450 45099283 HC EMERGENCY SERVICE-LEVEL 3 1 2,355.95 OQI‘I 3/1 Q 0320 32073030 HC SHOULDER MIN 2 VIEWS 1 947.27 09/1 3/1 9 0320 32073562 HC KNEE MIN 3 VIEWS 1 ‘1 .125.15 09/13/19 0351 351 70450 HC CT HEAD SCAN W/O CONTRAST ‘l 4,778,33 09/13/1 Q 0351 351 70486 HC CT FACIAL W/O CONTRAST 1 5.41 6.88 09/1 3/1 Q 0250 25000000 LIDOCAINE HCL. 2 ”/o JELLY IN APPLICATOR (76329730137 1 22.80 5) Total Charges 1 4,644.39 Payments and Adjustments e Cross Anthem Payments and Adjustments 10/28/1 9 SELF-F’AY D SCOUNT POL CY ADJ O 983,29 Current Hospital Account Balance: 3,661 .10 Jan. 21. 2020 9:30AM No. 6797 P. 5/5 TYPE OF BILL DATE OF BILL (z) El Camil'lo Health Mai) Payment to: E1 Camino HospitalP.O. Box 390342500 Grant Road Mountain_' San Franclsoo, CA Emergency 01/1 7/20 1View, CA 94040 4378 941 3979034 Federal I D NO Q4-3157314 PAT'ENT NAME HOSPITAL ADMISSION DISCHARGEDATE DATEACCOUNT Gordon E.Mmtpete, 1000702421 wAE 09/13/19 omens-GROUP NUMBER,DAYSINSURANCE COMPANY NAME SUBSCRIBER ID Blue Cross Anthel‘n - Bxlbs Oul Of State - Bx EKClusiVe EPAAN7466443 003330125ECAGD10 Charges escr' )tlon HC EMERGENCY SERVICE LEVELS l2 \I (30d!) 09/1 5/1 9 45099233 Payments and Adjustments Description Alhuunl Blue Cross Anlhsn‘l Payn'lenls and Adjustlnents 0,00 1 1/04/19 SELF-PAY DISCOUNT POLICY ADJ fifi A1,_766,97 Current Hogpital Account Balance: 588,99 CEP AMERICA CALIFORNIA 1601 CUMMINS DR STE D MODESTO, CA 95358-6411 THE BALANCE OF THIS ACCOUNT REPRESENTS YOUR CO-PAY, DEDUCTIBLE AND/OR 800 498-7157 NON-COVERED SERVICES. YOUR ACCOUNT IS TAX ID94-2494000 30 DAYS PAST DUE. PLEASE REMIT PAYMENT. ACCOUNT NO. 773015-01 STATEMENT DATE 01/24/20 TRACY GORDON 460 FRANKLIN STREET MOUNTAIN VIEW, CA 94041 ------------------------------------------------------------------------------- DR# DATE PATIENT AT RF DESCRIPTION ICD10 AMOUNT ------------------------------------------------------------------------------- 09/13/19 ELLIOTT 1 1 99285 EMERGENCY DEPT VISIT 940.00 09/13/19 ELLIOTT 1 1 73030/26 RADEX SHOULDER COMPL 55.00 09/13/19 ELLIOTT 1 1 94760/26 NONINVASIVE EAR/PULS .00 10/15/19 ELLIOTT Claim 09/13/19 DENIED by - ANTHEM BC LIFE HEALTH 11/10/19 ELLIOTT Claim 09/13/19 DENIED by - ANTHEM BC LIFE HEALTH 12/22/19 ELLIOTT Claim 09/13/19 DENIED by - ANTHEM BC LIFE HEALTH 12/22/19 ELLIOTT Coinsurance Amount $465.87 12/22/19 ELLIOTT Reply - ANTHEM BC LIFE HE- FOR 09/13/19 12/22/19 ELLIOTT 871 CARRIER ADJUSTMENT 55.00- 01/16/20 ELLIOTT 871 CARRIER ADJUSTMENT 474.13- 01/16/20 ELLIOTT DOS: 09/13/19 - BLUE CROSS ------------ TOTAL CURRENT $465.87 , .. , .Q'NSIBLE PC; 73W 91 i ' .7 w . __ _, ,2: TRACY GORDON 28 156-SVDI ‘ 12-19-2019 SILICON VALLEY DIAGNOSTIC IMAGING INC PO BOX 2468 INDIANAPOLIS, IN 46206-2468 TRACY GORDON 460 FRANKLIN ST MOUNTAIN VIEW, CA 9404 1 - 1994 DOS Patient Physician Phys Tax ID Charge Description Amt Pmt Adj B21 09-13-2019 ELLIOTT GORDON 5-ALVAREZ, MARCOS 70450 26 - CT HEAD/BRAIN W/o DYE 259,00 0.00 0.00 259.00 09-13-2019 ELLIOTT GORDON s_ALVAREz, MARCOS 70486 26 - CT MAXILLOFACIAL Wlo DYE 356.00 0.00 0.00 356.00 09-13-2019 ELLIOTT GORDON 5-ALVAREZ, MARCOS 73030 26,RT - X-RAY EXAM 0F SHOULDER 54.00 0.00 0.00 54.00 09-13-2019 ELLIOTT GORDON s-ALVAREZ, MARCOS 73562 26,LT - X-RAY EXAM 0F KNEE 3 46.00 0.00 0.00 46.00 09-13-2019 ELLIOTT GORDON s-ALVAREZ, MARCOS c9637 - Doc >1 DOSE REDUC TECH 0‘00 0.00 0.00 0.00 Account $715.00 Balance: FOR BILLING QUESTIONS PLEASE CALL (866) 535-5196 Account Number: 28 156-SVDI 1 0f 1 JPONN 28 15675VDL7 176287 CEP AMERICA CALIFORNIA 1601 CUMMINS DR STE D MODESTO, CA 95358-6411 800 498-7157 TAX ID94-2494000 ACCOUNT NO. 773656-01 STATEMENT DATE 01/24/20 TRACY GORDON 460 FRANKLIN STREET MOUNTAIN VIEW, CA 94041 ------------------------------------------------------------------------------- DR# DATE PATIENT AT RF DESCRIPTION ICD10 AMOUNT ------------------------------------------------------------------------------- 09/18/19 ELLIOTT 1 1 99283 EMERGENCY DEPARTMENT 338.00 10/22/19 ELLIOTT Claim 09/18/19 DENIED by - ANTHEM BC LIFE HEALTH ------------ TOTAL CURRENT $338.00 e) El Camino Health 2500 Grant Road Mountain View. CA 94040-4378 Phone: 650-940-7000 www.elcaminohospitalprg 1 0/09/1 9 Tracy Gordon 460 FRANKLIN ST MOUNTAIN VIEW CA 94041-1 994 REQUEST FOR ADDITIONAL INFORMATION Patient Name: Elliott Peter Gordon Account #z 1000700308 Date of Service: From 09/13/19 To 09/13/19 Total Charges: $14,644.39 Dear Tracy Gordon, We submitted a bill to your insurance company,Bx/bs Out Of State - Bx Exclusive, for services rendered on the dates listed above. They have pended your claim as they are investigating the existence of other insurance coverage. Please contact your insurance company within 15 days to update your Coordination of Benefits. Othen/vise, you will be made responsible for the balance due of $14,644.39. Thank you for your prompt attention to this matter. Sincerely, Patient Accounts El Camino Hospital 2500 Grant Road, 0AK280 Mountain View, CA 94040 800-665-6540 patient_accounts@elcaminohospital.org (a El Camino Health P.0. Box 398534, San Francisco. CA 94139-8534 HB 01 000804 56718 E 7 B IIIIllllll|I||II|IIIIIIIIII'IIIIlullIIIlnlllllllllltlilulllllllil TRACY GORDON 460 FRANKLIN ST MOUNTAIN VIEW CA 94041-1994 Page 1 ( Statement of Hospital Services Statement Date: November 27, 2019 Guarantor Name: TRACY GORDON Thank you for choosing El Carnino Health for your hearth can needs. W913; This statement represents hospital charges only. Physicians are not employed by or agents of our iacility and their charges will be billed separately. 