Claim by Sara T. GillesJ". ~ /!
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CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
0 3 FEa ~ p pr~.~ ~. p Q
This written report constitutes your claim against the City of Dubuque, Iowa. You should com I h's~form in full and
attach any additional information that supports your claim. ' ' ~ ~~ ~Ji il„„
The claim must be filed with the City Clerk at City Hall, 50 West 13~h St., Dubuque, IA 52001. It will then b~~~e7err~ to
the appropriate department for investigation and to the City Attorney's Office. Once that investigation is completed, a
report and recommendation will be submitted to the City Council. You will be provided with a copy of that report and
recommendation.
The final decision on all claims is made by the City Council. No employee of the City of Dubuque has the authority to
make any representation to you as to whether your claim will or will not be paid.
1. Name of Claimant: ~a(a ~, ~~ ~ ~P S
2. Address:
3. Telephon
4. Date of Incident: ~ S- C~~
5. Time of Incident: ~ • ~n r7r~-~
6. Location of Incident (Be specific): (~~ i~~C' 2 ~ ~n n_ -- y ~~~ ~~ ~ k,
(ot`~ ~ ~ a-E F'l or -~P 1 Aar lu nr: I c~~- .
7. Describe the accident or occurrence that caused injury or damage. (Give full details upon which you base your
claim. If a City employee was involved, give the employee's name.)
C P I e at L ~'c~e~r -I-a i n C.t~1-~- ~~ -~-~
8. W hat were weather conditions like? ~~a~`~~ ~~ ~~y~~,~! (,+,~ ,~ u
9. Give name and address of any witnesses: 1V ~kk ~ ~Q~ J i S ~{~-~co ~,~ ~ ~ ~ a,ryLS
10. Did police investigate? (If so, give names of
11. Was anyone injured? (If so, give names, addresses, and extent of injuries.)
~ItS - Sara Gt1l<_s
12. Was any damage done to property? (If so, describe property and the extent of damages. Attach estimates of
damages or describe basis for ascertaining extent of damage.)
1n3.~What other damages do you claim, if any? ~1L IM ~!~ a¢ Il~t ~ ~ S ~p (^~ Yl f (~~}-I ~ S ~
l-i ll ~r` ~ p S -Y~ 1 /~ t~ "~~~/ ~~~ ~ ~~ ~_I ~ J 1 `, ~~~t" ~.) t I ~ S u-xti rt t + d (( 6t ~ ~ S
14. Have you been compensated for any part or all of your claim by any insurance company? (If so, give name and
address of insurance company and amount paid.)
~O
15. What amount do you claim from the City of Dubuque? ~~ ~ Cl , ~, r~r,1
~lp ~-~-;~-~ ~~ z
16. Why do you claim the City of Dubuque is responsible? ~~ P ,v. 1 a
17. Have you made any claim against anyone else for damages as a result of this incident? (If yes, give name and
address.)
18. If the answer to Question 17 is yes, have you received any payment from that source, and if so, in what amount?
Dated this ~ day of re~rct~T, 20 U
n
(Signature)
.S~ra ~ C~II~S
(Print Name)
INCIDENT REPORT
1 incidents of a serious nature shall be documented on this report. The report must be forwazded immediately to the Program Coordinator or
:sidential Supervisor: Only TYPE A incidents must be forwarded immediately to the Director of Adolescent Residential Services. for
~cident/Injury reports, copies of the report are forwarded to the Clients Clinical Record and/or Staff File, Nurse and Safety Director.
~_ 00~.,.
