Sample Submission/Checklist for a Workers’ Compensation Medicare

Set-aside Arrangement ("WCMSA") Proposal

This document, prepared in compliance with § 508 of the Rehabilitation Act of 1973, as amended, is intended to be used as a sample submission or checklist for a sample submission. Its publication is meant to aid submitters in organizing the information that is typically sent to CMS with a set-aside proposal. Cases using this or a similar format can generally be processed more quickly with fewer errors and development requests, resulting in faster determinations at less cost to submitters and the government.

This sample is not a required form or format. Each state may have required forms for processing workers' compensation cases and nothing in this sample is meant to interfere with each state's forms or requirements. Note that the endnotes are for explanation only and are not meant to be part of a suggested submission.

This sample is not a policy document, and it is not the intent of CMS to make or change policy by publishing this sample. Official CMS policy with respect to WCMSAs is published elsewhere on this website (www.cms.hhs.gov/workerscompagencyservices). Where any conflict is perceived between statements or information in this sample and official CMS published policy, the latter controls.

This sample is divided into numbered sections, corresponding to the electronic folders in which CMS scans and files documents for review. Use of these numbered sections by submitters enhances the scanning and review process and reduces errors. For cases filed on compact disc, grouping and naming documents by using the numbered folders is preferred, as this will eliminate the need for section dividers.

For cases submitted on paper, numbered section dividers on single sheets, rather than tabs, are recommended. This sample will assume a paper filing, showing the use of numbered section dividers. It also assumes each numbered section is being used, although this practice is not being suggested and rarely is necessary. Note, although the cover letter is very important, it does not need a section divider when paper filing is used because it should always be on top of the submission.

The following lists the numbered sections, whether the information in them is mandatory and what to include (and not to include) in each:

Section 05 (Cover Letter). Mandatory information. Include all pertinent names, addresses, phone and fax numbers; all demographic information about the claimant; and all summary numbers and other data for the settlement and the WCMSA. Reference attachments only after summarizing the important information on them.

Section 10 (Consent Form). Mandatory information. Include the signed consent, plus any applicable court papers if the consent is signed by someone other than the claimant (for example, guardian, power of attorney, etc.) Do not include unsigned consents or consents to obtain medical records from a provider.

Section 15 (Rated Ages). Optional information. Include a stand-alone statement indicating whether all rated ages obtained on the claimant are included. Also include all rated ages obtained on the claimant, even those that appear to have expired or appear not to be independent. Make sure they are on letterhead (which includes company name and address) of the insurance company or companies that made the rating or the settlement broker that obtained them from the insurance companies. Do not include actuarial charts or life expectancy charts from the CDC or elsewhere, or statements that there are no rated ages. If actual age is used, leave this section blank.

Section 20 (Life Care/Future T reatment Plan). Optional information, except for drug and dosage lists which must be included. Include all pricing charts, cost projections, pricing information, drug and dosage lists, and explanatory narratives and analyses.

Section 25 (Court/W C Board Documents). Optional information upon submission, but final settlement documents are required to complete case. Include only official documents, such as WC petitions, mediation documents, prior awards and settlements, court orders, draft and final settlement agreements, and annuity rate sheets.

Section 30 (W C MSA Administration Agreement). Optional information. Include any official stand-alone agreement that provides the name and address of the administrator of the WCMSA.

Section 35 (Medical Records). Mandatory information. Include first report of injury, medical records of major surgeries, and medical records for the last two years of treatment, no matter how long ago those last two years were or who paid for the services. Also include depositions from medical providers. Do not include insurance billing forms (except C-4 forms in New York), subpoena forms, or correspondence seeking records.

Section 40 (Payment Information). Mandatory information. Include payment histories (indemnity, medical, and expenses) from all carriers, third party administrators ("TPAs"), employers, pharmacies, and prescription drug suppliers. Also include any signed statements from carriers or their attorneys with payment information or the last date of treatment. Include billing information, where paid claims information is not available.

Do not include unsigned statements from carriers or their attorneys.

Section 50 (Supplemental/ Additional Information). Optional information. Include copy of official birth certificate and driver's license where date of birth is unclear, copy of state law that submitter discusses elsewhere, and Social Security or Medicare card or correspondence if needed to verify Social Security or Medicare number or entitlement. Do not include submitter resume or copies of documents sent by CMS to the WCMSA submitter.

Clarifications or questions concerning use of this sample submission/checklist may be directed to the Workers' Compensation Review Center, 301-575-0160. Any suggested modifications should be sent in writing to mspcentral@cms.hhs.gov.

