HomeMy WebLinkAboutClaim No. 681 - J. StonickCITY OF PALM DESERT
CITY CLERK DEPARTMENT
STAFF REPORT
REQUEST: CLAIM AGAINST THE CITY (#681) BY JENNIFER STONICK IN THE
AMOUNT OF $10,000
SUBMITTED BY: Rachelle Klassen, City Clerk
DATE: October 13, 2011
CONTENTS: • Staff Report
• Recommendations of Claims Adjusters and Staff
• Claim No. 681
Recommendation
By Minute Motion, reject the Claim and direct the City Clerk to so notify the
Claimant.
Background
Based on a review of the subject Claim and the recommendation of the Claims Adjuster,
Risk Manager, City Attorney, and staff, it is recommended that the Claim be rejected.
Discussion of this item should be held in Closed Session pursuant to Government Code
Section 54956.9(b), potential litigation.
Submitted by: App'oved:
Ra hel a D. Klassen, C C Joh M. W Imuth
City Clerk City Manager
rdk CITY COUNCIGAC ION
APPROVED ,/ DENIED
Attachments (as noted) RECEIVED OTHER.
MEETING DATE �Ic,3 -la �111,
AYES:
NOES: N4.nC
ABSENT: N L ate.
ABSTAIN:
VERIFIED BY: t� bra
Original on File with City Clerk's Office
September 19, 2011
TO: The City of Palm Desert
ATTENTION: Rachelle D.Klassen, City Clerk
RE: Claim
Claimant
D/Event
Rec'd Y/Office
Our File
S t" CLERK'S OFFICE
P4,(_1-1 DES- s:PT, ^y1
2911 SEP 21 AM 10: 31
Stonick vs. The City of Palm Desert
Jennifer Stonick
6/7/2011
7/29/2011
S-1582278-PMQ
We have received and reviewed the above claim and request that you take the action indicated below:
CLAIM REJECTION: Send a standard rejection letter to the claimant.
If the claimant is represented send the notice to
the attorney of record.
Please provide us with a copy of the notice sent, as requested above. If you have any questions please
contact the undersigned.
Very truly yours,
C ARREN & CO ANY
Rich, D. Marque
cc: CJPIA w/enc.
Attn.: Executive Director
CARL WARREN & CO.
CLAIMS MANAGEMENT CLAIMS ADJUSTERS COPY TO ��
770 Placentia Avenue, Placentia, CA 92870-6832
Mail: P.O. Box 25180 • Santa Ana, Ca 92799-5180
Phone: (714) 572-5200 • (800) 572-6900. Fax: (714) 961-8131 DPTE 2
TO:
I y 9 1 ? I I 1� I I � L" � 1
73-510 FRED WARING DRIVE
PALM DESERT, CALIFORNIA 92260-2S78
TEL:76o 346-o6ii
FAX: 760 340-0574
i nfoWpalm-desert.org
CJPIA (c/o CARL WARREN & CO.), CITY MANAGER, CITY ATTORNEY,
DIRECTOR OF PUBLIC WORKS, CITY ENGINEER, RISK MANAGER
FROM: CITY CLERK
DATE: AUGUST 1, 2011
SUBJECT: CLAIM NO. 681 - CLAIM AGAINST THE CITY BY JENNIFER STONICK IN
THE AMOUNT OF $10,000
The attached Claim No. 681 is being transmitted to you for the following:
❑ Information only.
or
NReview and recommendation to the Claims Review Committee for any action
required by the City of Palm Desert.
We would appreciate your report, if requested, by September 1, 2011, for timely response
to the Claimant.
Note: If there is a current project or contract that may be referenced in this matter, please
let me know or provide me with the appropriate materials. �tiFr�
s --� Ahl
RACHELLE D. KLASSEN, CIVIC
CITY CLERK �
Attachment (as noted)
�t PAINHO ON 11MIMPAPH
Klassen, Rachelle
From: Klassen, Rachelle
Sent: Wednesday, August 03, 2011 8:47 AM
To: 'Richard D. Marque (rmarque@carlwarren.com)'; Rosenblum, Gary;
'David. Erwin@bbklaw.com'
Subject: FW: Claim No. 681 - Stonick v. City of Palm Desert
Following is the recommendation from Palm Desert Director of Public Works Mark Greenwood regarding the subject
Claim.