93mm For questions regarding Billing, Payment options or Financial Assistance: a 650-940-7220 or 800-665-6540 o Monday through Friday, 9:00 am. to 4:00 pm. {Guarantor 'mormation \ a Email: palianLaccounls@alcaminoheaithmg Guarantor Name: TRACY GORDON Eahbxmhm . I Guarantor Number. 500088258 To make self-servnce, credn card payments. 24 hours' a day, T days a week: k J n 650-940-7220 or 800-665-6540 a l. E I. I I I f N myCare and the Estin'lator/Quick Pay online tools can beaccessed from your computer. tabla! or smart phone. 24Account summary hours a day, 7 days a week. Delinquent Account Balance $0.00 Payment plan Account Balance $0 00 myCare allows you to make payments with no sign-on . ' needed. myCare also allows you to set up an account Prev'ous A009unt Balance $3561 '10 to view both your service summary and/or detail. myCare Current Hospital Services Balance $588.99 can be accessed at httpsy/mycareslcaminohaanh.org. Total Guarantor Balance $4,250.09 The Estimator/Quick Pay allows you to make a payment or create an out-of-pockal estimate for hospital services withou the need for a sign-on and can be accessed through our website at www.elcaminohealthprg.Piease see reverse for account detail.k J We previously notified you that your insurance plan processed its portion of your bill for hospital services. The remaining bafance Is your responsnihty and Is now past due Please submit the full payment at your eafliest convenience. If you are unable 10 remit the iull balance please contact our Customer Service Team to discuss payment options. A335 FEE IS CHARGED FOR ALL RETURNED CHECKS. PAYMENTS WILL BE POSTED TO THE OLDEST BALANCE UNLESS OTHERWISE DIRECTED BY THE GUARANTOR. PLEASE MAKE CHECKS PAYABLE T0: EL CAMIND HEALTH D Yes. [have noted a change to my address or insuranceinfomation on the back of this page.(1) El Camlno Health P.0. Box 398534. San Francisco, CA 94139-8534 For your convenience we accept. Guarap_t__o_r [lime __ Guarantor Number Date Due ws‘ ,, mqun F TRACY GORDON 500088253 UPON D E D @r D A D LE RECEIPT Card Number Card Expiration Date r. d Print Cardholder's Name EL ammo HEALTH BILLING Signature Po Box 398534 SAN FRANCISCO CA 94139-8534 Amount Due Amount Enclosedmm llDSDUDBBESBLl371‘IDDDDHESUU‘IL E) El Camlno Health 0. Box 398534. San Francisco, CA 94139-8534 Previous Balance Account Detail Account Number: 1000700308 Service Date: September 13, 2019 Patient Name: ELLIO'I'I' PETER GORDON Account Balance: $3,661 .1 0 Previous' Balance Amount Now Due $3,661 .10 Current Hospital Service Detail -\ Account Number: 1000702421 Servlce Date: September 18. 2019 Patient Name: ELLIOTT PETER GORDON m 0450 +EMEHGENCY ROOM _. _._ ._ $235596 Charge Total $2,355.96m s_ELF-PAY DISCOUNT POLICY ADJ F $-1J§§=_9_Z Account Balance / Amount Now Due $588.99 __./ CHANGE OF ADDRESS OR HEALTH INSURANCE INFORMATION Page 2 of 2 mm-m ul‘ Hospital Scrtiws Statement Date: Guarantor Name: November 27, 2019 TRACY GORDON Befomomgmflnmmllonnuww: c Financial Asslslance Plograms avalable o State or Federal Health Care Coverage optlons o Associated provider contact information o Local Consumer Assistance contact information F9: Iaurimormfnn State and federai law require debt collectors lo neat you fairly and ptohibits debt collectors lrom making false a:atemenls or [meals of violence. using obscene or profane language. and making improper communications with third parlies, including your employer. Except under unusual circumstances. debt colleclots may not contact you before 3:00 am or afler 9:00 pm. Ir: gemrat a deb! uoltector may not glve Information nboul your debt to another person. other than youl attorney or spouse. A debt collector may contact another person to confirm your locatlon or to enforce a ludgement. For more Enlormaflon about debt coliectlon activities. you may contact the Federal ?vade Commissnn by telephone at 1-877-FTciHELP (382-4357) or ordlne al www.ftc.gov.MW Eeyes estatales y federales requiren que la agencies de cobra tralen a paciente de {orma iusla. y prohlben a Ias agencies da corbo de Ievantar false, de amenazas, de langualo absence o ptofane, y de comumcarse cor su ompleador. Excepto on ciortas ocasiones. las agencies de cobro no pueden contactarlos antes do las 8:00 am o despues de las 9:00 pm. En general. las agencies da cobro no pueden divulger su nformacaon de la dueda a nunguna otra persona excepto a su esposa/esposo o abogado. Las agencuas de cobro pueden contactar a otraa personas para conflrma: el domicilio pale enforsar una ordan do Ia cone. Peta mas informacion sobre actlvidades de colecolon de cobros. usted puede coniactar a la Comlslon Fedora? do Comerclo al numero 1-877-FTC-HELP (382-4367) o visits su pagina web www.flc.gov. If you have new health insurance or a new address, please enter the information below. newmonsss cm sure zpoooz uswmoue u Wu meow: one mam um or msuaso nuomPo/omsn msumuce PHONE n IF snow msuamcs.Mme o:mow{wmvmumamssocmmm msunmcecomm NAME msuamcamam mm Mam (a El (amino Health R0. Box 398534, San Franclsco. CA 941 39-3534 l-‘or Your Convenience All facility related charges will be billed separately from the facility. Any questions you may have regarding facility related charges should be referred to the billing office for the facility: El Camino Health Customer Service 650340-7220 or 800-665-6650 Consumer Support-Legal Assistance/Soporte al Consumido-Asistenda Legal] Efiifi -MW Bay Area Legal Aid/Health Consumer Center of Santa Clara County 8556934285. .._1:'..i_°'.