05 - C O V E R L E T T E R

W C MSA Consultants, L L C 100 Helpful Lane, Suite 300 City, State 11111-2222

Phone: (410) 555-1111, Fax: (240) 555-0000

January 21, 2009

CMS

c/o Coordination of Benefits Contractor PO Box 33849

Detroit, MI 48232

Re: Ima Hurten

100 Felldown Lane

City, State 22222-1111

Phone: (803) 555-1111

SSN: 123-45-6789

HICN: None Dear Sir/Madam:

We have been asked by the parties to refer the above case to your office for review and approval of a Workers' Compensation Medicare Set-aside Arrangement ("WCMSA"). The following is the pertinent information in regard to the above-captioned claimant:

A. Claimant Information

Gender: Female
Date of Birth: 07/03/49
Median Rated Age1: 67
Life Expectancy Used in Proposal2: 17
Consent attached (required): YES

B. Entitlement Information

1. Claimant has applied for Social Security Disability Benefits ("SSDB"): No

2. Claimant has been denied SSDB but anticipates an appeal: No

3. Claimant is in the process of appealing and/or re-filing for SSDB: Yes

4. Claimant is (or will be) at least 62 years and 6 months old 120 days from today: No

5. Claimant has End Stage Renal Disease ("ESRD") but does not yet qualify for Medicare based on ESRD: No

6. Other (Explain): No

C. Injury Information

Description of incident and injury: Claimant was tightening valves and felt her neck burning

All date(s) of injury being settled (list oldest first; show first and last dates of any cumulative traumas):

01/31/01

04/13/02

ICD-9 diagnosis codes and descriptions for body parts that are settling (list all that apply, in order of priority):

721.0-Cervical spondylosis without myelopathy 723.1-Cervicalgia

723.4-Brachial neuritis or radiculitis NOS

D. Contact Information:

1. Submitter

WCMSA Consultants, LLC 100 Helpful Lane, Suite 300

City, State 11111-2222

Phone: (410) 555-1111, Fax: (240) 555-0000

Contact:: Bea Friend @ (410) 555-1111 x2345

MSA Administrator

Claimant: YES

SSA Representative Payee: NO (if YES, include name, address, phone, and fax)

Professional Administrator: NO (if YES, include name, address, phone, and fax)

2.Claimant's Attorney

Legal Eagle, Esquire 200 Justice Ct Ste 210

City, St 33333-4444

Phone (800) 555-1111; Fax: (800) 555-0000

Employer

Cool Toys Manufacturing, Inc. 22 Playful Ln

City, St 55555-2222

Phone (212) 555-1111; Fax: (212) 555-0000

3. Employer's Attorney

Clarence Darrow & Associates 24 Playful Ln

City, St 55555-2222

Phone (212) 555-2222; Fax: (212) 555-3333

WC Carrier

Got U Covered, LLC 100 Carrier Blvd

City, St 66666-3333

Phone (412) 555-1111; Fax: (412) 555-0000

WC Carrier's Attorney Daniel Webster, LLC 102 Carrier Blvd City, St 66666-3333

Phone (412) 555-2222, Fax: (412) 555-3333

E. Settlement Details:
1. Total settlement amount5:	$260,000
2. Total proposed Medicare set-aside amount:	$95,891
a. Portion of set-aside for medical items and services: b. Calculated using (check one)6	$17,739
State fee schedule: YES
Full actual charges: NO
c. Portion of set-aside for prescription drugs:	$78,152

Set-aside is paid out as
1. Lump sum: NO
2. Annuity: YES

If annuity, proposed initial deposit (seed money)7: $12,340

State of Jurisdiction/Venue8: American Samoa If you have any questions or require any additional information, please contact me at

(410) 555-1111, Extension 11.

Sincerely, Signature Bea Friend

Benefit Coordination Specialist

BF/mlf Enclosures

10 - CONSENT FORM

CONSENT RELEASE FORM

The Privacy Act of 1974 (Public Law 93-579) prohibits the government from revealing information from personal files without the express written permission of the person involved. Disclosure of personal records to an attorney or other representative who is acting on behalf of another person is prohibited, unless the individual to whom the record pertains has consented.

I, Ima Hurten , hereby authorize the Centers for Medicare & Medicaid Services (CMS), its agents and/or contractors to disclose, discuss, and/or release, orally or in writing, information related to my worker's compensation injury and/or settlement to the individual(s) and/or firm(s) listed below. This consent is for my current workers' compensation claim and is on an ongoing basis. An additional consent to release form will not be necessary unless or until I revoke this authorization (which must be in writing).

PLEASE CHECK:

Claimant's attorney (name and/or firm) Legal Eagle, Esquire Employer's attorney (name and/or firm) Conrad Courageous, Esquire Workers' compensation carrier (name and/or firm) Got U Covered

Other (name and/or firm) WCMSA Consultants

Claimant's Signature: Signature

Date Signed: 10/18/08

Date(s) of Injury: 01/31/01, 04/13/02

Social Security Number or Health Insurance Claim Number: 123-45-6789

15 - RATED AGES

W C MSA Consultants, L L C 100 Helpful Lane, Suite 300 City, State 11111-2222

Phone: (410) 555-1111, Fax: (240) 555-0000

Rated Age Statement

Claimant: Ima Hurten SSN: 123-45-6789

All rated ages obtained on the claimant have been included.

WCMSA Consultants, LLC Submitter

V U L C A N INSUR A N C E C O MPA N Y

100 L ive Long and Prosper Lane C I T Y, ST A T E 22222-4444

Phone: (302) 555-1111, Fax: (302) 555-0000

An underwriting assessment for IMA HURTEN has been completed. Gender: Female

Date of Birth: July 3, 1949

Actual Age: 59

Rated Age: 67

Issue Date: November 15, 2008

SUNN Y SE T T L E M E N T BR O K E R, IN C.