Rachelle
From: Greenwood, Mark
Sent: Wednesday, August 03, 2011 8:27 AM
To: Klassen, Rachelle
Subject: Claim No. 681
Rachelle,
It is recommended that claim no. 681 be denied as the intersection in question clearly has adequate controls
which the claimant failed to heed.
Mark Greenwood, P.E.
Director of Public Works
City of Palm Desert
CITY OF PALM DESERT
ASSIG,N_E,D; C�I�►If4N0. _'
CLAIM AGAINST THE CITY OF PALM DESERT L ,; ' �; G F F I C L
(For Damage(s) to Person(s) or Personal Property) ; L. J 0 F S E � C
Received by: 4
C-t-2. - I�ecte�C
DUPLI CATE011 JUL 29 Phi 1. 21
via: U.S. Mail Interoffice Mail Over -the -Counter !�
A CLAIM MUST BE FILED WITH THE CITY CLERK OF THE CITY OF PALM DESERT WITHIN SIX
MONTHS AFTER WHICH THE INCIDENT OR EVENT OCCURRED. BE SURE YOUR CLAIM IS
AGAINST THE CITY OF PALM DESERT, NOT ANOTHER PUBLIC ENTITY. WHERE SPACE IS
INSUFFICIENT, PLEASE USE ADDITIONAL PAPER AND IDENTIFY INFORMATION BY
PARAGRAPH NUMBER. COMPLETED CLAIMS MUST BE MAILED OR DELIVERED TO THE CITY
CLERK, CITY OF PALM DESERT, 73-510 FRED WARING DRIVE, PALM DESERT, CA 92260.
TO THE HONORABLE MAYOR AND CITY COUNCIL, City of Palm Desert, California:
The undersigned respectfully submit(s) the following claim and information relative to damage(s) to
person(s) and/or personal property:
1. CLAIMANT INFORMATION:
NAMEj�V�I C.
ADDRESS
PHONE NO.BATE OF BIRTH: _
SOCIAL SECbmi i Y NO. DRIVER'SLICEty.)r_ ► u. —
2. Name, telephone number and post office address to which claimant desires notices to be
sent, if other than above:
3. Occurrence or event from which the claim arises:
a. DATE: b. TIME:c. PLACE (exact and specific
location)_
�— --J
d. How and under what circumstances did damage or injury occur? Specify the particular
occurrence, event, act or ommission you claim caused the injury or damage. (Use
additional paper if necessary.) 1 S' ,
l V
Ir..
V, ., ;�,n .iZc i-, H+9., l'l
G n YI 1 h t- f�•�. r� ci ►7 C <t as 1 rt 1101 a 1114 ell ''cl ° ,ray-k)
e. What particular action b� the City, or its employees, cadsed the a`^ffeg amag or��, �
ury? �t C 1 _ "� ' ma
s (AG
1 , _ 1�
��,,` 1 a C
Page 1 of 2 ► i " C # f' 6"tPCA
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4. Give a general description of the indebtedness, obligation, injury, damage, or loss incurred
so far as it may be known at the time of Presentation of the claim. If there were no
injuries, state "no injuries": ( h oA (a v) �h �_ �> jn h CAI 9C��
5.
6.
7.
8.
Gi a the n e s of a ity a yee(s causing the damage or injury:
l) t b'! KI 0
K C Qp/ ,l c 7�_ � s f� ►
,,. a n
Name'and aWes6of any otherperson(s injured: _ PVAn I tie Y
Name and ndrlrP-S nf the owner of any, damaged property: 1a in n I `L
Damages claimed:
a. Amount claimed as of this date:
b. Estimated amount of future costs: $
c. Total amount claimed: $
d. Basis for computation of amounts claimed in lud copies of all bills, invoices,
estimates. etc.):�
9. Nam
10.