-;.-7L;_ _ .. ._. _m_.m;;£ Help when you need It El Camino Health has developed several options to help alleviate the financial burden of necessary medical services for our patients. These options are described below and more information on each program can be obtained by calling our Customer Service Staff at 65 0-940- 7220 or 800-665-6540 or by accessing our website, www.elcaminohealth.org. Payment Plans We offer a number of extended payment plans which do not include interest or additional fees. Charity Care Patients who meet income and family size eligibility requirements can apply for charity care. High Medical Costs Financial assistance is also available for patients with high medical costs. Other Programs For more information about or applications for Covered California, Medi-Cal, Health Families or California Children's Services, please refer to their websites: Covered California/Medi-Cal/Healthy Families www.coveredca.com California Children‘s Services ww.dhcs.ca.gov/services/CCS/Pages/defaultaspx ”??? ""_='.:‘.‘-Z'*;-£?E-E. .. -' - ' ' “-3. Ayuda cuando la necesltas El Camino Health ha desarrollado varias opciones para ayudar a aliviar la carga financiera de los servicios médicos necesarios para nuestros pacientes. Estas opciones se describen a continuacién y se puede obtener més informacién sobre cada programa obtenida de nuestra pégina web, www.elcaminohealth.org 0 llamando a nuestro equipo de servicio a1 cliente al 650-940-7220 o 800-665-6540. Planes de pago Ofrecemos una serie de planes de pago extendido que no incluyen intereses o cargos adicionales. (I) El (amino Health P.O. Box 393534. San Franclsco. CA 94139.8534 Cuidado de caridad Pacientes que cumplen con ingresos y requisites de elegibilidad del tamafio de la familia pueden aplicar para el cuidado de caridad total. Altos costos médicos Asistencia financiera también esté disponible para los pacientes con altos costos médicos. Otros programas Para obtener més informacién sobre o aplicaciones para Covered California. Medi-Cal, Healthy Families o California Children's Services, refiera por favor a sus sitios web: Covered California/Medi-Cal/Healthy Families www.coveredca.com California Children’s Services www.dhcs.ca.gov/services/CCS/Pages/defaultaspx EEEJ. ' .. :31. ! E5mfi§¥fi fififig 2%:TfififlfiffiWfiklfigfifififififififififi’ifia‘fififi = E1 Camino HealthfififlETmfi x = m-Ffiiggjgggggfiag . gfiggggfi . afiififfia’ggfinfi, www.elcaminohealth.org fififi 650-940-7220 2% 800-665-5540 fiwffiwzfiflfiififififlfifi v {‘Wfl fif‘lffifiéfifiaifififlfifififlfiffimfifififi‘flfiffifl v Km 110%filkfiéflikmfifikmfi’9fifi: ’ Himifiafififififififififi ° fififlm fififlzhfi‘rfigfifififififi’flfiA ' filfifia‘fifififl v Kffififi fifiifiEéfififlCovered California v E-F ’ Wifififlfliiiflfiflfififlfifififi$fi§ ' fiiMTm ilk: Covered California]E ‘F/ffiffififi www.coveredca.com 7mi~H§EEHEi§ www.dhcs.ca.gov/services/CCS/Pages/deraulcaspx C) El Camlno Health P.O. Box 398534. Sal'l Francisco. CA 94139-8534 MB 01 003068 22711 E 13 B mlIll'"||-III-n'lll'll'lllilllll'"'III|"II1III"I""|I'I” TRACY GORDON 460 FRANKLIN ST MOUNTAIN VIEW CA 94041-1994 Guarantor Information N Guarantor Name: TRACY GORDON Guarantor Number: 500088258 J \Account Summary Delinquent Account Balance $0.00 Payment Plan Account Balance $0.00 Previous Account Balance $0.00 Current Hospital Services Balance $3.661.10 Total Guarantor Balance $3.661 .10 Please see reverse for account detail. J Thank you for choosing El Camino Health for your health care needs. Your insurance has completad processing your claim and the remaining balance on this account is your responsibility. Balances are due in full upon receipt of this statement. If you have any questions please contact our Customer Service Team and they will be happy 10 assist you. Thank you. Page 1 of 2 Statement of Hospital Services Statement Date: October 28, 201 9 Guarantor Name: TRACY GORDON Thank you for choosing El Camino Heaflh for your health care needs. Emma; This statement represents hospital charges only. Physicians are not employed by or agents of our facillty and their charges wilf be billed separately.mm For questions regarding Biliing, Payment options or Flnancial Assistance: I 650-940-7220 or 800-665-6540 a Monday through Friday. 9:00 am. to 4:00 pm. o Email:patient_accounts@elcarninohealth.org To make self-servica. credit card payments, 24 hours a day. 7 days a week: o 650-940-7220 or 800-665-6540 Qnflmfiaflmlmla myCare and the Esiirnator/Quick Pay omine tools can be accessed {rom your computer, tablet or smart phone, 24 hours a day. 7 days a weak. myCare allows you to make payments with no sign-on needed. rnyCare also allows you to set up an account to view both your service summary and/or detail. myCare can be accessed at https://mycare.elcaminohealth.org. The Estlmator/Quick Pay ailows you to make a payment or create an out-of-pockat estimate for hospital services without the need for a sign-on and can be accessed through our website at www.elcaminohealth.org. A $6 FEE IS CHARGED FOR ALL RETURNED CHECKS. PAYMENTS WlLL BE POSTED TO THE OLDEST BALANCE UNLESS OTHERWISE DIRECTED BY THE GUARANTOR. PLEASE MAKE CHECKS PAYABLE T0: EL CAMINO HEALTH (2) El Camlno Health [j R0. Box 398534, San Francisco. CA 94139-8534 Yes, I have noted a change to my addrsss or insurance information on the back of this page. For your convenience we accept: GuarantorName GuarantorNumber Date Due J- ' c _ T. fiac'yeonnou' " ""saowmr D W- D D 3W D RECEIPT Card Number Card Explration Date |"I'I'l'mIl'I'III'Ill-IIIIII'W|""|""|!III'I'*I-'I-I'l'l' Pm” ca'dm'der's Name EL CAMINO HEALTH BILLING Signature P0 BOX 398534 SAN FRANCISCO CA 941 39-8534 Am I'lt D = Amount EHCIOsed 1:ID5DDDBBESBLDEBL‘IUUDDBEELLD3 Page 2 of 2 (0‘) El (amino Health Statement of Hospital Services 20. Box 398534. San Francisco. CA 94139-8534 Statement Date: October 28. 