200 Sunnyside Lane

C I T Y, ST A T E 33333-5555

Phone: (804) 555-1111, Fax: (804) 555-0000

Name: Ima Hurten

File No.: 00WS458231

Gender: Female

DOB: July 3, 1949

Actual Age: 59 Ratings obtained from:

Good Life Ins Co, Charles N. Reilly, Phone (410) 555-0000, Fax (410) 555-9999 Gender: Female
Date of Birth: July 3, 1949

Actual Age:     59

Rated Age:      62

Issue Date:      November 11, 2008

2. Live Better Ins Co, Inc., Doris Day, Phone (410) 333-0000, Fax (410) 555-8888 Gender: Female

Date of Birth: July 3, 1949

Actual Age: 59

Rated Age: 65

Issue Date: November 12, 2008

3.Fortunate Life Ins Co, LLC, Ruff Day, Phone (410) 777-0000, Fax (410) 555-0000 Gender: Female

Date of Birth: July 3, 1949

Actual Age: 59

Rated Age: 72

Issue Date: November 12, 2008

4. Lively Life Ins. Co., Faye Ray, Phone (410) 444-0000, Fax (410) 555-1111 Gender: Female

Date of Birth: July 3, 1949

Actual Age: 59

Rated Age: 77

Issue Date: November 13, 2008

20 - Life Care/Future Treatment Plan

G R E A T L I F EPL A N, L L C

100 Easylife Way City, State, 22222

Phone: (888) 555-1111 Fax: (888) 555-0000

Life Care Plan

Future Medical Care - Medicare Covered Items and Services and Prescription Drugs

Client: Ima Hurten Date prepared: 10/18/2008

Prepared by: Rita Reviewer, RN, CCM DOB: July 3, 1949

DOI: 01/31/01, 04/13/02

Diagnoses: 721.1 Cervical spondylosis without myelopathy

723.1 Cervicalgia

723.4 Brachial neuritis or radiculitis NOS Median rate age: 67

Life expectancy: 17 years

Calculation of W C MSA for medical items and services related to work injury:

Medical Item or Service, Number, Every x years, # of years, Price per service, Lifetime Total Pain management, 4, every 1 year, for 17 years, price $80.56 per service, $5,478.08 Lab work Rx, 1, every 1 year, for 17 years, price $36.67 per service, $623.39 Orthopedist, 1, every 1 year, for 17 years, price $80.56 per service, $1,369.52

X-ray Cervical, 5, every 17 years, for 17 years, price, $111.31 per service, $556.55 MRI/CT Cervical, 3, every 17 yrs, for 17 years, price $1,386.19 per service, $4,158.57 Trigger point injection, 6, every 17 yrs, for 17 yrs, $80.00 per service, $480.00 Physiotherapy, 18, every 17 years, for 17 years, price $81.83 per service, $1,472.94 Epidural injections, 3, every 17 yrs, for 17 yrs, price $1,200.00 per service, $3,600.00

Lifetime total of all medical items and services: $17,739.05

Calculation of W C MSA for prescription drugs related to work injury:

Drug, National Drug Code, Dosage, Frequency, Length, Price per unit, Lifetime Total Zolpidem, 64679-0715-01, 10mg, 30/mo, for 17 yrs price $3.65 per unit, $22,338.00 Tizanidine, 00172-5736-70, 4mg, 90/mo, for 17 yrs price $1.39 per unit, $25,520.40 Hydrcdne/apap, 00591-0540-05, 10/500mg, 90/mo, for 17 yrs, price $0.18 per, $3,304.80 Gabitril, 63459-0404-01, 4mg, 30/mo, for 17 yrs, price $4.41 per unit, $26,989.20

Lifetime total of all prescription drugs: $78,152.40

25 - Court/W C Board Documents

BEFORE THE WORKERS' COMPENSATION COMMISSION

A M E RI C A N SA M O A

Commission File: 000000 Ima Hurten

(Hereinafter called "Employee")

Cool Toys Manufacturing

(Hereinafter called "Employer")

Got U Covered

(Hereinafter called "Carrier/TPA")

***AGREEMENT OF FINAL SETTLEMENT AND RELEASE***

THIS AGREEMENT OF FINAL SETTLEMENT AND RELEASE was made

and entered into on the day of by and between Employee, Employer, and Insurer.

The Employee, Ima Hurten, for consideration of the sum of $260,000, paid by or on behalf of the above captioned Employer/Carrier/TPA, shall release Employer/Carrier/TPA, from its obligation or liability to pay all benefits of whatever kind or classification available under the State Workers' Compensation Law on account of the above captioned manufacturing accident and any other known or unknown (discussed below) work related injury that the Claimant may have sustained while employed by the Employer and/or their successors, assigns, interests, officers, directors, employees, agents, shareholders or any other person or entity who may be responsible or liable for actions of the Employer.

I I

Claimant represents and affirms that all accidents, injuries, and occupational diseases known to have occurred or to have been sustained while employed by the Employer have been revealed but in any event, this Settlement Agreement and Release releases the Employer/Carrier/TPA from all Workers' Compensation liability and as such, Claimant bears the risk of arguably related conditions not yet manifested. It is the intention of the parties to resolve all claims actual or potential for any and all accidents and/or injuries, arising out of and in the course and scope of employment, in exchange for the monetary consideration outlined herein.