ype of Report: Staff Related ~ Client Related: Name: ~ 1\ [~ )L~ ~
• ~ m
ate of Incident: L I~") Time of Day Incident Occurred: Author of Report:1`'~,(~, . Q i~ ~Cl
iBJECTIVE DESCRIPTION OF INCIDENT OR ACCIDENT/INJURY:
a. t14 :.nne rl. °4 ~~~ . ~ ~~l..e....1s1,
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Witness(es): 0. { ~
lescribe First Aid or Care Given: _ ~~,=~'`u:~yC
,-~~ ~ . 1 ,. ~ n 1_`... n .. n 1~ l n A .. !~'~'~l~ f1I~ n `ice ~ n n~
C.T. Nurse of Physician Notified (Name/Date/Time)/:
'arentGuardian Notified (Name/Date/Time):
Zeferral Worker Notified (Name/Date/Time):
Follow-Up Action Needed: p
F
~~~ ~ ~ ~ ~'
administrative Review of Incident:
iignature/Date of Residential Supervisor
~K: 9/3/02 Forms Folder
'hysical Health Section
Witnesses-Names and addresses
Nikki Lewis
532 Rhomberg Apt #1
Dubuque, IA 52001
Lynn Murphy
1646 Finley
Dubuque, IA 52001
Laura Thole
2035 Chaney Rd
Dubuque, IA 52001
Anthony Williams
1397 Washington
Dubuque, IA 52001
UBUQUE RADIOLOGICAL ASSOC PC
1875 UNIVERSITY, PO BOX 1655
DUBUQUE, IA 52004-1655
FORWARDING SERVICE REQUESTED
Tax Id.e 420958542
E~lease direct all billing q'u€~~~3ons to:
5~3-583-8281
SARA J GILLES
335 KLINGENBERG TERR
DUBUQUE, IA 52001-4433
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C~ Pfe~s~ cFteck ~rcrx ii abcrv~: ~sclc9res<~~ is incarrecY or insur~nc~
ir'If1~l~r~i~tioro r~t~ ~. chan~~=~d, ~n~ ifldie.~t~; cF~~nc~e(s) orl r~va~rse side;.
DBQ l~ ~l'-~~~~3
01/05/09 1 SARA
01/05/09 1 SARA
01/05/09 1 SARA
IF PAYING BY CREDIT GARDE PLEASE FILL OUT BELOW
CHECK CARD USING FOR PAYMENT
II~~ , . \I ~
unnnsc~cara
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,
\\ //,, fAASTERCARD I_- -.. 7 VISA
CARD NUMBER AMOUNT
SIGNATURE IXP. DATE
1 02/03/09 i $102.00 DBQ 159109073
' $102.00
DBQ
DUBUQUE RADIOLOGICAL ASSOC PC
PO BOX 1655
DUBUQUE, IA 52004-1655
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PI _ t:.h~ f)~7ACVi 6a~#D 6~~~UI~N TOF' G'Ofd~FiO~ ~~i7F# y~U~~ P~Y~v1Ef~~i-
balance C~rac Up®n ~.ecei~t "~
,~
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11 C)ffice 3'I In~~Yi~nt ~7 O~rCp~tierrt FlcspiY~l 23 ~n~~lgel7cy I:r~on~ ~ HnspiL~l
i?~iY•'i,ln~ l1~3 +~~~i~~~~~~' ,=~~?~aa~~?~~Il'7.'~;l E /~r~il«~7~~i1i -
~L____~~ _ ~f _ - - ~ - -
23 73550/26 X-RAY FEMUR, 2 VIEWS 30.00
23 72170/26 X-RAY PELVIS; 1 OR 2 VIE 40.00
23 73590/26 X-RAY TI BI A& FIBULA, 2 VI 32. 00
Patient: SARA J GILLES
Services rendered at: THE FINLEY HOSPITAL
Claim 1 Total: 102. 00
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PLEASE CALL THE ABOVE TELEPHONE NUMBER IF YOU HAVE INSURANCE COVERAGE FOR THIS
BILL. YOU ARE RESPONSIBLE FOR PAYMENT IF YOU DO NOT CALL. THANK YOU.
02/03/09 7.02. 00
~e~oYti{I~~~n2~~~H'~11~) jc~~llTdl~~~~_- -
1 HUFFMAN, MAURI CE D, M. D. PRIMARY INSUR: FI NLEY HOSPITAL
2 SECONDARY INSUR: S I S C O
3 LOCATION OF SVC: THE FINLEY HOSPITAL
a REFERRING PHYS: HUNT, JILL M, MD
DUBUQUE RADIOLOGICAL ASSOC PC
1875 UNIVERSITY, PO BOX 1655
DUBUQUE, IA 52004-1655
Phone Number: 563-583-8281
A returned check fee ®f $25.00 will be assessed t®
y®ur acc®unt each time a check is returned.
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2011 01101 8726-26] F04 LBOBOB72 STOCK = F-AE
FTI IRN THIS PORTION WITH YOUR PAYMENT
TIIE FI~TLEY
I ®SPITAL
l_._~ ^ IOWA HEALTH s~~srE,~
PO BOX 356 -DUBUQUE, IOWA 52004-0356
Check box if Information is different than
^ on statement. Complete reverse side.
IF PAYING BY CREDIT CARD, PLEASE SELECT CORRECT CARD AND FILL OUT BELOW
^ ~~.~ ' ^ ~ ~
i a k
:~, 1
~_~ CARD VERIFICATION NUM.
