Claim by April Shoars 3 6 09
This written report constitutes your claim against the City of Dubuque, Iowa. You
should complete this form in full and attach any additional information that
supports your claim.
The claim must be filed with the City Clerk at City Hall, 50 West 13t" St.,
Dubuque, IA 52001. It will then be referred 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: ,^s 1~P4~~
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2. Address: 1~L~~ ~~ ,~ C ~'.i~.~_~F1 .~°~f~~ :~,~-} ;..~~ E's~ t ~~;'~.,~-~;~
3. Telephone Number t~_s - ~~~ ~.~~~~/'
4. Date of Incident: ~~~~~~~~~~~
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5. Time of Incident: ~J~~~~ ~-~;k.3 ~~ ~~~ :~~~~~/
6. Location of Incident (Be specific:
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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.) ,i C~~
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8. What were weather conditions like? ~~
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9. Give name and address of any witnesses: ~.`'y ~
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10. Did police investigate? (If so, give names of officers.) `~`' ~
11. Was anyone injured? (If so, give names, addresses, and extent of injuries).
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.)
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13. What other damages do you claim, if any?
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.)
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15. What am/ount doJ~ou clai/m /from tie City of Dubuque?
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,~1'6}. Why do you claim th City of Dubuque is responsible
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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 l9~ day of :~ , 20 Ul.
(~gnature)
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(Print Name)
Follow the Home Care Instructions given to you. (circled instruction sheets)
I Abdominal ~ Cast Care ConJunctlvitia Head Injury Lyme Diaesae Otitis Sinusitis I Urinary infection
Adult Gasto Child fever Eye injury ~ Hives Minor Teauma .Pain Soee throat ~ Vaccine schedule
Asthma Constipated Eye medication Immunization Miscarriage Pediatric fever Sprain lfraeture ~ Viral infection
Back Pain Croup ~ Febrile siezures I Inhaler Mono Pediatric gaatro ~ Suite bet;inninga ~ vk'ound Care
~ Sack Exercise Crutehea GERD I I~eecae Motrin RSV ~ Tender Heart I
I Bronehitia Eae Pain G}m/Gu (STD) I Kidney Stone Flitroglycerin Scabies ~ Upper rasp. I
I Burn Care EyeAbrasion headache I Labyrinthitls I
Aloaebleed ShinRl~ I Catheter care I
b'ollow-LTp Care
If not improviug as expected or develop new problems contact your physician or return here.
If your pain is reasonably controlled by medication or interventions contact your physician or return here.
1Vlake an appointment in Business Health
_ You have an appointment in Business Health on (l)ate) ---- _ _ at (time)
Idlake an appointment with the following specialist
tin appointment has been made with I)r. _- . _ _. _ _ ______ on (date) __ at (time) __ _ ___
®ther instructions: _ _ __ _ __
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I leave received and understand my home care instructions.
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III ®f-my questions have been addressed. Dr.
,, - Nurse ~ .
Patient or Guardian Relationship )'season foe ~s~~i(
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Di®C118rg~ Time: lu ~i,,~ii, ot'l :~ i~~~ ; t! f ~~a e ;ii' ~i~ L'~ I : ~li~t ~GhI. ~~ L l ( ~- _. I ~ •~, ~ ~~ r~ h , ; ~ ~ ~'~ ~ ~,
1'o assist in my follow up care I give permission for a copy of this record and tests to be sent to Dr.
Patient/Guartlian
T'he Finley Hospital
350 N. Grandview
I3u6uque, Ia. 52001
Page 1 of 1
® Relationship Witness
°** rl I 1 t t tl t~**
F
SHOARS, April g•
DNA N
pERSOIlAL FHYS ~ 230 PERSONP,S+
_ ter-; ; J} ~
1111111 VIII VIII VIII Illll Ilili VIII hill VIII IIII IIII
INST10181H (Rev. 02/07)
P~:I~. I~'PK I'PH
i_l ~~ 2282 Univergsicctryy ® ®p®®ubuyquyy~,~IPa 52QB1 ~~ ~ A,~ F'IPT
FINLE Y- NA®RT®iG (JV3) ~0®0°H I/O// /~~ ~fVp
DATE PATIENT NAME DATE OF BIRTH
PATIENT ADDRESS
Insurance Name
Patient relationship to Policy Holder Self
~ Thisp
1 Date ordered:
I
i
ALU~IUIVUIIVI CRUTCHES with PADS I~ GRIPS
DESCRIBE PRODUCTS ORDERED:
~ C~ ADULT ®TAI.L
~ I ESTIMATE the products ordered will be needed for:
~ No. of weeks No. of Months ~ iVO. of rears
j Physician signature Date of signature
Physician Full Name
- _.
Phone #
- ~_._ _.
Insurance #
Spouse Child
® YOiJTH ®CIIII,D ®TII~1Y T®T
Lifetime
UPIN # ~ Address
BILLING INFORMATION
___
Crutches Will be billed ~s PURL ASS of X60.00 ~ .ALL ~~ISII NOES INCILIII)I~IG
(~ .~ ~(~ Most insm•ance companies will only cover 1 paie° of purchased crutches every 5-6 years.
- -- - _-
f yoll hive ®tl~cdrealAssocicztes ®r~.FI~ ,T7~ ~' t7~~E~' illSUrance n® cI°utehes Will be
billed HS a I12t7)Z~~2ry ~-L'1Ztal dlle to iI1SUI°aIlce covel°age guidelines. You WILL BE REQUIRED TO RETURN RENTAL
CRUTCHES to .the FINLEY-HARTIG HOMECARE store location at 2282 Universiky Avenue. If you do not return the rented crutches you
will be personally billed the ~60.0~ ~iurchase puce and Finley-Hartig Homecare will proceed with collection activities of overdue accounts.