I I I

The Claimant specifically acknowledges that on finality of this Settlement Agreement and Release, rights to all future medical care and treatment related or arguably related to the workers' compensation claim, whether remedial or palliative in nature, are forever and fully relinquished whether or not the Claimant's condition has been brought to a state of maximum medical improvement and regardless of whether the Claimant's condition(s) improves or seriously deteriorates for any reason whatsoever. On finality of this Settlement Agreement and Release, except as specifically provided and limited below, the Employer/Carrier/TPA shall not be responsible for either the provision or payment of any medical benefits. Any future medical care treatment or expense that may arise in the future, regardless of the cause thereof, will be the responsibility of the Claimant. Claimant understands only authorized medical providers will be paid for authorized services rendered prior to the finality of this Settlement Agreement and Release. Any medical bills from authorized providers for authorized services rendered to the finality of this Settlement Agreement and Release shall be submitted for payment by the Employer/Carrier/TPA. All medical bills from unauthorized providers are the responsibility of the Claimant, not the Employer/Carrier/TPA. Medical bills from authorized providers for services rendered after the date of finality become the responsibility of the Claimant.

I V

The Medicare Set Aside funds in this case are to be self administered by the claimant. Claimant has been provided directives issued by CMS regarding her rights and responsibilities in this regard. Claimant understands that until she becomes entitled to Medicare, the MSA funds must not be used to pay the claimant's expenses. Claimant understands that the MSA funds must be placed in an interest bearing account, and this account must be separate from the individual's personal savings and checking accounts. The funds in this account may only be used for payment of medical services related to the work injury that would normally be paid by Medicare.

It is not the intention of the Workers' Compensation Carrier to shift responsibility of future medical benefits to the Federal government. The sum of $95,891 for future Medicare-covered expenses is intended directly for payment of these expenses. Upon proof that Medicare-covered expenses exceed $95,891, those expenses will be forwarded to Medicare for payment of covered expenses with proper documentation. It is the responsibility of the claimant/beneficiary to submit bills related to the work-related injury or illness totaling the amount of $95,891 before Medicare will make payment on any covered expenses related to the work injury or illness.

This allocation is based on the workers' compensation fee schedule. The injured worker should be advised that all payments to providers are to be adjusted accordingly, and any monies paid in excess of the fee schedule will not count toward the allocation.

Claimant and her family agree not to discuss the existence of this settlement or any of the terms to any persons in the employment of Cool Toys Manufacturing, Inc.or any former employees of Cool Toys manufacturing. The Claimant specifically agrees to keep the existence of and the terms of this settlement strictly confidential.

V I

The Employee accepts the following settlement as full and final compensation from her former employer:

Total WC Settlement Amount: $260,000 broken down as follows:

Cash to claimant for indemnity $115,000 Cash for initial deposit non-Medicare medical needs $809 Annuity payout for non-Medicare medical needs $1,600 ($100/yr. for life (est. 16 years) starting 08/04/10)

Cash for initial deposit Medicare set-aside $12,340

Annuity payout for Medicare set-aside $83,551 ($5,221.94/yr. for life (est. 16 years) starting 08/04/10)

Attorney fee $46,700

$260,000

In testimony whereof, the parties have hereunto set their hands and affixed their seals the day and year first above herein.

Employee: Signature Consented to by: Signature Legal Eagle, Esq.

Attorney for Employee State Bar No. 5678

And by: Signature Conrad Courageous, Esq.

Attorney for Employer/Carrier/TPA

Attest: Signature NOTARY PUBLIC, American Samoa

My Commission Expires: March 10, 2010

30- W C MSA

Administration Agreement

A D M INIST E RIN G Y O UR ST RU C T UR E D WORKERS' COMPENSATION

M E DI C A R E SE T-ASID E A RR A N G E M N T ( W C MSA)

Claimant: Ima Hurten SSN: 123-45-6789

DOI: 01/31/01, 04/13/02

Employer: Cool Toys Manufacturing, Inc.

Medicare regulations found in Title 42 of the Code of Federal Regulations §411.46, state that Medicare will not pay for Medicare-covered medical services or Medicare-covered prescription drug expenses related to this work-related injury until the WCMSA funds have been exhausted. Your WCMSA funds must be used to pay for all Medicare-covered medical services and Medicare-covered prescription drug expenses related to the workers' compensation injury, illness, or disease. A CMS lead Medicare contractor will monitor your expenditures from the WCMSA account upon receipt of the annual self- attestation letter that you are required to submit. Once the lead contractor has confirmed that the WCMSA funds have been exhausted appropriately, Medicare will begin paying for Medicare-covered services related to the workers' compensation injury, illness, or disease.

Instructions for establishing and administering a WCMSA account are listed below. If you have any questions regarding these requirements please contact the CMS lead Medicare contractor at the following address.

MSPRC

PO Box 33828

Detroit, MI 48232

Attention: MSP - Medicare Set-aside Reconciliation

Establishing and Using your Medicare Set-Aside Account

WCMSA funds must be placed in an interest-bearing account, separate from your personal savings or checking account.

WCMSA funds may only be used to pay for medical services and prescription drug expenses related to your work injury that would normally be paid by Medicare.

Examples of some items that Medicare does not pay for are: acupuncture, routine dental care, eyeglasses or hearing aids, etc.; therefore, these items cannot be paid from the WCMSA account. You may obtain a copy of the booklet "Medicare & You" from your Social Security office for a more extensive list of services not covered by Medicare.