(REQUIRED)
CARD NUMBER EXPR. DATE
SIGNATURE AMOUNT
DATE
03/09/09 PAY THIS AMOUNT
$320.00 ACCOUNT NUMBER
FED608851
PATIENT NAME
SARA GILLES AMOUNT
PAID
PLEASE REMIT PAYMENT TO:
W SARA J GILLES
335 KLINGENBERG TER
DUBUQUE, IA 52001-4433
I~I~I~~~I~III~~~II~~~~~~II~I~~I~I~III~~II~~~II~~~II~~I~I~II~~~I
FINLEY ED BILLING
PAYMENT PROCESSING CENTER
PO BOX 356
DUBUQUE, IA 52004-0356
I~I~I~~~I~III~~~II~~~~I~~III~~~~~II~~I~I~~II~~~I~I~~II~~~I~~II
42 00~~010000608851,0032000000000004
RETURN THIS PORTION WITH PAYMENT
PHYSICIAN STATEMENT
For Questions about this Statement call the Billing Office Monday through Friday, 8:00 AM to 4:30 PM CST: (563) 589-2364
Service Date Provider Service/Payment Description Charges PaymentlAdjustment Balance
01/05/09 HUNT, J Physician Service Level 4 320.00
BALANCE DUE: 320.00
SISCO PAYMENT (02/02/09) .00
DENIED/ADDTL INFO REQUESTE FROM INSURED
PLEASE CONTACT YOUR INSURA CE COMPANY
SISCO PAYMENT (03/02/09) .00
CHECK#: 3646
DENIED/ADDTL INFO REQUESTE FROM INSURED
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Account No. Stmt. Date Page No. PAYMENT DUE UPON RECEIPT Insurance In Process !.- • • , ~105~ ~~~
FED608851 03/09/09 1 THANK YOU .00 $320.00
25/ 1528
PATIENT NAME: SARA GILLES
1 ' Customer Service Phone Hours:
SIB KEEP THIS PORTION F®R YOUR RECOR®S Monday -Thursday 8:00 a.m. - 6:30 p.m.
Friday 8:00 a.m. - 4:30 p.m.
Toll Free 888-343-4165
IOWA TH sYSrem Questions: http://www.ihs.org/billing
March 06, 2009 d--
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Sara Gilles ~ _ - ' v~
335 KLINGENBERG TER ~ ``' ~-
DUBUQUE, IA 52001-4433 ~ o° ~~-
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4~
Dear Mr./ Ms.. Gilles
Your account at The Finley Hospital is now considered delinquent. Further delay in payment of your
outstanding obligation of $388.46 to The Finley Hospital may cause your account to be placed with
an independent collection agency. The handling of your account in this manner may result in legal
action or may have an adverse effect on your credit rating.
The Finley Hospital is committed to working with you to resolve this matter. In order to avoid
possible placement with an independent collection agency, payment in full must be received within
10 days of this notice. If you are unable to make payment in full, please contact our customer
service center immediately at 888-343-4165 to inquire about the possibility of payment
arrangements or financial assistance. Please disregard if payment in full has been sent.
This correspondence is for the express purpose of obtaining payment of your outstanding
account(s). Any information provided will be used for that purpose.
Thank you in advance for your prompt attention to this matter.
RETURN THIS PORTION WITH YOUR P14YIV1ENT
®SPIT
IOWA ~-iFAi TH SYSIhM
CENTRAL BILLING OFFICE
1200 PLEASANT STREET
DES MOINES, IOWA 50309
ELECT CORRECT CARD AND FILL OUT BELOW
IF PAYING
BYCREDIT CARD, PLEA
SE S
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^~, ~ ^L~ ~ V. CODE
L
CARD NUMBER EXPR.DATE
SIGNATURE AMOUNT
DATE PAY THIS AMOUNT ACCOUNT NUMBER
03/06/09 $388.46 154642623-0001
PATIENT NAME AMOUNT
SARA GILLES PAID ~P
^Please check box if address below is incorrect or insurance
information is changed. Indicate change(s) on reverse side.
208
IIIIIIIIIIIII111II111111IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
Sara Gilles
335 KLINGENBERG TER
DUBUQUE, IA 52001-4433
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
THE FINLEY HOSPITAL
PO BOX 7082
DES MOINES, IA 50309-7082
°THE FINLEY H®SPI°TP-L
REH,4E SERVICES ~-1' CRAN®VIEW
444 N. Grandview
Dubuque, Iowa 52001
(563) 589-2497
O 1 / 12/2009
MP°F'®Iltl~®ltllpppl~VT RC~pIY~I~IV®6R
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Dear SARA GILLES
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The following information is provided as a reminder of the appointments you scheduled at The
Finley Hospital Occtpatie~at Rehab Services.