2019 Guarantor Name: TRACY GORDON BE . ”H I r. o Financial Assistance P{ograms available current Hospita] service Beta" N o State or Fedetal Heanh Care Coverage oplions o Associated provider contact Information Account Number: 1 000700308 Service Date: Septem ber 1 3, 201 9 - Local Consumer Asslstance contact mlormation Patient Name: ELLIOTF PETER GORDON EQLYQuLlansnnn . ti State and federa law reqmre debt collectors to lreat you Ialrly and prohibits debt collectovs lrom making 0350 ‘COMPUTED TOMOGRAPHIC (CT) SCANS $1 0:193-21 {arse statements o: threats of violence, us-ng obscene 0450 "EMERGENCY ROOM $2,355.96 or protaneJanguege. and making improper 0250 ,pHAHMACY $2230 communications with lhird patties. including your employer. Except under unusual c-rcumslances. dlbt 9330 ‘RADLOI£GY'D_IA£NOSTIC__ . M- $207242 ooflectors may not contact you belore 8:00 arn or Charge Total $1 4,644.39 after 9:00 pm. :n general. a debt collector may not nt - tm nt give information about your deb! to another nelson. other than your attnmey or spouse. A debt collector SELE-PAY DIS-C-OU-N- ----- -$'1 01983-29 may contact another perSOn to confirm your location Account Balance / Amount Now Due $3,661 .10 or lo entorce a judgement. For more information bout j debt celleclion activities, you may contact the FederalTrade Commission by telephone at 1-877-FI'C-HELP 1382-4357) or on1ine at www.fto.gov. Leyes estatales y federaies raquaren que la agenmal de cobro uaten a' paclente de forma iusta. y prohibal‘l a ias agencies de colbo de levantar (also. d9 amenazas. de lenguaie obsence o profane. y de comunlcarse con su amplaador. Exceplo en cierlas ocasiones. Ias agencies de cobro no pueden contaclatlos anles de Ies 8:00 am o despues de Ias 9:00 pm. En genera. Ias agencies de cobro no pueden divulger su infermacion de na dueda a n:nguna one persona excepto a su esposa/esposo o abogado. Les agencies de cobto pueden contacts! a olras personas pata conlirmar el domlo Iio para enforsar una orden de la corle. Para mas informacion sobre actividades da colecclon de cobros. usted puede contactar a la Comision Federal de Cornerclo al numero 1-877-FrC-HELP (382-4357) o visits su pagina web www.flc.gov. CHANGE OF ADDRESS OH HEALTH INSURANCE INFORMATION If you have new health insurance or a new address. please enter the information below. NEWADM WY STATE DP CODE MW PHONE POLICY HOLDER'S NAMEMBATIONSNIP IO PATIENT POUCY ID I GROUP l EFFECTIVE DATE BIRTH DATE 0F INSUED HMOIFPOIOIHEH mm WNE l 1F GROUP INSURANCE.WE 0F GROUP (EMPLOYE. UNwWASOGATION) msunmce ooummnuTe msunmcs mnnsss EMPLOYER EMPLOYERMESS 6) El Camino Health R0. Box 398534. San Francisco. CA 94139-8534 For Your Convenience All facility related charges will be billed separately from the facility. Any questions you may have regarding facility related charges should be referred to the billing office for the facility: El Camino Health Customer Service 650-940-7220 or 800-665-6650 Consumer Support-Legal Assistance/Soporte a1 Consumido-Asistencla Legal/ GF'Ifi . fififlfi) Bay Area Legal Aid/Health Consumer Center of Santa Clara County 855-693-7285. Help when you need it El Camino Health has developed several options t0 help alleviate the financial burden of necessary medical services for our patients. These options are described below and more information on each program can be obtained by calling our Customer Service Staff at 650-940- 7220 or 800-665-6540 0r by accessing our website, www.elcaminohealth.org. Payment Plans We offer a number of extended payment plans which do not include interest or additional fees. Charity Care Patients who meet income and family size eligibility requirements can apply for charity care. High Medical Costs Financial assistance is also available for patients with high medical costs. Other Programs For more information about or applications for Covered California, Medi-Cal, Health Families or California Children’s Services, please refer to their websites: Covered California/Medi-CaI/Healthy Families www.coveredca.com California Children's Services Ww.dhcs.ca.gov/services/CCS/Pages/defaultaspx Ayuda cuando la necesitas E1 Camino Health ha desarrollado varias opciones para ayudar a aliviar la carga financiera de los servicios médicos necesarios para nuestros pacientes. Estas opciones se describen a continuacién y se puede obtener més informacién sobre cada programa obtenida de nuestra pégina web, www.elcaminohealth.org o llamando a nuestro equipo de servicio al cliente a1 650-940-7220 o 800-665-6540. Planes de pago Ofrecemos una serie de planes de page extendido que no incluyen intereses o cargos adicionales. (3) El Camino Health 9.0. Box 398534. San Fra nc-‘sco. CA 94139-8534 Cuidado de caridad Pacientes que cumplen con ingresos y requisites de elegibilidad del tamafio de 1a familia