TENNESSEE BUREAU OF WORKERS’ COMPENSATION FILED IN THE COURT OF WORKERS’ COMPENSATION CLAIMS
AT JACKSON April 1, 2019 TN COURT OF JAMES FOUTCH, ) Docket No. 2015-07-0374 WORKERS’ Employee, ) COMPENSATION v. ) State File No. 88348-2015 CLAIMS BURKEEN TRUCKING COMPANY, ) s6 PM Uninsured Employer. ) Judge Amber E. Luttrell
COMPENSATION HEARING ORDER GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT IN PART
This matter came before the Court on February 19, 2019, on Mr. Foutch’s Motion for Summary Judgment seeking workers’ compensation benefits for an ankle injury. Burkeen Trucking did not respond and has not participated in this case. For the reasons below, the Court holds he is entitled to judgment as a matter of law for his ankle injury.
Claim History
Mr. Foutch, a resident of Gibson County, Tennessee, worked as a truck driver for Burkeen Trucking. On September 24, 2015, while unloading lumber, Mr. Foutch fell off the truck and injured his right ankle. He gave notice to Burkeen Trucking, who failed to carry workers’ compensation insurance. Mr. Foutch sought emergency treatment at Henry County Medical Center and follow-up treatment from orthopedist Dr. Blake Chandler.
Mr. Foutch first saw Dr. Charles Rainbolt in the emergency room, who noted as history: “He was working on flatbed fell 8ft. landed on right foot has limited range of motion and lot of pain.” Dr. Rainbolt diagnosed a fracture of the right ankle and a possible tibia avulsion fracture. He referred Mr. Foutch to Dr. Blake Chandler.
Mr. Foutch saw Dr. Chandler at West Tennessee Bone and Joint Clinic and gave a consistent history of his work injury. Dr. Chandler diagnosed an ankle fracture and performed surgery. Mr. Foutch continued seeing Dr. Chandler or FNP Clay Nolen through January 6, 2016, when Dr. Chandler released him to return as needed. Dr. Chandler concluded Mr. Foutch sustained a two-percent permanent impairment to the body as a whole for his ankle injury based on the Sixth Edition of the AMA Guides.
1 Procedural History
Mr. Foutch filed a Petition for Benefit Determination seeking medical benefits for his ankle injury and an alleged shoulder injury.
Following an Expedited Hearing, the Court held Mr. Foutch was likely to prevail in establishing an ankle injury arising primarily out of and in the course and scope of his employment. It ordered Burkeen Trucking to pay Mr. Foutch’s past medical expenses for his ankle injury and ongoing medical treatment with Dr. Chandler. The Court denied benefits for the alleged shoulder injury.
A Request for Investigation was filed based on Mr. Foutch’s affidavit stating Burkeen Trucking was not insured for workers’ compensation. The investigator prepared an “Expedited Request for Investigation Report-Investigation Summary,” which indicated Burkeen Trucking was subject to the Workers’ Compensation Law and did not have insurance at the time of Mr. Foutch’s injury.
Following the Expedited Hearing Order, Mr. Foutch filed a Motion for Contempt based on Burkeen Trucking’s failure to comply with the Expedited Hearing Order. Upon finding a violation of the Bureau’s rules and the Workers’ Compensation Act, this Court referred Burkeen Trucking to the Compliance Unit for potential assessment of a civil penalty. An Agency Decision assessed a penalty.’
The Court ultimately entered a scheduling order, and Mr. Foutch later served Requests for Admissions to Burkeen Trucking on October 2, 2018. Burkeen Trucking did not respond to the requests. Mr. Foutch then filed this Motion for Summary Judgment.
Mr. Foutch’s Motion
Mr. Foutch argued that, by failing to answer the Requests for Admissions, Burkeen Trucking admitted all of the facts necessary to his claim. He argued there are no genuine issues of material fact for trial as to his entitlement to medical benefits, temporary, and permanent disability benefits for his ankle injury, and he is entitled to judgment as a matter of law.
While not included in his motion and Statement of Undisputed Facts, Mr. Foutch further asserted at the hearing that he is entitled to summary judgment for his alleged shoulder injury.
Law and Analysis
' The Court notes an almost two-year delay in this case due to Burkeen Trucking’s Chapter 11 bankruptcy filed in 2016. Upon Mr. Foutch’s notice of the dismissal of Burkeen Trucking’s bankruptcy in August 2018, the Court entered an order on September 4, 2018, setting a scheduling hearing.
2 Summary judgment is appropriate “if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law.” Tenn. R. Civ. P. 56.04. The Workers’ Compensation Appeals Board has stated:
The burden is on the party pursuing summary judgment to demonstrate both that no genuine issue of material fact exists and that the moving party is entitled to a judgment as a matter of law. If the moving party does not meet its initial burden of production, the nonmoving party’s burden is not triggered and the motion for summary judgment should be denied. If the moving party makes a properly supported motion, the burden of production then shifts to the nonmoving party to demonstrate the existence of a genuine issue of material fact.
Rye v. Calsonic Kansei N. Am., Inc., 2018 TN Wrk. Comp. App. Bd. LEXIS 64, at *7-8 (Nov. 29, 2018) (internal citations omitted).
