Claim by Terrance Reisdorf 5 12 09THE CITY OF
DUB E
Masterpiece on the Mississippi
MEMORANDUM
TRACEY STECKLEIN
PARALEGAL
To: Mayor Roy D. Buol and
Members of the City Council
DATE:
RE:
Claimant
May 15, 2009
Claim Against the City of Dubuque by the Terrance Reisdorf
Date of Claim
Terrance Reisdorf
05/12/09
Date of Loss
03/09/09
Nature of Claim
Personal Injury
This is a claim in which claimant alleges that as he boarded a City of Dubuque Keyline
bus and was walking towards a side seat, the bus driver accelerated and claimant was
thrown and suffered a broken left clavicle.
This claim has been referred to Public Entity Risk Services of Iowa, the agent for the Iowa
Communities Assurance Pool.
BAL:tIs
cc: Michael C. Van Milligen, City Manager
Jon Rodocker, Transit Manager
Terrance Reisdorf
OFFICE OF THE CITY ATTORNEY DUBUQUE, IOWA
SUITE 330, HARBOR VIEW PLACE, 300 MAIN STREET DUBUQUE, IA 52001-6944
TELEPHONE (563) 583-4113 /FAX (563) 583-1040 / EMAIL tsteckle@cityofdubuque.org
CLAIM AGAINST THE CITY OF DUBUQUE, IOWA
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 Nall, 50 West 13~' 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:
2. Address:
3. Telephone Number:. S'/ ~-~
4. Date of Incident: ,~AQlh/,/y_ ~t?jQq
5. Time of Incident: / ~ ", ! ri ' fT ,/~
6. Location of Incident (Be specific):
9. Give name and address of any witnesses: ~~~ U
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10. Did~plolice investigate? {If so, give names of officers.) "-'
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11. Vyas~anyone injured? (If so ive names, addresses, and extent of injuries.) ,-- ~~-:'
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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.)
7. Describe the accident or occurrence that caused ir~ry or damage. (Give full details upon which you base your
claim. If a City employee was involved, give the employee's name.)
Page 1 of 1
Tnfas~oe J. Nebodw( 8r.
1103 Qa~flddAve.
Dubuque, IA 5260 1-2 1 3 7
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Te~*anoe J. Helsdod Sr.
1103 asflddAve.
Dubuque, IA 5200 1-2 13 1
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EmergencyRrauma
Discharge Instructions
~ ~ ~ ~o ~-I~es
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X~ayse X-rays will be reviewed by a Radiologist. If any additional z-rays are needed you will be contacted.
Cultures: Cultures usually take 48 hours for reaalts. H additional treatment is needed you will be contacted.
Mtsdicatit~ May make yon drowsy. DO NOT DRIVE. OPERATE MACHINERY. OR USE ALCOHOL.
Prescriptions: Yon were given the following prescriptions, take as directed on label.
Name of dra Dose Number rescribed Number of refills
F.J~nm *4a Hnma ('ara anatr»wtinwe Divan to vnn_ irirrinn inamirnnn anr~rai
Abdominal Cast Care Con uncdvitis Head In u L Disease Otitis Sinusith Urfn infectbu
Adult Gusto Child fever E in u Hiva Minor Trauma Pain Sore throat Vaeeine schedule
Asthma Cowes ated E e medication Immuubatbu Misearria Pediatric fever S rain ffracture Viral infedbn
Back Pain Crou Febrile aieznres Inhaler Mons Pediatric astro Suite lasilu Wound Care
Back Eserdse Crutches GERD I Motrin RSV Tender Heart
BronehitL Ear Pala G Gu STD Kidn Stoue Ni cerin Scabia U rss; .
Burro Care ~ E eAbrssion Headache Lab rinthitls Nosebleed Sbin es Catheter care
Rnllnvv-iin ('srp
/ If not improving as ezpected or develop new problems contact your physician or return here.
/ If your pain is NOT reasonably controlled by medication or interventions contact your physician or return here.
Make an a ointment in Business Health
You have an a intment in Business Health on ste at time
Make an a ointment with the followin s ecialist
Ana nointment has been made with Dr. Qn date at timer
Other instructions:
I have received and understand my home care instructions.
All of my questions have been addressed. Dr.
Norse
Patient or Guardian Relationship Reason for visit
Discharge Time•
If you feel unsafe in your relatlonshlp please call 1-800-33Z~899
To assist in my follow-rap care I give permission for a copy of this record and tests to be sent to Dr.