pueden aplicar para e1 cuidado de caridad total. Altos costos médicos Asistencia financiera también esté disponible para los pacientes con altos costos t_nédicos. Otros programas Para obtener més informacién sobre o aplicaciones para Covered California, Medi-Cal, Healthy Families o California Children’s Services, refiera por favor a sus sitios web: Covered California/Medi-Cal/Healthy Families www.coveredca.com California Children’s Services www.dhcs.ca.gov/services/CCS/Pages/default.aspx EMEER fiwfl g;TSfiflfifl’fifl’flfiAliflfiEfifififiFfifififi’Jfia‘fififlg ' El Camino Health fifififi‘HETflifififi fl = MTEEgfi$figéfififi ° fiiéfiigfififi ' éfiifif‘lfi’fléfiflb www.elcaminohealth.org fiiflg 650-940-7220 E: 800-665-6540 Bamwggfigafififimg -W fifiififitgfifflfiflfiflifififlflfifi’flflfifih‘flfififl 4 Em fiflfifiAfiéqi/KflfiEAMWfiW ’ film$fiéfififii§$§fi v 5mm fifififilkfifififififififififi’flfik ' ?Efiiéfififififisb ° xm mg§§%fiflfiC0VEFEd California ‘ E'F ' @Eifififlfli'lifififlfififififigflm$fig ‘ Efiij’XT‘ffi ilk: Covered California/E *F/{fifiifi www.coveredca.com flfli‘l‘lfiafifififi www.dhcs.ca.gov/services/CCS/Pages/default.aspx ME STATEMENT ' m ' ' - ‘ ‘ ' ' B'illing Office Hours. 6:0Iam- 5. ' 0 I ' v- '_ Location of Service: EL CAMINO HOSPITAL . Monday_Ffiday (Closed On Major Ho'id'ays) - r Provider: KOLLY CHRISTOPHER, 0.0 Phone BOMQBmST fit’l‘fg‘atez 944494000 Outside The USA Email: billing@vituity.com D la E Account Information DUE NOW PAY ONL|NE SCAN FOR g a I Statement Date: 1111412019 WWW epayitonnnecom MOBILE E Patient: ELLIOTr GORDON $338-00 g HELP US Go GREEN ENT Account#: E13 773656 Patient Balance: $338.00 Enter Code ID: VITUBIL1 Access#: 9439823-1-1 382 .,E[I',m__a_rv Insurance: BLUE'CBOSS‘ Eatepf _ , . _ - ervlce_._D.escnpt|on.of.Semces - - 09/1 8/1 9 99283 EMERGENCY DEPARTMENT VISIT MODERATE $338.00 Total: $338.00 YOUR INSURANCE CARRIER HAS NOTIFIED US THIS CLAIM IS PENDING ADDITIONAL INFORMATION. PLETAHSAENfiOYNO'I'30T YOUR CARRIER PROMPTLY. SU SEGURO MEDICO NOS A NOTIFICADO QUE NECESITA INFORMACION ADICIONAL. POR FAVOR CONTACTE A SU SEGURO MEDICO. GRACIAS Payments can be made at www.epayitonline.com or with our automated system at: 1-866-954-4405 or International callers at 1-209-252-0601 If you are uninsured or have high medical costs, please contact Patlent Services at {800) 498-71 57 for information on discounts and programs for which you may be eligible. Including the Medicaid program. If you have Insurance coverage, please provide your Insurance lnformatlon at www.apayltonllna.com or contact Patient Services so that we may bill your plan. Please detach and relurn lhe bottom ponlur. with payment To Pay By Credit Card g0 t0: www.epay1t0nline.com 0r pay by phone _ ._ @ 866-954~4405 or 5 I ' u : ' STATEMENT DATE mwm’ 11114119 E18 773656 Please check box if address is incorrect or insurance Information .D has changed and indicate change(s) on reverse side. Patlemi ELLIOTT GORDON MAKf CHECK PAYABLE AND REMIT TU: CEP AMERICA CALIFORNIA PO BOX 582663 MODESTO CA 95358-0070 ‘9 vntunty‘ Mmmo‘bflmmw -0 .J AMOUNT DUE $338.00 |uh"H“rhnbhfldu""hflflhhdhuhhflhflhhflfl ”laq” Iuh““"4drflfld“flhdflflflflflhhhhuu"fldhflfl TRACY GORDON CEP AMERICA CALIFORNIA 460 Franklin St P0 BOX 582663 Mountain View CA 94041-1994 MODESTO CA 95358-0070 1.11:9l‘IDUUUUDBBBDUElHDUUT?HEEL FREQUENTLY ASKED QUESTIONS Q A. Q. A. PP YOUR U'Pb‘AT'ED'" ”MA'I'LI'Nd Abbhééém What if I can not pay? CEP America dba Vitunytwas a Payment Assastance Program that may cover some ot your balance. To determine if you qualify for payment assistance please call the number listed 0n the front 0t this statement. lreceived a bi“ from a doctor whom I did not see. Why? The hospital where you received treatment sends laboratory tests and x~rays to physicians to review. You wiil receive :1 separate bill from these physicnans for their services. How much do l really owe? You le not receive a statement or a bill from us until your insurance has paxd or denied your account. Your responsibitity is the "Amount You Owe" located in the Account Informatron Section of the statement. This balance will reflect any co-payments. deductibles. C0 Insurance 0r non--covercd services your Insurance indicates arc your responsibility. Please review your Explanation m E enef‘lts or comnct your insurance company with any questions. IF YOU HAVE RECEIVED THE SERVICES OF A HOSPITAL OR OTHER MEDICAL FACELITY YOU MAY RECEIVE TWO S}.il’.»‘\RF(l‘lj HILLS. 0N1; FROM 'l'l H? l-l(‘)Sl’]'l‘AL OR MEDICAL I"ACILI'I‘Y AN!) ONE FROM THE PHYSICIAN PROVIDING SERVICES 'i‘Hl; H(')Sl’lT/\I,OR OTHER MEDICAI FACILI'I‘Y‘S Bll‘l. MAY RE SEPARATE FROM THE l’l IYSICIAN‘S BILL. i TOTAL COST HOSPITAL OR MEDICAL FACILITY’S FEE PHYSICIAN’S FEE The 101:1! um I'm many medical scrviccs may hc comprised 01‘ two l'ccs‘. Each l'cc may hu hiHcd sepuralcly by lhc provider ol‘ [ho serviccx. 