Mr. Foutch filed a Statement of Undisputed Material Facts containing twenty-six statements with citations to the unanswered Requests for Admissions.” Tennessee Rule of Civil Procedure 36 governs requests for admissions. The rule provides that an unanswered request is deemed admitted and conclusively establishes it unless the court on motion permits withdrawal or amendment of the admission. Tenn. R. Civ. P. 36.02; Neely v. Velsicol Chem. Corp., 906 S.W.2d 915, 917 (Tenn. Ct. App. 1995). Procedurally, admissions under Rule 36 may be brought to the trial court’s attention through a motion for summary judgment. /d. Because Burkeen Trucking failed to respond to the Requests for Admissions, the Court holds Mr. Foutch conclusively established the facts contained in the requests for purposes of this action.
Further, as Burkeen Trucking did not respond to the Statement of Undisputed Facts, the Court holds there are no genuine issues of material fact for trial regarding the compensability of Mr. Foutch’s ankle injury and his entitlement to workers’ compensation benefits. Thus, the Court holds he is entitled to summary judgment as a matter of law for the ankle injury.
The Court holds the undisputed facts in this case conclusively established the following:
e Mr. Foutch, a Tennessee resident, sustained a compensable work injury to his right ankle on September 24, 2015, and gave proper notice of the injury.
e His treatment and the medical bills incurred at Henry County Medical Center and with Dr. Blake Chandler were reasonable and necessary for his ankle injury.
* For brevity, the Court incorporates by reference Mr. Foutch’s twenty-six statements of undisputed facts in an appendix to this Order. Mr. Foutch was on light duty, which Burkeen could not accommodate, from September 24 through November 16, 2015, and off work completely from November 16 through December 3, 2015.
He has a permanent impairment of two percent to the body.
Mr. Foutch did not return to work at Burkeen Trucking because he was fired due to his workers’ compensation claim.
He is entitled to the increased benefit multipliers of 1.35 for not returning to work and 1.2 for his age.
His compensation rate is $497.91.
Mr. Foutch is entitled to a judgment against Burkeen Trucking for his ankle injury, including temporary disability of $4,979.10 and total permanent partial disability benefits totaling $7,259.53 (representing $4,481.19 original award and increased benefits of $2,778.33).
Mr. Foutch is further entitled to a judgment against Burkeen Trucking for his outstanding medical expenses at Henry County Medical Center and with Dr. Blake Chandler and a collection fee of $522.20 due to medical bills sent to collections for non-payment.’ See Sandra Jane Gardner v. Randstad North America, L.P., No. M2009-01214-WC-R3-WC 2010 Tenn. LEXIS 1023 (Tenn. Workers’ Comp. Panel Nov. 1, 2010)(when medical charges are discounted because of insurance and/or governmental health care, the employer is only responsible for the discounted amount.)
Further, although this Court holds Burkeen Trucking must provide Mr. Foutch
with past and ongoing medical benefits, temporary and permanent disability benefits, it is unclear whether payment will occur because Burkeen Trucking did not have workers’ compensation insurance at the time of the accident. The administrator of the Bureau has discretion to pay limited temporary disability and medical benefits to an injured employee who suffered a workplace injury and who meets the criteria below:
1. The employee worked for an employer who failed to carry workers’ compensation insurance;
2. The employee suffered an injury arising primarily out of and in the
course and scope of employment after July 1, 2015, at a time when the
employer did not have workers’ compensation insurance;
The employee was a Tennessee resident on the date of injury; and
4. The employee provided notice to the Bureau within sixty days of the injury and of his employer’s failure to provide workers’ compensation insurance.
wo
Tenn. Code Ann. § 50-6-801(d)(1)-(4). The undisputed facts showed Mr. Foutch met all the criteria for seeking discretionary payment through the Uninsured Employers Fund. He
> Mr. Foutch’s medical expenses provided in the attached bills do not match the amount of $24,591.30 asserted in his motion. The Court attaches as exhibit 3 to the appendix of this order the medical bills for which Burkeen Trucking is obligated to satisfy the outstanding balances and collection fee.
4 lived in Tennessee as a resident at the time of the accident, which occurred after July 1, 2015. He worked for an employer who failed to carry workers’ compensation insurance at the time of his injury. He provided notice to the Bureau within sixty days of his injury and Burkeen Trucking’s failure to provide workers’ compensation insurance. The Court, therefore, holds that he is eligible to seek benefits from the UEF.
Regarding the alleged shoulder injury, the Court holds Mr. Foutch did not meet his burden of demonstrating there is no genuine issue of material fact regarding his entitlement to workers’ compensation benefits. Neither the twenty-six statements of undisputed facts nor the requests for admissions reference the shoulder injury. Thus, the Court holds Mr. Foutch is not entitled to summary judgment as a matter of law for the shoulder.
Based on the above findings, the Court holds there is no genuine issue of material and Mr. Foutch is entitled to judgment as a matter of law for his ankle injury. The Court denies summary judgment as to the alleged shoulder injury. Accordingly, the Court holds, under Tennessee Rules of Civil Procedure Rule 54.02, that this is a final judgment as to the ankle injury and there is no just reason for delay of benefits for the ankle.
IT IS THEREFORE, ORDERED as follows: 1. Mr. Foutch’s Motion for Summary Judgment for the ankle injury is granted. 2. Burkeen Trucking shall satisfy Mr. Foutch’s outstanding medical bills with Henry County Medical Center and Dr. Blake Chandler and satisfy the collection fee of $522.20.