Any addition
this claim:
WARNINGHT IS A CRIMINAL
INSURANCE CODE 556.1).
ing
72;
I have read the matters and statements made in the above claim, and I know the same to be true of
my own knowledge, except as to those matters stated upon information or belief as to such matters
I believe the same to be true. I certify under penalty of perjury that the foregoing is TRUE AND
CORRECT.
Signed this day of � 2011 , at �, F. !rj :? rY�
SIGNATURE OF CLAIMANT
Of ice< ofthe City Clerk, Palm Desert, California DOC. NO. DATE FILED
Page 2 of 2
d.
Crry OF RANG O MIRAGE
File W ith:
City Clerk's Office
City of Rancho Mirage
69825 Highway 111
Rancho Mirage, CA 92270
CLAIM FOR MONEY OR
DAMAGES AGAINST
THE CITY OF RANCHO
MIRAGE
iiI ;-&IIV[ i t)Ii I II_iN('a:-)I;AMI
CLAIM NO. _
A claim must be presented, as prescribed by the Government Code of the State of California, by the claimant or a person
acting on his/her behalf and shall show the following: 771
,r.
If additional space is needed to provide your information, please attach sheets, identifying tb o parag�ph(s)
being answered. G `T &
1. Name and Post Office address of the Claimant: U%
Name of Claimant: -
Post Office Address:
2.
Post Office address to which the person presenting the claim desires notices to be sent:
Name of Addressee: �CI �� (� ` (��;� Telephone:
Post Office Address:
3
3. The date, place and other circumstances of the occurrence or transaction which gave rise to the claim asserted.
Date of Occurrence: I;V Time of Occurrence:
Location:
Circumstances giving rise to this claim: M. V) r,d-VI P ` �'Yl Irl(� (llaYYl�z c', s a
t,-� I I a vi rl C IUY (X i f i v,n nn .
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4. General description of the indebtedness, obligation, injury, damage or loss incurred so far as it may be known at
the time of the presentation of the claim.
I A ):Z, see u , In 0�1i�r t S014,/ I'd1 Wit- � CA-1 � iv1�.
1►) r`n-.l Ib,�Qr^ ind./ � ,,(- Vv��n) 1 kffAt 4,-, InAvti. CA- rTSt' n
0
The name or names of the public employee or employees causing the injury, damage, or loss, if known.
U
K l l f (1 J L% i ,1 �c rS Ct t tv aL .i t I[ V-.� c,-� S VA C� •r � J l f f l
Page 1 of 3
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6. If amount claimed totals less than $10,000: The amount claimed if it totals less than ten thousand dollars
($10,000) as of the date of presentation of the claim, including the estimated amount of any prospective injury,
damage, or loss, insofar as it may be known at the time of the presentation of the claim, together with the basis of
computation of the amount claimed.
Amount Claimed and basis for computation: B 61 Ci 611
If amount claimed exceeds $10,000: If the amount claimed exceeds ten thousand dollars ($10,000), no dollar
amount shall be included in the claim. However, it shall indicate whether the claim would be a limited civil case.
A limited civil case is one where the recovery sought, exclusive of attorney fees, interest and court costs does not
exceed $25,000. An unlimited civil case is one in which the recovery sought is more than $25,000. (See CCP §
86.)
u Limited Civil Case LI Unlimited Civil Case
You are required to provide the information requested above in order to comply with Government Code
§910. Additionally, in order to conduct a timely investigation and possible resolution of your claim, the
[CITY/AGENCY] requests that you answer the following questions.
7. Claimant(s) Social Security Number(s): j
9
10.