'i‘hc hospital or other mcdicui Eku'ility's foe covers Ihc cml of providing [ht tcchniciuns. equipment and Supplies involved in pcrformmcc ol‘ your scrvicc. The physician‘s‘ l'cc is‘ for services provided by your phyiciun 211 his anicc 01' another medical fucilily. if your physician is not employed by Ihc medical fncilil}. whore you rcccivcd scrviccx, you may l'cccivc scp:u alL pinstci m 21ml lalcilily bills MAILING ADDRE S APT 4: cm STATE ZIP CODE PHONE u CELL a (OPTIONAL) YOUR UPDATED INSURANCE INFORMATION PATIENT NAME PATIENT REFERENCE t: INSURANCE COMPANY NAME INSURED‘S NAME (IF NOT PATENT) EFFECTIVE DATE INSURANCE :D n GROUP 9: PLAN a RELATIONSHIP 0F pATIENT To INSURED INSURED'S PHONE a INSURED'S CELL # (OPTIONAL) ‘2 SELF CI SPOUSE ”I DEPENDANT CHILD f1 OTHER :NSURED’S EMPLOYERS NAME EMPLOYERS PHONE u :NSURED’S DATE 0F BIRTH OTHER INFORMATION DMS VlTUHY-72I2 SILICON VALLEY DIAGNOSTIC IMAGING INC .' PO BOX 2468 E E INDIANAPOLIS, IN 46206-2468 " E . Ways To Pay... TRACY GORDON 460 FRANKLIN ST MOUNTAIN VIEW CA 94041-1994 Automated Attendant 1.866.535.5196 (24 hours a day Online www.mydocbl!l.comISVDI FarPayments Please Cali: 1.866.565.5202 Forming Questions Please Call: 1,866,535.51. Date Due Upon Receipt AccountNumber Amount Due StatementDato 281 56-QSVDI $71 5.00 09l25/1 9 Account Summary Account Number 281 SB-QSVDI Paifant Payments In Last 30 Days 0.00 Current Statement Balance 71 5.00 Charges Pending w! Insurance 0.00 ”M” " ' Total Account Balance 715.00 Sea Dotall on Back New & Improved Online Experiencfl Go Green www.mydocbill.com/SVD| Pay Online | Update Info Galn the power to paxzour bill or update your Information at your convenlence hours a day. Thla not only benefits the environment it benefits you and your tlmel Insurance Information PLEASE CONFIRM THAT INFORMATION IS CORRECT About Your Statement TO UPDATE GO TO WWW mydocblllnomlSVDl Our records Indlcate there is still an outstanding palm“ balanca on this account. You may make a payment Insurance onlina. If you have insurance and your statement does not reflect your Insurance lnfonnation or that GrOUPIPIan the claim has been filed please go online and make ID Number sure wa have your correct insurance information. You SECONDARY can also call our automated phone system 24 hours a clay at the number listed above to make a payment or '"su’m‘ update your Insurance. Thank youl Address CltyistateIle GrouplPIan ID Numb” See Statement Details on Backfl SILICON VALLEY DIAGNOSTIC IMAGING INC PO BOX EH55 INDIANAPOLISw IN HEEDE-EHEE ‘l‘fl1 Patlent Name: ELLIOTT GORDON Invoice Number: 34185 Bllllng Questions: 1.866.535.5196 'lII'I'll"”II'|II"'|II|I|I"|*”"I'IIII'III'II'l'lll'II'IIII' mm, - TRACY GORDONfi LIED FRANKLIN STMOUNTAIN VIEU CA fiHDHL-l'fill UUUBHl5EUDD7ISDUUDUDDUDEEIEESVDID --------------------------------------------------------- 09125“ 9 281 56-QSVDI CHARGES AND CREDITS MADE AFTER STATEMENT DATE MLL APPEAR ON NEXT STATEMENT. SHOW AMOUNT PAID HERE- MAKE CHECKS PAYABLE! REMIT TO:w SILICON VALLEY DIAGNOSTIC IMAGING INC P0 BOX BREE INDIANAPOLIS-n IN HEEDb-EHEB III-I'-I'I'III'|l'|I'I|-"II|'-'III'-"IlIII'Illlll-Il'u'l'llhl Pay Onllne: www.mydocbill.comlSVDI 1., _ --.-.-n---- -...-. ---.--.-- * ----- .ICON VALLEY DIAGNOSTIC IMAGING INC ll G0 Green Pay Onlme | Update Info W,mydocbm_com,svp. Summary ofServzce Charges PROC PAY] INSUR. PATIENTDATE CODE UNITS DETAILS OF SERVICES CHARGES ADJ PENDING BALANCE Patient' ELLIOTT GORDON Referred By. ALEX H LINKER Services Were Provided at: EL CAMINO HOSPITAL MTN VIEW ER 09-13-19 70460 1 CT HEAD/BRAIN WIO DYE 259.00 Im ”I 259.00 09-20-19 GUARANTOR RESPONSIBILITY DATE (CHARGEID: 39424) 09-13-19 70‘86 1 CT MAXILLOFACIAL WIO DYE 358.00 ton m 356.00 09-20-19 GUARANTOR RESPONSIBILITY DATE (CHARGEID: 89435) 09-13-19 73030 1 X-RAY EXAM OF SHOULDER 54.00 mm ”I 54.00 09-20-19 GUARANTOR RESPONSIBILITY DATE (CHARGEID: 89446) 09-13-19 73862 1 X-RAY EXAM OF KNEE 3 48.00 law m 48.00 09-20-19 GUARANTOR RESPONSIBILITY DATE (CHARGEID: 89457) Cu rrent 31-60 Days 61-90 Days Over 90 Days DATE DUE: BALANCE DUE: $71 5.00 $0.00 $0.00 $0.00 UFO" Receipt $71 5.00 SILICON VALLEY DIAGNOSTIC IMAGING INC Po Box 2468 INDIANAPOLIS, IN 46206-2468 1.866.535.5196 If your insurance has issued payment directly to you. please send us this payment immediately to stop the collection efforts. hen you provide a check as payment, you authorize eitherto use information from your check to make a e-time electronic fund transfer from your account or to )cess the payment as a check transaction. atient Statement For: TRACY GORDON Statement Date 09/25/19 Account Number 28} 5.6;QS_VD| . ___ . .. STATEMENT SEE REVERSE SIDE FOR IMPORTANT BILLING INFORMATION d i m T y p e C l a i m N u m b e r P a t i e n t M e d a l M o d i c a l M e d i a ! M e d i n a : M o d ‘ u l M e d i a l 2 6 1 9 2 7 0 6 5 3 8 5 E l l i o m o z m w z o o 2 6 1 9 2 3 1 0 2 1 7 4 E l r m t o z / o e n o o 2 0 1 9 2 6 3 2 4 5 1 7 E m a n w z l w z o o 2 5 1 9 2 3 2 0 2 9 5 0 E l i o m o z / o m o o 2 6 1 9 2 7 3 3 2 7 4 4 s u m ( o z / o a r z o o 2 0 1 9 2 6 5 0 1 7 3 3 E m o m o z r o a r z o o S e w i o e D a t e v a a a a d a y a i m S e p 2 5 , 2 0 1 9 s u m B a y M e a i c s 3 2 9 . 0 0 s a p 1 a . 2 0 1 9 c e s i u m : E m e r y s 3 3 8 . 0 0 S a p 1 s . 2 0 1 9m a m s 2 3 5 5 . 9 6 S o p 1 s , 2 0 1 9 s m r s a y M e d i c s 2 2 5 . 0 0 S e p 1 3 . 2 0 1 9 c a l m s m u g s 9 9 5 . 0 0 s e p 1 3 . 2 0 1 9 M m A v a n a u e s m u s s M m P a i d S 0 . 0 0 3 0 . 0 0 S 0 . 0 0 S 0 . 0 0 S 0 . 0 0 S 0 . 0 0 3 0 . 0 0 S 0 . 0 0 S 0 . 0 0 S 0 . 0 0 S 0 . 0 0 S 0 . 0 0 S 0 . 0 0 5 0 . 0 0 S 0 . 0 0 5 0 . 0 0 S 0 . 0 0 3 0 . 0 0 C o i n s u r a n o e 5 0 . 0 0 3 0 . 0 0 S 0 . 0 0 5 0 . 0 0 S 0 . 0 0 3 0 . 0 0 0 ° 9 8 ! s 0 . 0 0 S 0 . 0 0 s o . c o s 0 . 0 0 s 0 . 0 0 s o . o o 3 3 2 9 . 0 0 S 3 3 8 . 0 0 S 2 3 5 5 . 9 6 S £ 5 . 0 0 S 9 9 5 . 0 0 S 1 4 6 4 4 . 3 9 Y o u r C o s t S 3 2 9 . 0 0 S 3 3 8 . 0 0 S 2 3 5 5 . 9 6 3 2 2 5 . 0 0 S 5 9 5 . 0 0 S 1 4 6 4 4 . 