3. Mr. Foutch shall recover from Burkeen Trucking temporary disability benefits of $4,979.10 representing ten weeks from September 24 through December 3, 2015.
4. Mr. Foutch shall recover from Burkeen Trucking permanent partial disability benefits totaling $7,259.53.
5. Mr. Foutch shall receive future medical benefits under the statute with Dr. Blake Chandler.
6. Mr. Foutch is eligble to request discretionary payment from UEF for certain temporary disability and medical benefits under Tenn. Code Ann. § 50-6-801.
7. Absent an appeal, this order shall become final thirty days after issuance. Upon entry of this order, the Court’s legal assistant, Tina Woods, will forward the
parties the Court’s available dates for a Status Hearing for the remaining shoulder injury claim. ENTERED April 1, 2019.
APPENDIX
JUDGE AMBER E. LUTTRELL Court of Workers’ Compensation Claims
1. Statement of Undisputed Material Facts In Support of Employee’s Motion for Summary Judgment
2. Employee’s First Set of Requests for Admissions Propounded to the Employer,
Burkeen Trucking
3. Mr. Foutch’s medical bills
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of this Order was sent to the following recipients by the following methods of service on this the 1* day of April, 2019.
Name Certified|First Class} Via | Service sent to: Mail Mail Email Charles L. Holliday, X = | chuckh@garretylaw.com Employee’s Attorney X | masher@garretylaw.com Billy Burkeen, xX xX xX 34 Gibson Wells Brazil Rd., Self-represented Employer Humboldt, TN 38343 burkeentrucking@gmail.com
Uninsured Employer’s X | Lashawn.pender@tn.gov Fund
Le J uc fin
Lien, OE
Penny Shrum, Court Clerk
Court of Workers’ Compensation Claims
EXHIBIT ST Pepe FILED
Ex |
November 30, 2018
TN COURT OF IN THE COURT OF WORKERS’ COMPENSATION CLAIMS — WORKERS’ COMPENSATION AT JACKSON ecaimaaa Time 11:07 AM JAMES FOUTCH, * * Employee, * State File No. 88348-2015 mi Docket No. 2015-07-0374 Vv. c * BURKEEN TRUCKING, i * Employer. f
STATEMENT OF UNDISPUTED MATERIAL FACTS IN SUPPORT OF EMPLOYEE’S MOTION FOR SUMMARY JUDGMENT
Employee, James Foutch, through counsel, files this Statement of Undisputed Material Facts pursuant to Tennessee Rule of Civil Procedure 56.03 in support of his Motion for Summary Judgment.
STATEMENT OF UNDISPUTED MATERIAL FACTS
1. James Foutch was an employee of Burkeen Trucking on September 24, 2015. See Request for Admission No. 1.
2. On September 24, 2015, Mr. Foutch suffered a work injury to his right ankle in the course and scope of his employment. See Request for Admission No. 2.
3. Mr. Foutch gave Burkeen Trucking proper notice of his injury under the law. See Request for Admission No. 3.
4. The care Mr. Foutch received at the Henry County Medical Center and from Dr. Blake Chandler was reasonable and necessary and necessarily incurred due to the injury he sustained.
See Request for Admission No. 4. 5. Mr. Foutch was off work from November 16, 2015 to December 3, 2015. See Request for Admission No. 5.
6. From September 24, 2015 to November 16, 2015, Mr. Foutch was on light duty, limited to sedentary work only and that Burkeen Trucking would have had no work for him meeting those restrictions. See Request for Admission No. 6.
7. Burkeen Trucking has not filed a wage statement in this case. See Request for Admission No. 7.
8. Mr. Foutch’s average weekly wage for this claim is $746.87, which results in a compensation rate of $497.91. See Request for Admission No. 8.
9. Mr. Foutch has an impairment of 2% to the whole person due to his work injury on September 24, 2015. See Request for Admission No. 9.
10. Through no fault of his own, Mr. Foutch did not return to work at Burkeen Trucking following his injury. See Request for Admission No. 10.
11. Please admit that Burkeen Trucking fired Mr. Foutch due to his workers’ compensation claim. See Request for Admission No. 11.
12. At the time of this injury, Mr. Foutch was over 40 years of age. See Request for Admission No. 12.
13. Mr. Foutch did not have a meaningful return to work. See Request for Admission No. 13.
14. The medical bills attached to these undisputed material facts as Exhibit A are authentic business records of the facilities that produced them and are admissible into evidence
without further foundation. See Request for Admission No. 14.
-2- 15. The medical records from Henry County Medical Center attached to these undisputed material facts as Exhibit B are authentic records of the facility that produced them and admissible into evidence without further foundation. See Request for Admission No. 15.
16. | The medical records from Dr. Blake Chandler with West Tennessee Bone & Joint attached to these undisputed material facts as Exhibit C are authentic business records of the facility that produced them and admissible into evidence without further foundation. See Request for Admission No. 16.
17. The impairment rating from Dr. Blake Chandler attached to these undisputed material facts as Exhibit D is authentic and admissible into evidence without further foundation. See Request for Admission No. 17.
18. Dr. Chandler’s opinions in his records are admissible as expert opinions without further foundation and in lieu of his deposition. See Request for Admission No. 18.
19. At the time of Mr. Foutch’s injury, Burkeen Trucking was subject to the requirement of providing workers’ compensation insurance coverage. See Request for Admission No. 19.