11
Claimant(s) Date(s) of Birth:
Name, address and telephone number of any witnesses to the occurrence or transaction which gave rise to the
claim asserted:
If the claim involves medical treatment for a claimed injury, please provide the name, address and telephone
number of any doctors or hospitals providing treatment: _
If applicable, please attach any medical bills or reports or similar documents supporting
If the claim relates to an automobile accident:
Claimant(s) Auto Ins. Co.:
Insurance Policv No.:
11 Lfi `15 •: i ,
"I S
Insurance Broker/Agent: .� L 1 .(L L k3Telephone: - Lc,+ Lt�- _� j L> { LA lc---,
Address:
Claimant's Veh. Lic. No.: Vehicle Make/Year: o (A
Claimant's Drivers Lic. No.: Expiration: [ (-I Ct tiq
Page 2 of 3
ploase <Iltach'vly rc/).a/rt»Ils, ustu11010S vi sIIIII/ / (/Ucu(7IV/ tS s1.if)/)011i1 ly y00r ctMm.
READ CAREFULLY
For all accident claims, place on following diagram name of City/Agency Vehicle; location of City/Agency vehicle at time of
streets, including North, East, South, and West; indicate place of accident by "A-1" and location of yourself or your vehicle at the
accident by "X" and by showing house numbers or distances to time of the accident by "B-1" and the point of impact by "X."
street corners. If City/Agency Vehicle was involved, designate by
letter "A" location of City/Agency Vehicle when you first saw it, NOTE: If diagrams below do not fit the situation, attach hereto a
and by "B" location of yourself or your vehicle when you first saw proper diagram signed by claimant.
CURB
77
SIDEWALK
ALK
CURB
Warning: Presentation of a false claim is a felony (Penal Code §72). Pursuant to CCP §1038, the City/Agency
may seek to recover all costs of defense in the event an action is filed which is later determined not to have been
brought in good faith and with reale cause.
Signature:
Date: j I cj -
Page 3 of 3
u1111 IJI:JN t� 1\I Vl13i 4, LtL 11Vl Ilia - kivu IG IV IapIJ
To see all the details that are visible on the
screen, use the "Print" link next to the map.
9
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of 1 7/ 14/2011 7:10 PM
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3) 1 was driving East on Dinah Shore Drive at the posted speed limit of 45mph before dawn. I came
to the completely unlit intersection of Dinah Shore and Portola. There are no signs notifying that the
road ends. There is one lane continuing east that if taken will take a vehicle head on into a dead end.
The other three lanes are right turn only lanes and there is no notification of right turn only until you are
approx. 100' or so from the stop sign, which is halfway through the turn. I did not have enough warning
or time to make the right turn because there are no street lights and the intersection is completely dark
and I continued through the intersection and hit the median. My car was not drivable and incurred over
$13,000 in damage. There needs to be adequate lighting, a lowered speed limit approach, and
'dangerous curve ahead' or 'right turn ONLY' signage; at the very least.
4) My vehicle was in the shop for two months and it had over $13,000 in damage. I had a $500
deductible for my insurance. I had to rent a car that totaled approx. $1500 for the time I spent without
this vehicle. My cervical spine C5/C6, and Lumbar L5/L6, both of which I'm already being treated for for
a variety of medical problems including degenerative disc disease and spinal stenosis, was aggravated to
the point that I needed four epidural shots in my lower back and an MRI for my neck. I was on a heavily
increased prescription for pain medication and I have had to move my spinal neural stimulation surgery
up to mid -July because of the unbearable pain incurred from the accident.
5) None.
6) $9,999. This amount covers all of the inconvenience and associated fees from not having my
vehicle for two months and the fact that my neck and back problems and pain sky -rocketed because of
the accident. I have had to move my back surgery date up to July 20th because of this. I know this is a
low claim for this type of accident but I believe that this can be taken care of quickly without involving
lawyers.
$1500- rental car fees
$500-car insurance deductible
$7,999- pain and suffering
10) Doctor info.
WILLIAM STONICK���
CAPM812 0711812 6184 #01 EST
VEHICLE 01198 /6764930 11 ENDEAVOR 4WD S
LIC ( L 'MILES OUT 10295 FUEL OUT $18
K CAP 21.4 STALL F A 004
ESTIMATE OF.CHARGES
RENTED: 06110111 00:25 @ PALM SPRINGS AIRPORT
RETURN: 06116111 00:15 r@ PALM SPRINGS AIRPORT
THIS IS ONLY AN ESTIMATE. Taxable charges are denoted by a T, an(
additional details about some charges appear beneath the table. Our
estimates of You. tote! 61'arges appear on the right of the table below.