Patient/Guardian
The Finley Hospital
350 N. Grandview
Dubuque, Ia. 52001
Page 1 of 1
Relationship Wihtess
***Original to chart -Copy to Patient***
INST10181H (Rev. 02/07)
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{ I J FINLEY-HARTIG HOMECARE ~ 1
~` 2282 University Ave. ~ ~ t` "~
Dubuque, IA 52001 `'~ ~ ~`
(800) 588-8707
ORDER DATE: TAKEN BY: Ig Date of Discharge
-%, f. ; t
ll , ~~ Hospitalized Discharge To
Retail Store Transaction ^ Home Delivery ^ Other Delivery
PATIENT
NAME ~ ~ DOB ~ ..-
f Phone #
Address
i City State ZIP
ORDERING PHYSICIAN:
^ NEW PATIENT
Complete billing information. ^ CURRENT PATIENT
Have Changed Insurance
Please complete billing information. ^ CURRENT PATIENT Have Changed
t]' ordering Physician
~-New Unrelated Product ^ CURRENT PATIENT Have Not
changed insurance and this is not a new
product and/or is not a different
Ordering Physician since last order.
Person Responsible
for Payment of
Account Relationship ^ Self ^ Parent of minor
to Patient ^ Legal Guardian ^ Health Care Agent
^ Spouse ^ Other:
Address
i Phone #
Primary
Insurance.rr. ,. ~ : • Secondary
Insurance
~#~ ^ See Card Copy ID#: ^ See Card Copy
Policy
Holder DOB Policy
Holder DOB
Patient Relationship to Policy Holder
^ Self ^ Spouse ^ Child ^ Other: Patient Relationship to Policy Holder
^ Self ^ Spouse ^ Child ^ Other:
WORK Date of Employer Employer
COMP Injury Phone #
DELIVERY ORDER /BILLING KEY
Estimated Costs shown do not reflect insurance verification and are subject to change due to your insurance policy deductibles, co-pays, policy exclusions, or failure to meet
your policy qualifications. If you have questions regarding your financial responsibility, please call the FHH billing staff at (800) 588-8707.
Insurance Billing: The item(s) listed below will be billed to your insurance company according to the insurance coverage guidelines and if it is ordered by a physician
IR= Rental -Will be billed to your insurance as a Monthly rental chazge. The minimum rental period is 1 month and ongoing rental is month to month only.
IP= Purchase -Will be billed to your insurance as a purchase.
Private Billing: The item(s) listed below will be billed to you personally if it is non-covered according to insurance guidelines and/or was not ordered by a physician
PR= Rental -Will be billed to you personally as a Monthly rental charge. The minimum rental period is 1 month and ongoing rental is month to month only.
PP= Purchase -Will be billed to you personally as a purchase.
Billin Code ITEM UPC # or Serial # Quantity Estimated Cost
,.
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Patient Hgt Wgt I have had same or similar equipment within the past 6 years ^ Yes ^ No
Information If YES ^ Rented ^ Purchased Date: Ins: Vendor:
BY SIGNING BELOW I hereby acknowledge that I, the patient or representative have read and agree to all of the terms and conditions appearing on the front and
reverse side of this agreement form, and that I have received a copy of this order form. In addition, I acknowledge that I have received and fully inspected the equipment
and that it is complete and in good working order and that I have received orientation for the operation and maintenance of the equipment as appropriate.
Delivery Date Patient /Patient Representative Signature Serviced By•
Relationship Reason Patient cannot sign:
^ Minor ^ Incapacitated ^ Incompetent ^ Other:
Address Phone
6735028W7
Menlcu Assocv~Tes
1605 Associates Drive, Suite 101
P.O. Box 5002
Dubuque, IA 52002
Address Service Requested
5-DIGIT 52^^1
3?7 ^•8502 AV ^•324
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TERRANCE REISDORF 8
1103 GARFIELD AVE
DUBUQUE, IA 52001-2131
EXPLANATION OF BENEFITS
My eLink is a new online tool giving members easy access ~
to claims and benefits information. Now available at
www. mahealthcare.com
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Questions?
Please contact Customer Service at
(563) 584-4885 or (866) 821-1365
Patient's Name: TERRANCE
REISDORF
Identification #: 81107318001
Claim Number: 09089000293X
Dates of Service 03/09/09 - 03/09/09
Group Name: MEDICARE
COMMUNITY
Provider Name: DUBUQUE
RADIOLOGY
Date Paiu: 04/20/C9
amine Days/ Billed Allowed Disallow Denied Copay Deduct Coins Other Ins Amount Expl.