20. The document attached as Exhibit E is a true and correct copy of the investigative report completed by the Tennessee Bureau of Workers’ Compensation and is admissible without further proof. See Request for Admission No. 20.
21. | Theuninsured employer’s fund, T.C.A. §§ 50-6-801 ef. seq. is applicable to this case. See Request for Admission No. 21.
22. | Mr. Foutch was employed by Burkeen Trucking and Burkeen Trucking failed to secure payment of compensation pursuant to the Workers’ Compensation Act. See Request for
Admission No. 22. 23. Mr. Foutch suffered an injury on or after July 1, 2015 primarily within the course and scope of his employment at a time where Burkeen Trucking had failed to secure payment of compensation. See Second Request for Admission No. 18.
24. Mr. Foutch was a Tennessee resident on the date of injury of September 24, 2015. See Second Request for Admission No. 19.
25. Mr. Foutch provided notice to the Bureau of Workers’ Compensation of the injury and Burkeen Trucking’s failure to secure payment of compensation within a reasonable time after the date of the injury. See Second Request for Admission No. 20.
26. Mr. Foutch is entitled to a judgment for workers’ compensation benefits against Burkeen Trucking for the injury at issue in this case, including temporary total disability of $4,979.10, permanent partial disability of $7,259.53, medical expenses of $24,591.30, and a collections fee of $522.20 due to medical bills being sent to collections for non-payment. See Second
Request for Admission No. 21.
Respectfully submitted,
LAW OFFICES OF JEFFREY A. GARRETY, PC
s/Charles L. Holliday Charles L. Holliday, #25459 Attorney for Employee
65 Stonebridge Boulevard Jackson, Tennessee 38305 Telephone: (731) 668-4878 CERTIFICATE OF SERVICE
I hereby certify that on this the 30" day of November, 2018, a copy of the foregoing was served upon Mr. Billy Burkeen, Burkeen Trucking Company, via e-mail to burkeentrucking@gmail.com.
s/Charles L. Holliday
EXHIBIT <7 FILED
inci 3 6x: De November 30, 2018 TN COURT OF WORKERS’ SATIO IN THE COURT OF WORKERS’ COMPENSATION CLAIMS ae AT JACKSON Time 11:07 AM JAMES FOUTCH, ; * Employee, * State File No. 88348-2015 * Docket No. 2015-07-0374 Vv. a * BURKEEN TRUCKING, « * Employer. *
EMPLOYEE’S FIRST SET OF REQUESTS FOR ADMISSIONS PROPOUNDED TO THE EMPLOYER, BURKEEN TRUCKING
COMES NOW the Employee, James Foutch, pursuant to Rule 36 of the Tennessee Rules of Civil Procedure, and propounds the following written Requests for Admissions to be answered by the Employer under oath within thirty (30) days after service and to supplement or amend its responses as required by Rule 26.05 of the Tennessee Rules of Civil Procedure. REQUESTS FOR ADMISSION REQUESTNO.1: Please admit that James Foutch was an employee of Burkeen Trucking on September 24, 2015.
RESPONSE:
REQUEST NO. 2: Please admit that on September 24, 2015, he suffered a work injury to his right ankle in the course and scope of his employment.
RESPONSE: REQUEST NO. 3: Please admit that Mr. Foutch gave you proper notice of his injury under the law.
REQUEST NO. 4: Please admit that the care he received at the Henry County Medical Center and from Dr. Blake Chandler was reasonable and necessary and necessarily incurred due to
the injury he sustained.
REQUEST NO.5: Please admit that from November 16, 2015 to December 3, 2015, Mr. Foutch was off work.
REQUEST NO.6: Please admit that from September 24, 2015 to November 16, 2015 he was on light duty, limited to sedentary work only and that Burkeen Trucking would have had no work for him meeting those restrictions.
REQUEST NO. 7: Please admit you have not filed a wage statement in this case.
RESPONSE: REQUEST NO. 8: Please admit that Mr. Foutch’s average weekly wage for this claim is $746.87, which results in a compensation rate of $497.91.
REQUEST NO. 9: Please admit that Mr. Foutch has an impairment of 2% to the whole person due to his work injury on September 24, 2015.
REQUEST NO. 10: Please admit that, through no fault of his own, Mr. Foutch did not return to work at Burkeen Trucking following his injury.
REQUEST NO. 11: Please admit that Burkeen Trucking fired Mr. Foutch due to his workers’ compensation claim.
REQUEST NO. 12: Please admit that at the time of this injury Mr. Foutch was over 40 years of age.
REQUEST NO. 13: Please admit that Mr. Foutch did not have a meaningful return to
work. RESPONSE:
REQUEST NO. 14: Please admit that the medical bills attached to these Requests for Admissions as Exhibit A are authentic business records of the facilities that produced them and admissible into evidence without further foundation.
REQUEST NO. 15: Please admit that the medical records from Henry County Medical Center attached to these Requests for Admissions as Exhibit B are authentic business records of the facility that produced them and admissible into evidence without further foundation.
REQUEST NO. 16: Please admit that the medical records from Dr. Blake Chandler with West Tennessee Bone & Joint attached to these Requests for Admissions as Exhibit C are authentic business records of the facility that produced them and admissible into evidence without further foundation.
REQUEST NO. 17: Please admit that the impairment rating from Dr. Blake Chandler attached to these Requests for Admissions as Exhibit D is authentic and admissible into evidence without further foundation.