Our estimates assume (1) YOU will rent and return the vehicle at the
times and places indicated. (2) If a mileage charge applies, You will drive
no more than the distance indicated and (3) You will not incur any charge
that either are listed belo'n opposite **** Or cannot Le calculated U'Itil
return. 11 any of these assumptions Is incorrect, additional charges or
charges at higher rates may apply.
CHARGE RATE 1 AMOUNT CHARGE ESTIMA7
TIME 1 MILEAGE CHGS: RATE PLAN - WEBW
CLASS - I
1 @ $ 169.49/ WEEK WITH ALL MILES FREE
$
169.z
EXTRA CHARGES IF APPLICABLE
$ 24.211 EX DAY
$ 12.111 EX HOUR
$ 18.831 XDY XHR
VEHICLE UPGRADE $ 5 1 DAY 1$ 3.751 HOUR
$
30.0
PROMOTIONAL COUPON 158782 1
$ -
50.0
SUBTOTAL 1
S
149.4
DISCOUNT- R 100/a
$
14.9
SUBTOTAL 2
T$
134.5
ADDITIONAL CHARGES
FEES FOR ANY ADDITIONAL AUTHORIZED
OPERATORS NOT NCLUDED.
TS
'**'
OPTIONAL SERVICES
FUEL & SERVICE $.619 JMl $ 9.29 /GAL 21.41TK CAP
F$
**""
ASSESSMENTS I FEES I TAXES
CONCESSION FEE RECOVERY 11.11%
T$
15.2
CA TOURISM ASSESSMENT 3.50%
$
4.7
FACILITY FEE
$
10.0
INCREASED VEH UC RECOVERY FEE
T$
2.2
TAX 1 8.750b 01J-A:<ABLE TTL OF $ 151.96
$
13.2
TAX 2 2 75CFA ON �;AL.FORNIA REFUELING
$
****
TOTAL ESTIMATED CHARGE $ 179.9E
CC AUfH WOULD BE
PROGRESSIVE CLAIMS
150 S. LOS ROBLES AVENUE
STE 500
PASADENA, CA 91101
012141
WILLIAM P STONICK
�I11�1111�1'll�l'rlr�Il'III�II'1'II����I11'I'�1„������111���111'
PROGREWYE"
Underwritten By:
Progressive Choice Insurance
Company
Claim Number: 11-2424407
Loss Date: June 7, 2011
Document Date: June 8, 2011
Page 1 of 2
claims.progressive.com
Track the status and details of your claim,
e-mail your representative or report a
new claim.
Progressive Repair Network
Auto Body Repair Consumer Bill of Rights
You have the right to select the repair facility of your choice for the repairs to your vehicle under California Code of
Regulations, Title 10, Chapter 5, Section 2695.8(e)(2). Progressive has developed a network of repair facilities based on
their high quality, priority service, hassle -free customer service, and lifetime guarantee. Vehicle repairs completed within
the network are covered by a written guarantee, backed by Progressive and the collision repairer, for as long as you own
the vehicle. Please ask your Progressive Claims Representative about the nearest repair facility or visit our Web site at
claims. progressive.com for the location nearest you.
AUTO BODY REPAIR CONSUMER BILL OF RIGHTS
A CONSUMER IS ENTITLED TO:
1. SELECT THE AUTO BODY REPAIR SHOP TO REPAIR AUTO BODY DAMAGE COVERED BY THE INSURANCE COMPANY. AN
INSURANCE COMPANY SHALL NOT REQUIRE THE REPAIRS TO BE DONE AT A SPECIFIC AUTO BODY REPAIR SHOP.