SCIIEDULED APP®IhTT1VIENTS:
Date: 01/13/2009 Time: 5:00 Case #: 721255
Procedure:PT EVAL
Date: 01/15/2009 Time: 5:30 Case #: 721256
Procedure:PT VISIT
Rey~aenzber to bri~zg any papers or prescriptions that your doctor has given you regarding
your therapy. It is very important that we have your current insurance information and any
updated medical information, including your medications. If your insurance information has
changed, please update this information with our receptionist when your arrive for your
appointments.
For questions or concerns regarding this schedule, or to cancel this appointment, please call
(563)589-2497.
Sincerely,
Finley Rehab Services at Grandview
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xxx*E1VII'LOI'EE RETURN TO WORK C'ERTIFICA7`i;_i[; ,`:;' ':_.1'~ ~~ ~~
r,~: ,.,., ,~. r
INITIAL VISIT AT THIS CLINIC CONFIDENTIAL
^ FOLLOW-UP VISIT
EMPLOYEE EMPLOYER
Date of injury/incident Diagnosis
May return to work: with/without restrictions Immediately Off work until
WORD RESTRICTIONS: THESE RESTRICTIONS ARE FOR WORK ANI) N®N-WORD ACTIVITIES
Restrictions: Start Date Stop Date Permanent
No use of No extensive reaching
No lifting or calTying (or equivalent pushinglpulling) Liptit/No above shoulder level activities
over pounds Limit/No forceful gripping
Limited bending Limit repetitive activities
Limited stooping and twisting No exposure to respiratory irritants
Limit walking, standing or climbing/stairs No exposure to skin irritants
Sitting work preferred/only- No exposure to temperature extremes
__ Allow frequent position changes _ __ Taking medics=lion which may indice drowsiness
No squatting, kneeling or crawling ~ Other
One-eyed work/no depth perception
May not work overtime
IF WORK THAT SATISFIES THE ABOVE RESTRICTIONS CANNOT BE PROVIDED, THE PATIENT IS NOT TO WORK AND
SHOULD RETURN FOR APPOINTMENT AS SCHEDULED
FOLLOW-UI' CARE:
^ Following your treatment in the Finley Emergency Department, please call Finley Occupational Health 585-1290
between 7:30 a.m. and 5:00 p.m., Monday through Friday, for an appointment. Fax number is 585-1274
^ Appointment at Occupational Health: Date
^ Appointment with another specialist, Dr.
^ No further appointments
Medications
Time
on at
Additional instructions/comments:
Time in the clinic
Time in Time out Employee Signature
Provider's Signature Date
THE EMPLOYEE IS TO PRESENT A COPY OF THIS FORM TO THEIR EMPLOYER.
White copy-Medical Record Yellow copy-Employer Pink Copy-Employee
Rev. 07/03/08
.Dili u d ~ °` ~W ~ ~ ~ !!I:~u ~
~ 1 E R E C~_
stew
a X-rays a reviewed by $ Biologist. If any ~diti®nul z-rays ire ne~d~d you will be cont~ct~d®
Ir Cultures usus$Ily tike 40 hours for results. If ~ddition~l tre~tent is needed you will be cont~ete.
! tl May utske you droway. D® N®T D i/E. ®l'E 1'E P/IaCIiINEItY. ®R USE aLC®Ii®l.,.
Prescritlonse Y®u were given the foil®wing prescriti®ns, take ~s directed on label.
Nuane ®f drug Dose Number IDrescribed Nuanber of refills
F®11®sv the FIonae Cure Instructi®ns given t® v®ta. (circled instrtacti®n sheetsl
abdominal Cast Care Con'unctivitis Flead In u L me t)is se ®titis Sinusitis Urines infection
adult Gaeta Child fever E e in'u Flives I~linor T u Pain Sore throat Vaccine schedule
asth Coasti ated E e medication [mmu ' tton R9iscarria a Pediatric fever S rain /fracture Viral iafectton
);ask Pain Crou Febrile sieaures Inhaler iVloao Pediatric astro Suite b lania a Wound Care
hack Exercise Crutches GE I eccac fmlotriu V Tender heart
~roachitis Ear Pa(n G n/Gu (STi9 ICidne Stoae Nitro 1 ceria Scabies U er res .
burn Care E eabrasioa Ileadaehe Lab rinthitls Nosebl Shin lee Catheter sere
l+~tlll®W-6JD l:~re
®ther ln3trlaCtllDns:
IDigc~lar'~e TIlt1~7 ~~ iii D u~ i I'in i ` ~ ~u~ ~ ~ii,0 '~~~i_' G ~ ~~,i;~~ +~iilli~ ~ ~ f~il~
1'0 assist in any f®llow-tap care I glue per>stissiola for ~ copy of this record end tests to be sent t® Dr.