RESPONSE: REQUEST NO. 18: Please admit that you will stipulate that Dr. Chandler’s opinions in his records are admissible as expert opinions without further foundation and in lieu of his deposition.
REQUEST NO. 19: Please admit that at the time of Mr. Foutch’s injury, you were subject to the requirement of providing workers’ compensation insurance coverage.
REQUEST NO. 20: Please admit that the document attached as Exhibit E is a true and correct copy of the investigative report completed by the Tennessee Bureau of Workers’ Compensation and is admissible without further proof.
REQUEST NO. 21: Please admit that the uninsured employer’s fund, T.C.A. §§ 50-6-801 et. seq. is applicable to this case.
REQUEST NO. 22: Please admit that Mr. Foutch was employed by you and you failed to secure payment of compensation pursuant to the Workers’ Compensation Act.
REQUEST NO. 18: Please admit that Mr. Foutch suffered an injury on or after July 1,
-5- 2015 primarily within the course and scope of his employment at a time where you had failed to secure payment of compensation.
REQUEST NO. 19: Please admit that Mr. Foutch was a Tennessee resident on the date of injury of September 24, 2015.
REQUEST NO. 20: Please admit that Mr. Foutch provided notice to the Bureau of Workers’ Compensation of the injury and your failure to secure payment of compensation within a reasonable time after the date of injury.
REQUEST NO. 21: Please admit that Mr. Foutch is entitled to a judgment for workers’ compensation benefits against you for the injury at issue in this case, including temporary total disability of $4,979.10, permanent partial disability of $7,259.53, medical expenses of $24,591.30, and a collections fee of $522.20 due to medical bills being sent to collections for non-payment.
RESPONSE: Respectfully submitted,
s/Charles L. Holliday Charles L. Holliday, #25459 Attorney for Employee
65 Stonebridge Boulevard Jackson, Tennessee 38305 Telephone: (731) 668-4878
I hereby certify that on this the 2" day of October 2018, a copy of the foregoing was served upon Mr. Billy Burkeen, Burkeen Trucking Company, via e-mail to burkeentrucking@gmail.com.
s/Charles L. Holliday NALVIVEVO I AINU IMAGING ASOUL P O BOX 1178
PARIS TN 38242
PEPSONAL 4 CONFIDENTIAL
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JAMES FOUTCH 79 GRIERS CHAPEL RD TRENTON, TN 38382-9444
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PATIENT # PATIENT NAME 56269 JAMES, SR. R FOUTCH DOB HOME TELEPHONE
40/05/1957 (734) 514-8323
Chaim: Procedura Date of ! Past Date | Type | faason Plan | Supervising | Ins. 1 iis. 2 - o Service i ! 8... £Prowder t “Claim 10 285219 : 245219: 27792,RT | era 10/09/2015 | euAHEE 27792,RT : PATIENT : G: " CHANOLEH i 238219! 27792,AT '09/29/2 eastovenrcss| ADJUSTMENT} COLLECT (RRC) | PATIENT i whet ee ee EN QUTSTANDING | “54.00 | 40 a0 ee eee eee ee ee ee ee eee OUTSTAUING COLLECTIONS : Clalm ID 2387930 ce1930| 99024 + 10/14/2015 | 10/21/2015; CHARGE! 39024 | PATIENT | G i i ' + CHANDLER _ QUISTANDING | $0.00; £000: “Claim io 299217 — : e737” TRELO ART | 117 /12/2015 | j11/20/2015 | CHARGE | ___73610,1,R7 |PATIENT: NOLEN! 