2. AN ITEMIZED WRITTEN ESTIMATE FOR AUTO BODY REPAIRS AND, UPON COMPLETION OF REPAIRS, A DETAILED INVOICE.
THE ESTIMATE AND THE INVOICE MUST INCLUDE AN ITEMIZED LIST OF PARTS AND LABOR ALONG WITH THE TOTAL PRICE
FOR THE WORK PERFORMED. THE ESTIMATE AND INVOICE MUST ALSO IDENTIFY ALL PARTS AS NEW, USED,
AFTERMARKET, RECONDITIONED, OR REBUILT.
3. BE INFORMED ABOUT COVERAGE FOR TOWING AND STORAGE SERVICES.
4. BE INFORMED ABOUT THE EXTENT OF COVERAGE, IF ANY, FOR A REPLACEMENT RENTAL VEHICLE WHILE A DAMAGED
VEHICLE IS BEING REPAIRED.
5. BE INFORMED OF WHERE TO REPORT SUSPECTED FRAUD OR OTHER COMPLAINTS AND CONCERNS ABOUT AUTO BODY
REPAIRS.
6. SEEK AND OBTAIN AN INDEPENDENT REPAIR ESTIMATE DIRECTLY FROM A REGISTERED AUTO BODY REPAIR SHOP FOR
REPAIR OF A DAMAGED VEHICLE, EVEN WHEN PURSUING AN INSURANCE CLAIM FOR REPAIR OF THE VEHICLE.
COMPLAINTS WITHIN THE JURISDICTION OF THE BUREAU OF AUTOMOTIVE REPAIR
Complaints concerning the repair of a vehicle by an auto body repair shop should be directed to:
Toll Free (866) 799-3811
California Department of Consumer Affairs
Bureau of Automotive Repair
10240 Systems Parkway
Sacramento, CA 95827
The Bureau of Automotive Repair can also accept complaints over its Web site at: www.autorepair,ca.gov
Claim number: 11 2424407
Date of loss: June 7, 2011
Page 2 of 2
COMPLAINTS WITHIN THE JURISDICTION OF THE CALIFORNIA INSURANCE COMMISSIONER
Any concerns regarding how an auto insurance claim is being handled should be submitted to the California Department
of Insurance at:
(800) 927-HELP or (213) 897-8921
California Department of Insurance
Consumer Services Division
300 South Spring Street
Los Angeles, CA 90013
The California Department of Insurance can also accept complaints over its Web site at: www.insurance.ca.gov
If you -have -any questions or concerns, please contact me at the number below.
JOSHUA BOLSTER
Claims Department
1-626-710-1475
1-800-PROGRE SSIVE (1-800-776-4737)
Fax:1-626-710-1490
Form Z507 CA (12/09) • CA
HEALTH SCAN
IMAGING
HEALTH SCAN IMAGING
Palm Desert Office
74-000 Country Club Dr., Ste .E1
Palm Desert, CA 92260
Phone: (760) 674-8800
WILLIAM M. KELLY M.D., INC.
FEDERAL I.D. # 33-0904696
HEALTH SCAN IMAGING
Palm Springs Office
1080 N. Indian Cyn. Dr., Ste, 104
Palm Springs, CA 92262
Phone: (760) 322-3036
HEALTH SCAN IMAGING
La Ouinta Office
79-440 Corp. Ctr. Dr. Ste. 118
La Quints, CA 92253
Phone: (760) 777-4646
TkULY OPEN MRI
TRULY OPEN MRI
Palm Desert Office
72-980 Fred Waring Dr., Ste. A
Palm Desert, CA 92260
Phone: (760) 776-8001
Patient Name Cj >Lon i LV4, enry Fir Date
Address
st►••t city slat• zto
Date of Birth ( Social Security # Phone #�
Appointment Date Time <
HIGH FIELD MRI, 3D CT AND
ULTRASOUND LOCATIONS
OPEN
MRI LOCATIONS
HEALTH SCAN IMAGIOG
PALM DESERT
HEALTH SCAN IMAGING
PALM SPRINGS
HEALTH SCAN IMAGING
LA QUINTA
FAX TO: (760) 674-8646
FAX TO: (760) 322-3037
FAX TO (760) 777-4622
MRI w/o Contrast
F__]
MRI w/o Contrast
MRI w/o Contrast
MRI w/wo Contrast
MRI w/wo Contrast
MRI w/wo Contrast
PAR An;!agram
F-]
MR Angiogram
MR Angiogram
MR Arthrogram
MR Arthrogram
Ultrasound
X-Ray (Walk-in)
CT w/o Contrast + 3D Recon
CT w/o Contrast + 3D Recon
TRULY OPEN MRI
CT w/wo Contrast + 313 Recon
CT w/wo Contrast + 3D Recon
PALM DESERT
CT Angiogram + 3D Recon
CT Angiogram + 3D Recon
FAX TO:• .