If you have a question regarding Medicare's coverage of a specific item, service, or prescription drug, to determine if you may pay for it from the WCMSA account, please call 1 800-MEDICARE (1-800-633-4227) or visit CMS' website: www.cms.hhs.gov/home/medicare/asp.

Please note: If payments from the WCMSA account are used to pay for services other than Medicare allowable medical expenses related to medically necessary services and prescription drug expenses, Medicare will not pay injury related claims until these funds are restored to the WCMSA account and then properly exhausted.

Record Keeping

As administrator of the account, you will be responsible for keeping accurate records of payments made from the account. These records may be requested by CMS's lead Medicare contractor as proof of appropriate payments from the WCMSA account.

You may use the WCMSA account to pay for the following costs that are directly related to the account: document copying charges, mailing fees/postage, any banking fees related to the account, and income tax on interest income from the set-aside account

Annually, you must sign and forward a copy of the attached form, which states that payments from the WCMSA account were made for Medicare-covered medical expenses and Medicare-covered prescription drug expenses related to the work-related injury, illness, or disease

An annual accounting shall be submitted to the Medicare lead contractor listed on Page 1 of this agreement no later than 30 days after the end of anniversary year (beginning with one year from the date of settlement).

The annual self-attestation should continue through depletion of the WCMSA account.

I, Ima Hurten, have read and understand the above-listed terms and conditions. I agree to abide by these terms and conditions in order to protect my ability to obtain Medicare coverage for my work-related injury medical expenses once the WCMSA account is depleted. I understand that if I fail to abide by the above listed terms and conditions, I may not be eligible for Medicare coverage for my work-related injury medical expenses.

Claimant: Signature Date: 11/01/08

I, Legal Eagle, counsel for Ima Hurten, have reviewed the above agreement with the Claimant and have explained it, in detail. I believe that Ms. Hurten fully understands the complete contents of the document and the duties she is undertaking to administer her WCMSA.

Signature Date: 11/01/08

35 - Medical Records

AMERICAN SAMOA BOARD OF WORKER'S COMPENSATION

EMPLOYER'S FIRST REPORT OF INJURY OR OCCUPATIONAL DISEASE

OSHA File No.:

Carrier/TPA File No.: ABC-987654321

Employer/Address: Cool Toys Manufacturing, Inc., 22 Playful Ln, City, ST 11111 Employer Phone: (684)-555-1111

Employer FEIN: 12-3456789

Employer Location address (If Different): Nature of Business: Manufacturing

Carrier/TPA & Address: Got U Covered, LLC, 100 Carrier Blvd, City, St 66666-3333 Carrier/TPA Phone: Phone (412) 555-1111

Carrier/TPA FEIN:

Place of Accident or Exposure: Cool Toys Manufacturing, Inc. Occupation: Construction personnel

Employee Name (Last, First): Hurten, Ima Date of Birth: 07/03/49

Social Security Number: 123-45-6789

Address: 100 Felldown Lane, City, ST 22222-1111 Date of Injury: 01/31/01 & 04/13/02

Home phone number: 803-555-1111 Number of dependents including spouse: Gender: Female

Time of Injury:

Time workday began: Date Employer Notified: Date Hired:

Did Employee work the Next Day?: No

First Date Employee Failed to Work a Full Day: Did Employee Receive Full Pay for Date of Injury? Hours Worked Per Day:

Hours Worked Per Week:

Number of Days Worked Per Week: 5

List Normally Scheduled Off Days: Saturday, Sunday Wage Rate at Time of Injury or Disease:

If employee is paid hourly, on commission or piecework basis, enter average weekly amount:

If board, lodging or other advantages were furnished, enter average weekly amount: Did Injury/Illness/Exposure Occur on Employer's Premises?: Yes

Type of Injury/Illness: 59-USING TOOL OR MACHINERY Part of Body Affected: 25- NECK NOC

How Injury or Illness/Abnormal Health Condition Occurred. What was the employee doing just prior to accident?: SHE WAS TIGHTENING DOWN A VALVE AND FELT HER NECK START BURNING

If Returned to Work, Give Date: Returned at What Wage per Hour?: If Fatal, Give Date of Death:

Treating Physician (Name and Address): Initial Treatment:

Hospital/Treating Facility (Name and Address):

Report Prepared By (Print or Type): Johnny Q. Supervisor Position:

Telephone Number: Date of Report : 2/3/01

EMPLOYER'S FAILURE TO SUBMIT THIS REPORT TO CARRIER/TPA IMMEDIATELY MAY RESULT IN PENALTY

FOR USE BY CARRIER/TPA/SELF-INSURER Average Weekly Wage: $700.00

Weekly Benefit: $ Date of disability: Date of First payment: Compensation Paid: $ Penalty paid: $

Previous Medical Only: Yes ( ), No ( )

BENEFITS ARE PAYABLE FROM FOR:

( ) Total/temporary total disability ( ) Temporary partial disability

( ) Permanent partial disability of % to for weeks UNTIL WHEN THE EMPLOYEE ACTUALLY RETURNED TO WORK ALL OTHER SUSPENSION REQUIRE THE FILING OF FORM WC2 WITH THE BOARD OF WORKERS' COMPENSATION AND THE EMPLOYEE

By (Carrier/TPA/Self insurer: Type or Print Name of Person Filing Form or Sign): Johnny Q. Adjuster

Date: 02/03/01 Phone:

Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties of up to $10,000 per violation.