297317! sriei0L AT [11/12/2008 toafeenIS | ADJUSTMENT} COLLECT (RRC) |PATIENT: 2 NOLEN | : see er a ee Be ee CUITSTANDING | 59.00} $0.00: ___ _ __. - © __OVTSTANUING COLLECTIONS | 290311 99024 | 11/12/2015 j11/20/20151 CHARGE | 90024 |PATIENT| 2 NOLEN UISTANDING 90.00! $0.00 ‘ciamio aninap ns ; 303792 | 73030,NT | 12/03/2015 | 12/14/2 01S} CHARGE} 73030,0T | PATIENT | TRNOLEN; 9} * 303092 : 73030,RT | 12/03/2015 04/23/2016 | AQJUSTMENT! COLLECT (RRC){PATICNT! R NOLEN | oak. SUTSTANRING | $0. on $0.00° : OUTSTANDING COLLECTIONS | ‘303792 - *73810,1,87 $22/03/2015 }12/14/2015! CHARGE! = /3610.1,K1 }PANIENI} — RNOLEN| ‘ “403792 —_-73640,1,RT | 12/03/2015 | 94/23/2016 | ADJUSTMENT | COLLECT (RAC) | PATIENT | “RNOUN; QUTSTANDING | $0.00 4 $0.00° Sepia veepeeneceene QUTSTANCING COLLECTIONS | 0s 393792. g90z4 | 12/03/2015 112/14/2015 ) "CHARGE | 92024 | PATIENT) — RENOLEN | i : oe OUTSTANOING | $0.00 $0.00° 303792 99213,24 | 12/03/2015 (12/18/2015 | CHARGE) === S9zi3,24ipaneNT! NOLEN] =i "gongz! == 39.213,26 | 12/03/2015 08/23/2016 | ADJUSTMENT: COLLECT ranc) (PATIENT! RNOLEN } i : EUITSTANDING | $0.00 £0.00: SuIS LANDING COLLECTIONS | t coi o attang oe _.. i. a BARELY 73610,1,A7 {01/06/2016 | {09/23/2016 | CHARGE | 73610..87 TPATIENT Gt * ae abseedie ie i ‘ — _—_ CHLANELER | 211842: 73610.1,0T | oxfos/zons jones "ROAUSTMENT | COLLECT icy PATENT, Gt
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a ol a et cuanucen | . . __ 7 a “OUTS STANDING | 50.00: $30.00: 30.00; : QUTSTANUING COLIECTIONS | | P3147 Ai "HRA MAISCCOLLFEE20% | poretznie onteaizane CHARGE MISCERLUFEE 20:8 PATIENT j Gj : 1 $$22.20; 7 | | CHANDLER | _ 3 : : 21862: MISCCOLLFEEZO% } Loeves/20%s “n/23/2016 | ADJUSTMENT | couvec tine) | pavicnr Gi $922.20 : od cis ‘ : y, CHANDLER! :
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FOTAL CHARGE OUTSTANDING AS OF 08/03/2016 | 130.00; $0. 00° $0 00
https://athenanet.a(henahealth.com/3533/42/clientclicntstatementesp?PRINTVIEW=1&DE... 5/3/2016 Date: 11/16/2015 12.43.50
| RY COUNTY MEDICAL CENTER
PO BOX 1030 PARIS, TN 36242
Phone #: (731 ) 642-1220
Federal iD: XX-XXXXXXX
PATIENT NAME FACKITY |VISIT ID FC BIRTH DATE ADMIT DATE DISCH. DATE FOUTCH, JAMES R 001 1417199-0001 P 10/06/1557 09/29/2015 09/29/2015 TO: BURKEEN TRUCKING SERUEREROM SERVICE THRU 34 GIBSON WELS BRAZIL ROAD ee eee HUMBOLT, TN 38343 PATIENT TYPE SDS Same Day Surgery ATTEND PHY 00433 CHANDLER BLAKE Primasy Insurance Secondary Insurance Tertiary Insurance PRIVATE PAY HWY 77 PARIS, TN 38242 SERVICE CHARGE CODE DATE |CHARGE DESCRIPTION CPT4 QTY PRICE TOTAL 70701876 PHO_Rx_Charge 09/29/2015 GLYCOPYRROLATE 1ML INJ 1 30.00 30.00 70708219 PHO_Rx_Charge 09/29/2018 PROPOFOL 20ML Iv 1 17 So 17.50 70709248 PHO_Rx_Charge 09/29/2015 BUPIVACAINE 0 5% SOML 1 1750 17.50 250 PHARMACY 3 85.00 70709074 PHO_Rx_3754 05/29/2015 SOD CHL 0.9% IRRI 3000ML 1 65.00 65.00 71606043 PHO_Rx_3754 09/26/2015 NS 50ML 1 30 00 30.00 71608043 PHO_RX_3617 09/29/2015 NS 50ML A 30 00 0,00 258 \V SOLUTIONS 1 65.00 61700280 PHO_Other 05/26/2015 OXYGEN - PER HOUR 1 23 00 23.00 62518703 MM093015_SUF 09/29/2015 SUTURE GROUP 2 2 26.00 32.00 62522458 MM093015_SUF 09/29/2015 DRILL BIT SOLID-STRYKER 1 256.50 256.50 62525611 MM093015_SUF 09/29/2015 GUIDEWIRE 150MM STRYKER 1 131.76 131,75 62525611 MM093015_SUF 09/29/2015 GUIDEWIRE 150MM STRYKER 1 131 75 131.75 62527512 MM063015_SUF 09/29/2015 PACK MAJOR SURGERY 1 96 00 96.00 62526014 MM093015_SUF 09/29/2015 STAPLER SKIN 35 W 2 30.00 60.00 272 STERILE SUPPLY 9 75100 62517771 MMO053015_SUF 05/29/2015 PLATE FIBULA STRYKER ORTHO CI713 1 1,318.50 1,318.50 62518585 MM093015_SUF 09/29/2015 SCREW LOCK 3.5 STRYKER C1713 1 307.50 307,50 62518585 MM093015_SUF 09/29572015 SCREW LOCK 3.5 STRYKER C1713 4 307.50 1,230.00 62516585 MM0G3015 SUF 05/26/2015 SCREW LOCK 35 STRYKER C1713 3 307.50 922.50 278 OTHER IMPLANTS 9 3,776.50 70100001 PHO_Laboralory 09/29/2015 SPECIMEN COLLECTION FEE 36415 1 18,00 18.00 70255010 1F150928HBA = -09/29/2015 ABO 66900 1 39.00 39.00 70258020 1F150929HBB = =: 09/29/2015 RH 86901 1 39.00 39.00 70255030 IF150929HBB = 99/29/2015 ANTIBODY SCREEN 86850 1 123.00 423.00 300 LABORATORY 4 219.00 70255551 IF150929HBB = =—-00/29/2015 CROSSMATCH 1 UNIT §, IMMEDIATE SPIN 66920 1 100 00 100 00