CT Myelogram + 3D Recon
CT Myelogram + 3D Recon
❑
MRI w/o Contrast
Ultrasound
Ultrasound
MRI w/wo Contrast
MR Angiogram
LOCATION MAPS
APPEAR ON THE BACK SIDE OF
THIS FORM
Body Part(s) to be Examined
C-6rv'�1'jF�/L£
Clinical Diagnosis
CC,
rvrc-2-,
Referring Physician Name
P. L6C
Phone
(Please Print)
(OPTIONAL) PRECERTIFICATION OF INSURANCE: With your permission, Health Scan Imaging will
provide assistance obtaining insurance
authorization. Please ensure that the insurance information section of the order is complete and fax a copy of the patient's insurance card(s) with this
order. If additional information is needed, we will contact your
office. Thank you for your referral.
CPT
ICD-9
Insurance Company
Auth. Dept. Phone #
Pre -Authorization needed Yes
No Ins Auth. #
'? 981, ERED WARING DRIVE SUITE A
aA,._E.1 DES;4?T. f;k CC-RNIA 922^0
Patient Name
STONICK, JENNIFER
At the Request of
JASON LEE, M.D.
MRI CERVICAL SPINE
TRUiLY LOPENkARI
Date of Birth
Ape Sex
r �~h 60
FAx
'Dni,n4! I-,igas arr0 `Import,
arrilM.r;r+dllhSCdtl�?tTd�,^� ;;7m
MRN
Exam Date
06/20/2011
CLINICAL HISTORY: 34-year-old female with left neck pain for four months and left
radiculopathy. The patient's symptoms have not responded satisfactorily to conservative
medical management including temporary bed rest, physical therapy, over-the-counter,
non -steroidal, anti-inflammatory medications, prescription analgesics, oral steroids and
epidural injections.
COMPARISON STUDY: None available.
TECHNIQUE: This imaging examination was accomplished using a Philips (Marconi)
Medical Systems Proview OPEN MRI system equipped with high-performance gradient
magnets, advanced RF coils with enhanced signal reception capabilities and noise
filtration technology. The following pulse sequences were obtained:
PLANE WEIGHTING SEQUENCE OPTION
Sagittal T2 3D CBASS
Sagittal T1 FSE
Axial T2 3D CBASS
FINDINGS:
There is straightening with mild reversal of the cervical lordosis at C5-6. Otherwise,
vertebral body heights, bone marrow signal intensity, craniocervical junction, caliber and
signal intensity of the spinal cord are normal. Mild -to -moderate degenerative disc
disease is noted at C5-6. The remaining intervertebral disc heights and signal intensity
are unremarkable.
C2-05: There is no disc/osteophyte complex. No spinal canal or neural foraminal
stenosis. Facet joints are unremarkable.
C5-6: There is mild disc/osteophyte complex and mild -to -moderate left uncovertebral
joint spurs as well as mild -to -moderate left degenerative facet disease. Moderate -to -
severe left neural foraminal stenosis. The spinal canal is patent. Right neural foramen is
unremarkable. Right facet joints are also unremarkable.
C6-7: There is mild disc/osteophyte complex and mild -to -moderate bilateral
uncovertebral joint spurs. Facet joints are unremarkable. Mild left and mild -to -moderate
right neural foraminal stenosis. No spinal canal stenosis.