Coun Amount Amount Amount Amount Amount Amount Amount Pa ment Paid Code
1 1 39.00 .00 .00 39.00 .0 .00 .00 .00 .0 17
*Patient's Responsibility reflects only applicable Deductible, Copay, Coinsurance, and Denied Amounts on this claim.
**You may also be responsible for any denied amounts and/or amounts over usual and customary.
Line Service Descr_ption
1 73030 DIAGNOSTIC RADIOLOGY & NUCLEAR MEDICINE
Ex 1. Code Descri tion
17 REQUESTED INFORMATION WAS NOT PROVIDED OR WAS
INSUFFICIENT/INCOMPLETE
SUBRO /ACCIDENT INFORMATION NEEDED
101
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673,50260U7
My eLink is a new online tool giving members easy access _
MELMw_ASSOI"IATES to claims and benetits information. Now available at
1605 Associates Drive, Suite 101 www.mahealthcare.com
P.O. Boa 5002 ,;
Dubu ue IA 52002 2UUY04U7U~42
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Questions. o
5-DIGIT 5201 Please contact Customer Service at
201 x.5176 AV x•324 (563) 584-4885 or (866)821-1365
11111"I'11~'I11'I11~~~111~~~11~~1~111~11~~11111~111~~~~111~111~~ __ _
TERRANCE REISDORF ~ Patient's Name: TERRANCE N
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113 GARFIELD AVE REISDORF W
DUBUQUE, IA 52001-2131
Identification #: 81107318001
Claim Number: 090870850021
Dates of Service 03/02/09 - 03/02/09
Group Name: MEDICARE
COMMUNITY
Provider Name: FINLEY HOSPITAL
EXPLANATION OF BENEFITS Date Paid: 04/Ob/09
ine Days/ Billed Allowed Disallow Denied Copay Deduct Coins Other Ins Amount Expl.
__ Coun Amount Amount Amount Amount Amount Amount Amount Pa meat _ papa __ Code_
1 1 145.00 .00 .00 145.00 .0 .00 .00 .00 .0 38
*Patient's Responsibility reflects only applicable Deductible, Copay, Coinsurance, and Denied Amounts on this claim.
**You may also be responsible for any denied amounts and/or amounts over usual and customary. ~
L_ ine -Service Description __ __ _ ____ _ __-._________ -
1 510 HOSPITAL ANCILLARY
ExQI. Code Description _ _____ _ ________- _ __ _ __
38 SERVICE NOT PROVIDED AND/OR AUTHORIZED BY OUR PROVIDERS
REFER TO CONTRACT SECTION 5. TIMOTHY MILLER IS NO IN-PLAN
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67itU28UU7 '
MEDICAL Asscx:ITrt:s
1601 Associates Drive. Suite 101
P.O. 130 5002
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Address Service Requested
5-DIGIT 52001
51B 0.5234 AV ~-324
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TERRANCE REISDORF 8
1103 GARFIELD AVE
DUBUQUE, IA 52001-2131
My eLink is a new online tool giving members cosy access _
to claims and benefits information. Now available at
ww w. mahealthcare.com
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Questions?
Please contact Customer Service at
(563) 584-4885 or (866) 821-1365
Patient's Name: TERRANCE
REISDOIZF
ldentification #: R 1 l 073 l 8001
Claim Number: 09114000338X
Dates of Service 03/31/09 - 03/31/09
Group Name: MEDICARE
COMM-UNITY
Provider Name: DAVID S FIELD , MD
EXPLANATION OF BENEFITS Date Paid: 05/04/09 ~
ine Days/ Billed Allowed Disallow Denied Copay Deduct Coi~is Other lns mount Expl.
Coon Amow~t Amount Amount Amount Amount Amount Amount Payment Paid Code
--- ------- ------
1 1 95.92 .00 .00 95.92 .0 .00 .00 .00 .0 l
2 1 72.42 .00 .00 72.42 .00 .00 .00 .00 .0 17
~U P'~t~~~t~t R~~~~S~~~lt~.y. ....... 1~i8.3r
*Patient's Responsibility reflects only applicable Deductible, Copay, Coinsurance, and Denied Amounts on this claim.