Continued on nexi page
[ Date: 117162015 12.4250 | 1 dRY COUNTY MEDICAL CENTER. Page 2 of 3 | PO BOX 1030 PARIS, TN 38242 Phone #: (73% } 642 -1220 Federal ID: XX-XXXXXXX PATIENT NAME FACILITY |VISIT ID Fe BIRTH OATE ADMIT DATE OISCH. BATE FOUTCH. JAMES R 001 1417199-0001 Pp 10/06/1957 Osf2972015 09/25/2015 SERVICE FROM | SERVIC TO: @URKEEN TRUCKING EFRO * THRU it 34 GIBSON WELS BRAZIL ROAD pele EO) 05/25/2015 HUMBOLT, TN 38343 PATIENT TYPE SOS Same Day Surgery ATTEND PHY 00433 CHANDLER BLAKE Primary Insurance Secondasy Insurance Tertlary Insurance PRIVATE PAY HWY 77 PARIS. TN 38242 SERVICE CHARGE CODE DATE |CHARGE DESCRIPTION CPT4 ary PRICE TOTAL 70255551 1F156928HBB 09/29/2015 CROGSMATCH 1 UNIT $, IMMEDIATE SPIN 86920 4 100 00 100.06 302 IMMUNOLOGY 2 200 00 70400251 PHO_Radiology 09/25/2015 XR-ANKLE RT-3V 73610RT 1 207 00 207.00 320 DX X-RAY 1 207.00 62100001 MM093015 SUF 09/25/2015 MAJOROR CHARGE 1ST HR 1 3022 00 3,022.00 ~ 62100002 M093015_SUI 09/29/2015 MAJOR OR. EAADD 15 MIN 1 431 00 431.00 360 OR SERVICES 2 3,453.00 70800040 MM093015_SUF 05/25/2015 General Anesihesia 0-30 mutes 1 594 00 594.00 70800560 MM093015_SUF 05/29/2015 GENERAL ANESTHESIA EAAOD 15 MINUTES 3 189.00 $67.00 370 ANESTHESIA 4 1,161.00 61706015 PHO Other 09/29/2015 SAO2 MULTIPLE 94761 1 106 00 406 00 460 PULMONARY FUNC 1 106.00 70700754 PHO_Rx_Charge 09/29/2015 EPHEDRINE 50MG INJECTION J3490 1 36 80 36.80 C$290 PHO_Rx_3617 09/29/2015 INJ. BUPIVACAINE LIPOSOME, 1 MG C9290 266 2.56 680,40 C9290 PHO_Rx_3754 09/29/2015 INJ. BUPIVACAINE LIPFOSOME., 1 MG C9290 266 2.56 680.40 30690 PHO_Rx_3754 09/29/2015 INJ. CEFAZOLIN SCDIUM, S0OMG 50690 6 875 52.50 J1170 PHO_Rx_Charge 09/29/2015 INJ. HYDROMORPHONE UP TO 4MG J1170 1 17 50 17.50 J2001 PHO_Rx_Charge 09/29/2015 INJ, LIDOCAINE HCL, 10MG 12004 10 475 17,50 J2250 PHO Rx_Charge 09/29/2015 INJ, MIDAZOLAM HCL PER iMG J2250 2 875 17,50 J240§ PHO_R«_Charge 05/29/2015 INJ, ONDANSETRON HCL, PER 1MG J2408 4 438 17.50 J2795 PHO_Rx_3754 05/25/2015 INJ, ROPIVACAINE HCL, 1MG 42795 150 0.45 67.75 82755 PHO_Rx_3617 05/29/2015 INJ. ROPIVACAINE HCL, 1MG J§2795 -150 0.45 67.75 $3010 PHO_Rx_Charge 05/25/2015 INJ. FENTANYL CITRATE, 0 1MG 43010 3 5.83 47.50 J7120 PHO_Rx_3612 09/29/2015 LR 1000ML J7120 1 40.00 40.00 636 DRUGS REQ DETAILED CODING 28 216,80 62166000 PHO_Other 09/29/2015 PACU | FIRST 30 MINUTES 1 §14 00 $14.00 62188010 PHO_Other 09/29/2015 PACU I-EA ADD 15 MIN 1 87 00 87.00 62188010 PHO_Other 09/29/2015 PACUI-EAAOD 15 MIN 1 87 00 87.00
Continued on next page t WRY COUNTY MEDICAL CENTER
PO BOX 1030 PARIS, TN 38242
Phone #: (731 } 642 -1220 Federal ID: XX-XXXXXXX
PATIENT NANE FACILITY |ViSIT ID Fe BIRTH DATE ADMIT DATE DISCH. DATE FOUTCH, JAMES R 001 1417199-0001 P 10MB/1957 08/29/2015 08/29/2015,
TO: BURKEEN TRUCKING SERVICE FROM | SERVICE THRU