(CONTINUED)
Continued Report - Page 2 of 2
Patient Name Date of Birth MRN
STONICK, JENNIFER
At the Request of Age Sex Exam Date
JASON LEE, M.D. 34 F 06/20/2011
MRI CERVICAL SPINE
C7-T1: There is no disc/osteophyte complex. No spinal canal or neural foraminal
stenosis. Facet joints are unremarkable.
No paraspinous soft tissue abnormality demonstrated. Normal vertebral artery flow void
noted bilaterally.
IMPRESSION:
1. DEGENERATIVE DISC, UNCOVERTEBRAL JOINT SPURS AND
DEGENERATIVE FACET DISEASE AT C5-6 AND C6-7 WITH MODERATE TO
SEVERE LEFT NEURAL FORAMINAL STENOSIS AT C5-6 AND MILD -TO -
MODERATE BILATERAL NEURAL FORAMINAL STENOSIS AT C6-7.
2. OTHERWISE, NO NEURAL FORAMINAL STENOSIS DEMONSTRATED AT THE
REMAINING LEVELS. NO SPINAL CANAL STENOSIS.
3. STRAIGHTENING OF THE CERVICAL LORDOSIS WITH MILD REVERSAL OF
THE LORDOSIS WHICH MAY BE DUE TO A COMBINATION OF MUSCLE
SPASM AND DEGENERATIVE DISC DISEASE.
Thank you kindly for referring your patient to Truly Open MRI
Loc Tran, M.D.
Board Certified Neuroradiologist
LT:tb
0 TB
Approved by: Loc Tran, M.D. on 06/21/2011 at 19:17
PATIENT COPY
PATIENT CONSENT
PATIENT NAME: JENNIFER STONICK
PHYSICIAN: REINHART MD APC AND ASSOCIATES
PROCEDURE TRANSFORAMINAL EPIDURAL STEROID INJECTION UNDER
FLUOROSCOPY
• I consent to the performance of surgeries and procedures listed above in addition to any
my physician may consider necessary or advisable in the course of the procedure. This
authorization includes the administration of blood or blood product transfusions.
• I agree to and am aware of the risks and complications of the anesthetic to be given. I
consent to the administration of such anesthetics as may be considered necessary or
advisable by the physician responsible for this service.
• The nature and purpose of the procedure, possible alternative methods of treatment, the
risks involved, the possible consequences, and the possibility of complications have been
explained to me by the physician to my satisfaction.
• I acknowledge that no guarantee or assurance has been given by anyone as to the results
that may be obtained.
• I consent to the photographing or videotaping of the procedures to be performed for
medical or educational purposes, provided my identity is not revealed by the pictures or
by descriptive tests accompanying them.
• For the purpose of advancing medical knowledge; I consent to the admittance of qualified
observers to the operating room.
• I consent to the disposal of any tissues or body parts, which may be removed.
• If complications arise, I agree to be admitted and treated at a hospital mutually agreed by
my physician and myself if possible.
• I hereby acknowledge and am aware of the fact that my treating physician may have
ownership interest in this surgical facility. I have elected, however, to use this facility.
• 1 authorize ADVANCED PAIN MANAGEMENT to disclose complete information
concerning medical findings and treatment of the undersigned from the initial office visit
until date of conclusion of such treatment to those individuals who in his//her sole
determination, are required to receive such information for the purpose of medical
treatment, medical quality assurance, and peer review.
• I understand that like any other medical procedure, the administration of anesthesia is
associated with some risk. Complications are rare, but they can result in permanent
disability or death. I understand that the physician will discuss this risks and
complications with me, should I desire.
SIGNATU /13/2011
WITNESS IL
ADVANCED PAIN MANAGEMENT STONICK, JENNIFER
39700 BOB HOPE DRIVE #204 MR#
RANCHO MIRAGE, Ca 92270 760-776-7520 REINHART MD APC AND ASSOCIATES
DATE: 6/13/2011