FORM WC-1 (REV. DATE 7/2002) EMPLOYER'S FIRST REPORT of INJURY or

OCCUPATIONAL DISEASE

American Samoa Regional Medical Center 123 South Main Street

Pago, Pago, American Samoa 54321

PATIENT: Hurten, Ima PT DOB: 07/03/1949

DICTATED: 07/26/2002 11:31 A ADMITTED: 07/26/2002 TRANSCRIBED: 07/26/2002 14:51 P DISCHARGED:

mq/856954 Jack G. Skellington, M.D.

010006879846546/2A 211202

58-62-48

OPERATIVE NOTE: Jack G. Skellington DATE OF OPERATION: 07/26/2002

PREOPERATIVE DIAGNOSIS: C5, 6 cervical disk herniation POSTOPERATIVE DIAGNOSIS: Same

SURGEON: Jack G. Skellington ASSISTANT: Kathleen Wratchet, R.N., F.A.

OPERATION:

C5, 6 cervical diskectomy with anterior intrabody fusion (Allograft)
Codman slim lock anterior cervical plate stabilization ANESTHESIA: General endotracheal

OPERATIVE INDICATIONS: The patient is a 53-year-old female who presented with cervical myelo-radiculopathy. MRI demonstrated a massive disk herniation at the C5, 6 level with signal changes in the spinal cord.

DESCRIPTION OF OPERATION: The patient was brought to the Operating Room. Preoperatively for one week before this procedure she had been on a high dose of Decadron. Immediately pre-op in the holding area she was started on the Methyl Prednisolone spinal cord injury protocol for additional steroids. She was brought to the Operating Room, underwent an awake fiberoptic intubation. The patient was then positioned on the operating room table with a towel beneath her shoulders and her head in a sand bag doughnut in a neutral position exactly the way we were going to be performing the operation. Neurologic examination was documented with the patient moving both her arms and legs. After this was done she was put to sleep. I then prepped and draped the left lateral neck, a transverse incision was then made at approximately the level of the cricoid cartilage. This was carried from the midline to the medial border of the sternocleidomastoid muscle. The wound was deepened, the platysma was identified. It was divided in the direction of its fibers in an intra-fascial dissection technique and finally dividing the superficial, middle and deep cervical fascia sequentially. The pre- vertebral space was then visualized, the anterior cervical spine identified. The intraoperative x-ray localization was obtained confirming that we indeed were at the desired level. The overlaying longus colli muscles were then dissected in a subperiosteal plane along the medial border. The tooth blades of the black belt self retaining retractor system were then anchored around the C5, 6 disk space. Casper distractor posts were placed in the middle of the C5 and C6 vertebral body. The C5, 6 disk space was then sharply incised. Anterior diskectomy was carried out removing all disk material laterally to the level of the vertebral joints and posteriorly to the level of the annulus.

Cartilaginous end plates were then taken down to good bleeding sub-condylar bone. I could actually see a hole in the posterior annulus with a significant amount of disk material in the sub-ligamentous compartment. This was gently teased out with the micro- pituitary rongeur. I could actually see the posterior longitudinal ligaments through the hole now. The Collin knife was used to sharply incise both the posterior annulus and the posterior longitudinal ligament. I insured the epidural space, the ventral cord was identified. Additional disk material was removed. All marginal osteophytes were taken down. The foraminotomy was performed as needed. When I was done I did the depth cage, sized the disk space. I then took tri-cortical and iliac crest bone graft which was reconstituted and cut in the appropriate dimensions. The graft was introduced and slightly counter sunk. Posts were removed, placed in the graft in a compressive mode.

Grafts were mainly checked to make sure it was secure. Satisfied, I then moved on to the stabilization portion of the procedure. Unfortunately, this patient's shoulders were in the way and even with retraction I could not get them out of the way, therefore I free handed rather than use an intraoperative x-ray localization to guide pilot hole placement. A Codman anterior cervical plate was selected to expand from C5 to C6. Two pilot holes were drilled at that level using anatomic land marks. The holes were placed in the converging configuration to create a triangulation effect resist pullout. Holes were superficially tapped and because the bone was so hard I used a soft drill to drill in screws. These were 12 mm in length and 4.5 mm in diameter. Two holes were placed at the C5, 6 level. Cams were tightened down completing the construct. It was very clear that we had a rigid construct. The wound was copiously irrigated with Bacitracin containing fluid. Hemostasis was obtained as needed with the bipolar electrocautery and thrombin soaked Gelfoam. The wound was then closed in multiple layers in an anatomic fashion. 3-0 Vicryl was used to approximate the platysma, inverted 3-0 Vicryl for the subcuticular and a running 4-0 subcuticular stitch was used to bring the skin edges together. Benzoin followed by Steri-Strips were applied to the wound edges. Dry sterile compressive dressing followed. The patient was placed in an Aspen hard cervical collar, awakened, extubated and transported to the PACU in stable condition. The Solu-Medrol will be continued postoperatively.

Cc: Jack G. Skellington

OrthoQuest Office Visit

Name: Ima Hurten Birthdate: 07/03/49 SSN: 123-45-6789

Date: 12/02/08

Subjective:

The patient returns today for a six-month re-evaluation and medication refill. She continues to have daily and continuous pain; at worst 8/10 and at best 4/10. The pain is severe several times a week and continues to limit her yard work, exercise, hobbies, and sleep. The pain is sharp, aching, and tingling. She has also recently been hospitalized for a myocardial infarction and is on medication. She has fully recovered from her cerebral aneurysm.