34 GIBSON WELS BRAZIL ROAD caraer20iS Cee HUMBOLT, TN 38343 PATIENT TYPE SDS Same Day Surgery ATTEND PHY 00433 CHANDLER BLAKE Primary Insurance Secondary insurance Tertiary Insurance PRIVATE PAY HWY 77 PARIS, TN 38242 SERVICE CHARGE COOE DATE |CHARGE DESCRIPTION CPT4 QTY PRICE TOTAL 62188020 PHO_Other 09/29/2015 PACU II -FIRST 30 MINUTES 1 257 00 257.00 62488030 PHO_Other 09/29/2015 PACU II - EACH ADD 15 MINUTES 1 §3 00 53.00 710 RECOVERY ROOM 5 996.00 80000181 CA01_10-04-201 10/05/2015 Private Pay Discount - OP 1 -4,970.59 -4,970.59 C01 ADJUSTMENTS 1 -4,970.55 TOTAL CHARGES 11,220,360 PATIENT PAYMENTS/ADJUSTMENTS -4,970.59 INS PAYMENTS/ADJUSTMENTS 0.00
**** INVOICE TOTAL 6,248.71
[_ Date: 11/16/2015 12.44.00
t JRY COUNTY MEDICAL CENTER
Phone &: (731 ) 642 -1220 Federat ID: XX-XXXXXXX
| Page 1 of 2 |
PATIENT NAME FACIUTY /VISiT ID Fe BIRTH DATE ADMIT DATE DISCH. DATE FOUTCH. JAMES R 001 1416557-0001 P 10/06/1957 09/24/2015 09/24/2015 TO: BURKEEN TRUCKING SERVICE ROM ,SERUC ERrHRU 34 GIBSON WELS BRAZIL ROAD eee Oar2ar2015 HUMBOLT, TN 38343 PATIENT TYPE ER Emergency Room ATTEND PHY 00879 RAINBOLT CHARLES D Primary insurance Secondary insurance Tertiary Insurance PRIVATE PAY HWY 77 PARIS, TN 30242 4140283826 SERVICE CHARGE CODE DATE |CHARGE DESCRIPTION CPT4 QrTy PRICE TOTAL 70100001 ARR_20150924- 09/24/2015 SPECIMEN COLLECTION FEE 36415 1 18 00 18.00 70101405 ARR_20150824- 09/24/2015 BASIC METABOLIC PAN/BIG 8 60048 1 378 00 378 00 300 LABORATORY 2 396.00 70100219 ARR_20150924- 09/24/2015 CBC AUTO DIFF 65026 1 164 00 164.00 305 HEMATOLOGY 1 164.00 70400251 ARR_20150924- 09/24/2015 XR-ANKLE RT-3V 73610RTF 1 207 00 207 00 320 DX X-RAY 1 207 00 70400821 ARR_20150524- 05/24/2015 XR-CXR-1V 71010 1 188 00 188.00 324 CHEST X-RAY 1 188.00 70423005 ARR_20150924- 09/24/2015 CT-RECON W POST IMAGING CONCURRENT 76376 1 1366 00 1,366 00 70423076 ARR_20150924- 09/24/2015 CT-LOWER EXT W/O-RT 73700RT 1 1469 00 1,489.00 350 CT SCAN 2 2,855.00 62311060 PHO_Other 09/24/2015 ER-LEVEL5 9928625 1 2,024 00 2,024.00 62311146 PHO_Other 09/24/2015 IV PUSH- INITIAL 96374 { 230.00 230,00 62311133 PHO_Other 09/24/2015 iV PUSH SEQUENTIAL, EAADD/SAME DRUG 96376 1 221.00 221.00 450 EMERG ROOM 3 2,475.00 J2270 ARR_20150924-188 09/24/2015 INJ, MORPHINE SULFATE, UP TO 10MG J2270 1 1? $0 17.50 $2270 ARR _20150824-189 09/24/2015 INJ, MORPHINE SULFATE, UP TO 10MG 52270 1 17 50 17 50 $2270 ARR_20150924-189 09/24/2015 INJ. MORPHINE SULFATE, UP TO 10MG J2270 1 17.50 17.50 32405 ARR_20150924-189 09/24/2015 INJ. ONDANSETRON HCL, PER 1MG $2405 4 4% 17.50 636 DRUGS REQ DETAILED CODING 7 70.00 70301020 ARR_20150924- 09/24/2015 ELECTROCARDIOGRAM (EKG) 93005 1 211 00 211.00 730 EKG/ECG 1 211.00 40000181 CA01_09-29-201 05/30/2015 Private Pay Discount - OP 1 -2 SOB 74 -2,908 74
Continued on nexi paga
[ Date: 1171612015 12.44.00 | t JRY COUNTY MEDICAL CENTER
PO 8OX 1030 PARIS, TN 38242
Phone #: (731 ) 642 -1220 Federal ID: XX-XXXXXXX
PATIENT NAME FACILITY [visit ID Fe | BIRTH DATE ADMIT DATE | OISCH. DATE FOUTCH, JAMES R 001 —-|1416557-0001 P 10/06/1957 09/24/2015 09/24/2015 RVICE FROM | SERVIC TO: BURKEEN TRUCKING Se epee 34 GIBSON WELS BRAZIL ROAD os/2a/io ie 08/24/2015 HUMBOLT, TN 38343 PATIENT TYPE ER Emergency Room ATTENDPHY 00079 = RAINBOLT CHARLES D Primasy Insurance Secondary insurance Tertiary insurance PRIVATE PAY HWY 77 PARIS, TN 38242 414028828 SERVICE ee CHARGE CODE DATE |CHARGE DESCRIPTION cPTs ary PRICE TOTAL 80000181 10012015ADJew 10/04/2015 Private Pay Discount - OP 1 -2:90874 2,908.74 C0+ ADJUSTMENTS 2 0.00 TOTAL CHARGES 6,588.00 PATIENT PAYMENTS/ADJUSTMENTS 0.00 INS PAYMENTS/ADJUSTMENTS 0.00
**° * INVOICE TOTAL 6,566.00