3 9 S t a t u s D e n i e d D o n b d D e n i e d D e n i e d D o m e d IN RE ELLIOTT PETER GORDON CASE NO.: 20CV36747O MC-350 ATTACHMENT 173(2) RETAINER AGREEMENT adamson ahdoot 1150 south robertson bouievard los angeies. ca 90035 t310.888.oo24 f888-895-4665 adamson ahdoot www.aa-Hp.com ATTORNEY-CLIENT CONTINGENCY FEE AGREEMENT 1. Parties. This agreement is made by and between ("Client”), and the law offices of Adamson | Ahdoot LLP ("Attorney"). 2. Scope of Services. Attorney shall provide legal services to Client as follows: representation of Client‘s Legal services for related or unrelated matters are not contemplated by this contract and shall be subject to separate negotiations and agreement, and shall not affect or alter the rights of Attorney and Client under this Agreement. 3. Client's Duties. This office shall make no settlement of Client’s case without Client’s complete approval. Client agrees, however, that Attorney has made no promises or guarantees to Ciient regarding the outcome of this case. Client agrees, at all times throughout Attorney's representation of Client, to: keep Attorney advised of Client's current address and phone number; to be honest and truthful to Attorney with respect to all matters involving Client's claim or the subject matter of the representation of Client by Attorney; and to fuily and truthfully advise Attorney of all potentially relevant or material facts involving Client's claim or the subject matter of the representation of Client by Attorney 4. Legal Fees, Costs, and Billing Practices. Attorney will only be compensated for legal services rendered if a recovery is obtained for Client. NO RECOVERY NO FEE In the event Ciient receives a recovery in this matter by way of a settlement, judgment, or verdict, or by any other means, Attorney shall be entifled to a contingency fee in the higher amount of (i) or (iii) below: (i) One Third (1/3") of the amount of the Gross Recovery if resolved prior to filing a lawsuit I arbitration, or Forty (40%) of the amount of the Gross Recovery if resolved after a lawsuit is filed in court or demand for arbitration, or Forty Five Percent (45%) of the Gross Recovery if resoived at or after the first dav of trial or arbitration ; or (ii) The amount awarded by the court for attorneYs fees. Gross Recovery shall include the amount of attorney's fees and costs awarded by a judge or arbitrator. Costs, disbursements, and expenses as described in Paragraph 5 below shall not be deducted from the Recovery in order to compute the attorney's portion of the contingency fee. Any third-party fees and all costs and expenses W11! be reimbursed to Attorney or paid to the third-party, if not previously paid, out of your portion of the Gross Recovery. Sanctions awards are not part of recovery. _ Q 5. Costs and Expenses. ln addition to the Attorney's fees stated above, Client agrees to pay all costs - Including, but not limited to. court filing costs, deposition reporter costs, Xeroxing, messenger services, expert witness fees, and process server costs. Through our experience, Costs and Expenses usually amount to $300.00 inmam. Costs and fees will be higher if a case is litigated and shall be itemized. This amount is to be deducted from the gross recovery at the conclusion of this matter. The costs and expenses required in prosecuting the case (above $300.00) may be either advanced by the client or by the Attorney. The client may choose either option. If the client e|ects to advance the money for costs and expenses, the client must pay each cost and expense as it is incurred. If the client elects to have the Attorney _advance the money for costs and expenses, the moneym be borrowed by the Firm from a third party lender and with an upterest rate which will be disclosed to the Client, statements are available upon request and piaintiff may pre-pay at any time. At the conclusion of the case, all such monies, including principal, interest and costs related to such advances shall be reimbursed to the law firm by the client from the recovery proceeds. 6. Attorney Discharge and Withdrawal. Client shall have the right to discharge Attorney at any time upon written notice to Attorney. Such discharge shall not affect Client’s obligation to reimburse Attorney for costs incurred prior to such discharge. In addition, Attorney shall be entitled to his full contingency fee if he has fully performed his obligations under this Agreement (except for any incidental obligation he has been prevented from performing) and has obtained a recovery for Client either by way of award, verdict, judgment, settlement, or compromise (whether or not actually paid. Attorney may withdraw as Client's Attorney for good cause. 7. Bonafide Offer of Settlement. If a bonafide offer of settlement is made, which in the opinion of Attorney shoutd be accepted, Client will have the right to insist that the matter proceed to trial, but in the event, and only in that event, Client shall advance all court costs, including expen fees, incurred or to be incurred from and after the date Client is advised of the settlement offer and of Attorney's opinion that it should be accepted. 8. Appellate Engagement. If an appeal is agreed upon or if the opposing party appeals, a separate written agreement, to be negotiated between Attorney and Client. shall provide for additional fees and costs. 