**You may also be responsible for any denied amounts and/or amounts over usual and customary.
Line. _ Serv_ice_Description__ ___
---- -- -- - - - ----- -- - -
l 99213 OFFICE VISITS
2 73000 DIAGNOSTIC RADIOLOGY & NUCLEAR MEDICINE
Excel. Code .Description
- - -- -
17 REQUESTED INFORMATION WAS NOT PROVIDED OR WAS
INSUFFICIENT/INCOMPLETE
SUBRO /ACCIDENT INFORMATION NEEDED
101
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MFDKAL ASSOCL1TfS
1605 Associates Drive, Suite 101
P.O. Box 5002
Dubuque, IA 52002
Address Service Requested
5-DIGIT 52001
13 ^-8496 AV 0.324
11111111111~~~1,I~lllllrllllllll~~llllllllill~l~l~ll~lllll~l~lll
TERRANCE REISDORF 1
11U3 6ARFIELD AVE
DUBUQUE, IA 52001-2131
EXPLANATION DE BENEFITS
My eLink is a new online tool giving members easy access ~
to claims and benefits information. Now available at
www. mahealthcare.com
2UU904140149
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Questions?
Please contact Customer Service at
(563) 584-4885 or (86b) 821-1365
Patient's Name: TERRANCE
REISDORF
Identification #: 81107318001
Claim Number: 09084000141X
Dates of Service 03/17/09 - 03/17/09
Group Name: MEDICARE
COMMUNITY
Provider Name: DAVID S FIELD , MD
iDate Paid: 04/13/09
amine Days/ Billed Allowed Disallow Denied Copay Deduct Coins ther Ins Amount Expl.
Coun Amount Amount Amount Amount Amount Amount Amount Pa ment Paid Code
1 1 104.11 .00 .00 104.11 .0 .00 .00 .00 _ .0 17 _
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*Patient's Responsibility reflects only applicable Deductible, Copay, Coinsurance, and Denied Amounts on this claim.
**You may also be responsible for any denied amounts and/or amounts over usual and customary.
Line Service_Description____ ___ ___ - -
1 99241 CONSULTATIONS
Ex~l• Code Description -_ _ __ _ ______.__-_ -- -
17 REQUESTED INFORMATION WAS NOT PROVIDED OR WAS
INSUFFICIENT/INCOMPLETE
SUBRO /ACCIDENT INFORMATION NEEDED
101
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6:i5U28W7
MEDICAL ASSOCL\7E5
1605 Associates Drive, Suite 101
P.O. Box 5002
Dubuque, IA 52002
Address Service Requested
5-DIGIT 52001
13 ^•8496 AV 0.324
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TERRANCE REISDORF 1
1103 GARFIELD AVE
DUBUQUE, IA 52001-2131
My eLink is a new online tool giving members easy access _
to claims and benefits information. Now available at
www. mahealthcare.com
Patient's Name: TERRANCE
REI SDORF
Identification #: 81107318001
Claim Number: 090970850089
Dates of Service 03/09/09 - 03/09/09
Group Name: MEDICARE
COMMUNITY
ider Name: FINLEY HOSPITAL
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Please contact Customer Service at
(563) 584-4885 or (866) 821-1365
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Days/ c~iavi, v+
Billed y~-------~
Allowed -
Disallow
Denied
Copay
Deduct
Coins
Other Ins
Amount -
Expl.
Coun Amount Amount Amount Amount Amount Amount Amount Pa ment Paid Code
1 1 161.00 .00 .00 161.00 .0 .00 .00 .00 ___.0 17
2 2 246.00 .00 .00 246.00 .00 .00
---------- .00
----- .00
-- - .0
--- 17
~lttilni~n P'atfl~ttt.:~ptt~S .. ~<:::>:~;>::::: _;::f.;;::.:1
*Patient's Responsibility reflects only applicable Deductible, Copay, Coinsurance, and Denied Amounts on this claim.
**You may also be responsible for any denied amounts and/or amounts over usual and customary.
Line Service Description - _ _ _- - - -
1 320 DIAGNOSTIC RADIOLOGY & NUCLEAR MEDICINE
2 4S0 ROOMS
Expl Code Description _____ --- -----
17 REQUESTED INFORMATION WAS NOT PROVIDED OR WAS
INSUFFICIENT/1NC OMPLETE
WAITING FOR ACCIDENT INFORMATION
to Paid: 04/13/09
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