Objective:

On examination she is pleasant and cooperative but is obviously restricted in her cervical range of motion. Sensation is diminished in the left hand at digits four and five. Grip strength and wrist extension are pain limited. Cervical range of motion is guarded with 10° flexion extension and bilateral rotation.

Impression:

C5-6 fusion
Left C7 radiculopathy

Recommendations:

I will recommend continuing with her present medication. She has maintained her functional level with medication which allows her to continue light household chores and social activities. She displays no aberrant behavior. She continues to have significant impairment and disability.

She will follow-up in six months for evaluation.

John Henry "Doc" Holliday M.D.

Board certified PMR

Board certified Pain Medicine

OrthoQuest Office Visit

Name: Ima Hurten Birthdate: 07/03/49 SSN: 123-45-6789

Date: 06/02/08

Subjective:

The patient returns today for re-evaluation after six months. She has left arm pain that is unchanged. She has good and bad days. She is unable to tolerate strenuous activity.

Medications are still effective and are lasting. She denies any adverse side effects. She is still recovering from her brain aneurysm.

Objective:

She still has mild facial droop. The cervical region is extremely guarded. She does have tenderness in the paraspinals. Her left arm strength is 2/5 and guarded secondary to pain.

Impression:

C5-6 fusion
Left C7 radiculitis
Left upper extremity paresis
Right brain aneurysm status post craniotomy

Recommendations:

Her condition remained stable and unchanged. She is managing on medication without adverse side effects or aberrant behavior. She is still totally disabled from her previous occupation. She will follow-up in six months for medications.

John Henry "Doc" Holliday M.D.

Board certified PMR

Board certified Pain Medicine

OrthoQuest Office Visit

Name: Ima Hurten Birthdate: 07/03/49 SSN: 123-45-6789

Date: 12/04/07

HISTORY OF PRESENT ILLNESS:

The patient returns today after her last visit in June with continued left arm pain and weakness. She has been using more Hydrocodone due to more frequent bad days. In the interim, she has had surgery for a ruptured cranial aneurysm on the right. She was in the hospital in October and is still having some arm paresis and facial droop. She is not driving at this time and is still under the surgeon's care. Her weakness in the upper extremity is back to her baseline.

MUSCULOSKELETAL EXAM: She has left facial droop. She has a well healed right craniotomy scar. She is ambulating normally. Cervical flexion is still extremely limited in all directions with marked guarding and tenderness. The cervical area appears unchanged.

SKIN: Skin is without lesions.

NEUROLOGIC EXAM: She still has diminished sensation in digits four and five. Her grip strength is still 5-, but she has more generalized weakness at 4 out of 5 in the more proximal arm and shoulder. Leg strength is 5 out of 5. Spurling Maneuver is still positive on the left.

IMPRESSION:

C5-6 fusion
Left C7 radiculitis, unchanged
New left upper extremity paresis

RECOMMENDATIONS:

At this time, she is somewhat still concerned about an apparent discrepancy on her disability statement, being sedentary versus total disability. I believe she is still totally disabled from her previous occupation.

John Henry "Doc" Holliday M.D.

Board certified PMR

Board certified Pain Medicine

OrthoQuest Office Visit

Name: Ima Hurten Birthdate: 07/03/49 SSN: 123-45-6789

Date: 06/05/07

CHIEF COMPLAINT:

Left arm pain, left neck pain

HISTORY OF PRESENT ILLNESS:

The patient returns today for her six-month follow up evaluation. We increased her medication dosage to the 10-milligram tablet, which has helped. The pain is now at worst an eight on a scale of ten and at best a three. She has good and bad days. She has had flares the last several days, decreased with rest. It is aggravated by over activity. She still gets numbness in the hand. She gets pins and needles and drops things. Her arm feels heavy on the left.

REVIEW OF SYSTEMS: She had a knee arthroscopy of the left knee for a torn cartilage. SOCIAL HISTORY: She has applied for, and received, social security disability insurance.

PHYSICAL EXAM:

Height: 5'5"

Weight: 178 pounds

GENERAL APPEARANCE: Pleasant, cooperative and in no acute distress.

CARDIOVASCULAR: Pulse is two out of four and symmetric in the upper and lower extremities. There is no edema.

LYMPHATIC: There is no adenopathy.

MUSCULOSKELETAL EXAM: Today she is somewhat antalgic on the left with a single-point cane. Cervical flexion is limited, as is extension and rotation bilaterally. She is very guarded. There is diffuse tenderness predominantly at the left paraspinals.

SKIN: Skin is without lesions.

NEUROLOGIC EXAM: There is hypoesthesia at digits four through five on the left. Grip strength is 5- on the left. Spurlings Maneuver is positive on the left.

IMPRESSION:

C5-6 fusion
Left C7 radiculitis with both mild sensory and motor loss

RECOMMENDATIONS:

At this time, she is stable and managed on her medication. I will see her back in six months for re-evaluation and will continue her current prescriptions of Zanaflex 4 milligrams tid, Lortab 10 milligrams tid, Gabatril 4 milligrams at night and Ambien 10 milligrams at night. We will give her five refills.

John Henry "Doc" Holliday M.D.