P~tient/Gu~rtiit;n eluti®nship f teases
~~~ r! I 1 t t tl ***
The Finley l3ospitsl ~ ''
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350 N. Gr$aadview ~ 4 ~
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Dubuque, Iu. 52001 r-,~ ~ _
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INST1018IH (Rev. 02/07)
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F I N~L ~~E V - N A R ~ LG®G Wtl'd~~~16~ ® 6/tt ~®Ct~td ~~ ~~ ~G6lid~ ~® 1' I
PLIY~ ! ; :I~~'I~'IC~TI~ F(1:-. I:~J~.~~.~ I~ ~IIrffi CAI. E~ JIPENT
This prescrireion muse be complvtvd and ciQned b the h sician in order or g'HH to bill the crutches, arm ads and hand ri s to tl:e ad
'Date ordered' ICD 9 #: DIAGNOSIS
insurance ~ a
I Physician signature
Physician Full Name
Date of signature
UPIN # ~ Address
~II,I.II~ ~ INFO 'Y'I®I~1
CONSENT/AUTI-IOILiZATION: I understand that my signature on this agreement authorizes the provision of products, equipment or servrces to me
by Finley-Hartig Homecare. I also understand that the products and/or services provided to me by company or its agents are provided under the direction
of my physician and that Finley-Hartig Homecare is not liable for any act or omission when following the instructions of my physician.
ASSIGNMENT OF BENEFITS: I authorize (a) direct payment to Finley-Hartig Homecare of any insurance benefits otherwise payable to me for any
product, equipment or services provided to me by the company, (b) my insurance company(ies) to furnish to Finley-Hartig Homecare all information
pertaining to my insurance benefits and status of claims submitted by the company for any products, equipment or services provided, and (c) Finley-
Hartig Homecare to release to my insurance company(ies) or HFCA and its agents any and all information pertaining to me for benefit determination.
Customer signature DATB
If customer is a minor,: responsible party to sign and write relationship - Phone#
Yellow copy to patient White copy to Finley-Hartig Homecare DME-4 1/OS
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DUBUQUE FAMILY PRACTICE, P.C.
320 N. Grandview
Dubuque, Iowa 52001
Phone (563) 583-9300
~.
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S~v~ rttic~~~~y. Lave b~t~er.
WE SELI. FOR LESS
MANAGER RD$IERT HRR1lTNG
{ 563 7 5$2 1003
ST# 2009 OF# 00005035 TE# 79 TR# 05553
RX# 705$491 D3$ QTY 1H 10,00 0
a NRS
Eq Z$UF~ROFEN 06$11317002pH 7.22 X
5U$TOTAL 17,22
TAX 1 7.OOD X 0.51
T®
CASH
END 20.7
CHANGE DUE 3,00
~~ ,~,
TC# 3903 2929 29$5 1932$ 91$2
I I IIIII ~IIIIIIIIIIII IIII III(( I ~I~I (II(II I~III~~( ~I
Gel Free Hdlld~~ Sevlns~ ba Cell! Diel
#WMT ®r Ylelf td~lmert.cnm/mab11e1nF~
01/05/09 1$:57:19
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~ Signature Required Y
01/05/2009 06:54:14 PM
Page No : 1 of 2
e~cal Absence eprt
Name r ,~'~ ~ _~A-- ~sJ 1 ~( ~ ~~
has been under my care for/the following
from
to
and is able to return to work/school on
Limitations on activities ~~, ~~~ j ~;~-y-~
~, (~-
Patient was seen on at AM/PM
Martin D. Bagby, D.O.
Steven G. Haas, M.D. ~ '~`~ ` 'I
Cory L. Dietz, M.D. °~'
Brian J. Nelson, M.D..
Amy J. Ewen, M.D.
Date
GILLES °~
SARA
335 KLINGINGBUFiG TERR ~
DUBUQUE, IA 52001 ~ ~
(563) 582-4236 4 7 9 3 2 3 19 3~ 6 5
01/05/2009 (563)582-1519 ~
RX: 7058491 REF = 0 OC;# 655 923 441 076 592 760 107 659 238 '®
NPS
TOTAL: $10.00 ~