~ ------
If , 6 ~ t ti ~ t ~ ~ ~~~ ~~ INSTJ SCE You Will be biped the pureha~~ price of X60.00
BY SIGNING BELOW I HFItEBY CERTIFY THAT I, THE PATIENT/CUSTOMER
®Have read the terms and conditions listed on the front and back of this form and have received a copy
® Have received and fully inspected. the Egpipment and that. it is in good worlcing order without defects
® Have received instructions for the safe operation and maintenance of the equipment
®Have received a copy of the Patient Bill of Right/Responsibilities and Medicare Supplier standards
® Am the patient, or am duly authorized as the patient's general agent to execute this agreement and accept its terms
® Agree to be FINANCIALLY RESPONSIBLE FOR ANY BALANCE OWING ON MY ACCOUNT WHICH MAY INCLUDE COPAYS,
DEDUCTIBLES OR CHARGES FOR NON- COVERAGE OF CRUTCHES or NON-RETURN of RENTAL CRUTCHES.
CONSENT/AUTHORIZATION: Iunderstand that my signature on this agreement authorizes the provision of products, equipment or services 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 DATE ,
If customer is a minor, responsible party to sign and write relationship • =~ Phone#
Yellow copy to patient White copy to Finley-Hartig Homecare
PHYSIC S CEItTIFICATI(I~ TAR I?U t' . r : EI~ICAI, E~UIPNIE~TT
n must be completed and signed by the physician in order.. forFHH to bill the crutches, arrn Dads and hand grips to the~atient's insurance
ICD 9 #: {DIAGNOSIS
DME-4 1105
iI~l -j
{~ SHIT'
~_- ~-~ I _ ! AN IOWA HEALTH SYSTEM AFFII.IATE
350 N. Grandview Ave.
Dubuque, IA 52001
563-589-2460
__~~
bairns, R.S., M.D. Orthopedic ~
320 N. Grandview Ave. Dubuque Surgery
1515 Delhi
Dubuque, IA 52001
~ Dubuque, IA 52001
~C1f~ice 556-5551 Office 557-7000
Cascade Medical Center Dubuque Urology Service, P.C.
610 2id Ave. N.E. P. O. Box 850 1500 Delhi St. Suite 4300
Cascade, [A 52033 Dubuque, IA 52001
Office 319-852-5050 Office 557-5971
Crescent Cormnunity Health Center Dubuque Visiting Nurse
Preventive Health 563-556-6200
1789 Elm St
Dubuque, IA 52001
563-690-2850 ~. ----
~.
Dubuque Dermatology n_ _
Field, David, M.D.
Sato, Kenzo M.D. Ph.D. 4005 Westmark Dr. STE 100
2140 JFK Rd Dubuque, IA 52002
Dubuque, IA 52002 ,\Office 582-6202
Off ce 582-9306
Dubuque ENT Head & Neck Surgery P.C. Fortson, Mark, M. D.
Ear, Nose, Throat Specialist 2255 JFK Rd
310 N. Grandview Ave. Asbury Square
Dubuque, IA 52001 Dubuque, IA 52002
Office 588-0506 Office 582-4357
Dubuque Family Practice Fuerste Eye Clinic
320 N. Grandview Ave 2020 JFK Rd.
Dubuque, IA 52001 Dubuque, IA 52002
Office 583-9300 Office 582-0769
Dubuque Internal Medicine P.C. Galena Clinic
1515 Delhi St. Family Practice
Dubuque,IA 52001 815-777-6910
Office 557-9111
Dubuque Neurology & Sleep Medicine
Sims, Ronald M.D.
777 Mazzuchelli Place
Dubuque IA 52001
Office 583-1558
Dubuque OB/GYN Great River Oral
1500 Delhi St Suite 3100 Maxillofacial Surgery
Dubuque, IA 52001 100 Bryant St
Office and Answering Service Dubuque, IA 52003
SS7-5959 -- - --
_ _ _ -..~ Office 557-1440
"Dubuque Orthopedic Surgeons, P.C, Hillcrest Family Services Clinic
1500 Delhi St. Suite 4200 Town Clock Plaza
Dubuque, IA 52001 Dubuque, IA 52001
.,office 557-5999 _ 583-6431
Dubuque Pediatrics,
1500 Delhi St. Suite 3500
Dubuque, IA 52001
Office 557-5911
Iowa Care Plan
Dept. Human Services
Office 557-8251
Dubuque Podiatry
1500 Delhi St. Suite 2200
Dubuque, IA 52001
Office SS7-5930
Isaac, George Rheumatological
2140 JFK Rd: Suite B
Dubuque, IA 52002
Office 583-4848
~~
r~
Medical Associates Clinic, P.C.
1000 Langworthy
1500 Associates Dr. West Campus
Dubuque, IA 52001/52002
~Oflice 584-4000
300 N. Cnandview Ave
Dubuque, IA 52001
Office 588-4675
Pines Healthcare for Women
Dr. Bohle-GYN
2100 Asbury Suite 8
Dubuque, IA 52001
Office 557-9663
Sims, Ronald M.D. Neurology
777 Mazzuchelli
Dubuque, IA 52001
583-1558
Tri-State Farnily Practice
1500 Delhi Suite 4100
Dubuque, IA 52001
Office 557-5900
University of Iowa Health Care
200 Hawkins Drive
Iowa City, IA 52242-1009
319-356-1616
1-800-777-8442
Wells, Michael
Galena Stauss Hospital & Healthcare Cnt
215 Suininit St
Galena, IL 61036-1697
815-776-7381
Women's Wellness Center
Penn. Ave
Dubuque, IA 52002
588-0011