9. Contingent Fee Disclaimer. Attorney has advised CIient that the foregoing contingent fee is a negotiated agreement and not set by law. 10. Attorney Lien. Attorney is hereby given a lien on said claim or cause of action. on any sum recovered by way of settlement, and 0n any judgment that may be recovered by way of suit thereon, for the sum and share hereinabove mentioned as his fee and any costs or advances made by Attorney to or on behalf of Client; and it is further agreed that Attorney shall have all general and special liens permitted by the common law, statutory law, and the Code of Ethics. 11. Attorney's Entitlement to Fees for Collection. It is agreed that in the event Attorney initiates legal proceedings in order to collect the Attorney's fees, costs, and advances provided for herein, Attorney shall be entitled to recover, in addition to court costs, reasonabie attorney's fees therefore. 12. Power of Attorney. Attorney is given a limited power of attorney to endorse Client's name on any draft or check for payment of settlement, judgment, or verdict presented by or on behalf of any defendant, and to deposit said funds into Attorney's Client Trust Account and thereafter disburse same in accordance with this Agreement. 13. Change, Modification, andlor Waiver of Agreement. There can be no change, modification, or waiver of any of the provisions of this Agreement unless the change is in writing and signed by both Client and Attorney. Any attempted change, modification, or waiver that is not in writing and signed by both Client and Attorney shall have no effect whatsoever. 14‘ Attomey-Client Dispute. Attorney and Client agree that in the event of any dispute under this agreement, they shall submit such dispute to non-binding mediation before resorting to litigation, and shall use their best efforts to resolve any such dispute through mediation. 15. File Retention. Adamson Ahdoot LLP maintains a paperless office. All documents are scanned and shredded upon receipt. Attorney retains original documents only where required. Unless otherwise notified by client, Attorney will shred and dispose of any originals thirty (30) days after the conciusion of the matter. Attorney will retain a digital copy of your file for two (2) years after the conclusion of your matter. Cl_ient Acknowledgmeqt. client acknowledges that he has read and fully understands all of the terms and conditions 0f thus Agreement before sugmng it, and has received a copy of this Agreement upon execution thereof. This Agreement represents the full and complete agreement between Client and Attorney, and supersedes any prior, simultaneous, or subsequent oral Irepresentation made by either party to the other. This Agreement is meant to be a totafly integrated contract that can be modrfied only in a writing signed by both parties. ACCEPTED AND AGREED TO THIS ON W ‘ i 2 g! 1(Date) . Signatfir EmoH“ 0W4 Pn‘nt Nam'e IN RE ELLIOTT PETER GORDON CASE NO.: 2OCV36747O MC-350 ATTACHMENT 18b(2) BANKING INFORMATION Wells FargoBank 599 Castro Street, #150, Mountain View, CA 94041 AMOUNT: $134,948.70 10 11 12 13 14 15 16 17 18 19 20 21 22 Z3 24 25 Z6 27 28 PROOF OF SERVICE STATE OF CALIFORNIA, COUNTY OF LOS ANGELES I am an employee in the County of Los Angeles, State of California. I am over the age 0f 18 and not a party to the within action. My business address is: 1150 S. Robertson B1vd., Los Angeles, California 90035. On March 5, 2021, I served the foregoing document, described as PETITION FOR APPROVAL OF COMPROMISE OF CLAIM OR ACTION OR DISPOSITION OF PROCEEDS OF JUDGMENT FOR MINOR OR PERSON WITH A DISABILITY 0n all interested parties in this action by placing a true copy thereof in a sealed envelope, addressed as follows: David A. Clinton, Esq. CLINTON 8L CLINTON 100 Oceangate, Suite 1400 Long Beach, CA 90802 T: 562-216-5000 F: 562-216’5001 Email: DAC@ClintonLaw.com Attorneys for Defendant, Soph, Inc., dba Papa John’s Pizza D (BY OVERNIGHT DELIVERY) I caused a true copy thereof to be enclosed in a sealed envelope With delivery fees provided for, and t0 be deposited in the box regularly maintained by Federal Express in Los Angeles, CA. X (BY ELECTRONIC MAIL) By electronically serving the document(s) to the electronic mail address set forth above on this date by 0r before 11:59 p.m., pursuant to California Rules 0f Court, Rule 2.251, and consistent with Code 0f Civil Procedure § 1010.6(a)(2), (4) and (5). D (BY FACSIMILE) I sent such document Via facsimile mail to the number(s) noted above. The transmission was reported as complete and Without error, and the transmitting facsimile machine properly issued the transmission report. D (BY MAIL) As follows: Iplaced such envelope, With postage thereon prepaid, in the United States mail at Los Angeles, California. I am “readily familiar” With the firm’s practice 0f collecting and processing correspondence for mailing. Under that practice, it would be deposited With the U.S. Postal Service on that same day, with postage thereon fully prepaid, at Los Angeles, California, in the ordinary course 0f business. I am aware that, on motion of the party served, service is presumed invalid if the postal cancellation or postage meter date is more than one day after the date of deposit for mailing in this affidavit. X (STATE) I declare, under penalty 0f perjury under the laws of the State of California, that the above is true and correct. Executed on March 5, 2021, at Los Angeles, California. Mflmwr Maria Gonzalez