Board certified PMR

Board certified Pain Medicine

OrthoQuest Office Visit

Name: Ima Hurten Birthdate: 07/03/49 SSN: 123-45-6789

Date: 12/05/06

CHIEF COMPLAINT:

Left arm pain and neck pain

HISTORY OF PRESENT ILLNESS:

The patient returns today after her last visit in June. She did well with the last injection. The pain is still daily. The Lortab is not helping as much and the pain is at best a three or four and frequently a seven on a scale of ten. She gets constant pins and needles into the fingers, weakness in the arm, and spasms occasionally at night or during the day with activity.

SOCIAL HISTORY: She is on disability. She has difficulty with driving, especially because she cannot turn her head. She avoids any lifting. She has a reacher.

PHYSICAL EXAM:

Height: 5'5"

Weight: 178 pounds

GENERAL APPEARANCE: Pleasant, cooperative and in no acute distress.

CARDIOVASCULAR: Pulse is two out of four and symmetric in the upper and lower extremities. There is no edema.

LYMPHATIC: There is no adenopathy.

MUSCULOSKELETAL EXAM: Cervical flexion and extension are very limited at 10° and guarded. Right and left lateral flexion is 10° and guarded. There is tenderness in the paraspinals and particularly in the left C-5 through C-7 region.

SKIN: Skin is without lesions.

NEUROLOGIC EXAM: There is hypoesthesia at digits four through five on the left. Grip strength is 3- and somewhat pain limited. Coordination is normal. Spurlings Maneuver is positive for radicular symptoms in the left.

IMPRESSION:

C5-6 fusion
Left C7 radiculopathy with primarily sensory and some motor loss

RECOMMENDATIONS:

At this time we discusses a spinal cord stimulator as an option for more prolonged pain relief and less dependence on medication. I will, however, give her an opportunity to increase the Lortab 10-milligram strength for now and follow up for prn trigger point injections or epidural steroid injections. We will see her back in six months or sooner if she wants to discuss spinal cord stimulator trial.

John Henry "Doc" Holliday M.D.

Board certified PMR

Board certified Pain Medicine

Name: Ima Hurten Birthdate: 07/03/49 SSN: 123-45-6789

Date: 06/06/06

CHIEF COMPLAINT:

Left arm pain and neck pain

OrthoQuest Office Visit

HISTORY OF PRESENT ILLNESS:

The pain has been worse over the past month, more constant and more severe at an eight out of a scale of ten. She is not getting any relief. It is fairly constant. Her left arm is number. She is getting worsening pins and needles into the upper extremity. She denies any change in strength.

SOCIAL HISTORY: She is avoiding most activities at this time, especially since the pain has been worse this month.

PHYSICAL EXAM:

Height: 5'5"

Weight: 178 pounds

GENERAL APPEARANCE: Pleasant, cooperative and in no acute distress. She displays no abnormal pain behavior. However, she is extremely guarded with any rotation of the neck. She holds her head with a slight list to the left.

CARDIOVASCULAR: Pulse is two out of four and symmetric in the upper and lower extremities. There is no edema.

LYMPHATIC: There is no adenopathy.

MUSCULOSKELETAL EXAM: Gait and station are normal. Cervical flexion is 10° and extension is 15°. Right rotation is 20° and left rotation is zero. Trigger points are noted particularly in the left C-5 though C-7 traps and paraspinals.

SKIN: Skin is without lesions.

NEUROLOGIC EXAM: There is hypoesthesia at digits four and five. Grip strength is 3+ and pain limited. Reflexes are two out of four and symmetric. Spurlings Maneuver is positive.

IMPRESSION:

C5-6 fusion
Left C7 radiculopathy with aggravation

RECOMMENDATIONS:

At this time we discussed an epidural steroid injection or possibly a spinal cord stimulator trial since the epidurals haven't helped that much in the past. She opted for trying trigger point injections since that was more expedient. We will refill Lortab, Zanaflex, Neurontin and Ambien today and see her back in six months for refills and re-evaluation.

Trigger point injections were performed at the left C-6/7 paraspinals, trapezius and levator scapula, after sterile preparation of the skin with Betadine. A solution of 6 cc of 0.25 percent Bupivacaine and 40 milligrams Depo-medrol was divided between three trigger point injections. There were no complications and she had moderate relief.

John Henry "Doc" Holliday M.D.

Board certified PMR

Board certified Pain Medicine

40 - PA Y M E N T IN F O R M A T I O N

Affinity Service Group, Inc.

Claims Payment Request for: Hurten, Ima Claim Number: ABC-987654321

Date Prepared: 1/15/09 Payment Category: All

Check Type	Check Date	Check Payee	Service Date	Check Amount
259781 Exp	01/10/09	Copy Cat, Inc.		$33.60
165487 Exp	01/08/09	C, C & C Law		$893.00
548632 Med	01/06/09	Orthoquest	12/02/08-12/02/08	$72.00
165468 Rx	12/13/08	Prime Rx		$4,500.00
876532 Med	11/24/08	Orthoquest	06/02/08-06/02/08	$80.00
465789 Ind	05/26/08	Hurten, Ima		$445.00
445646 Ind	04/23/08	Hurten, Ima		$445.00
879769 Ind	03/27/08	Hurten, Ima		$445.00
123244 Rx	03/15/08	Prime Rx		$3,750.00
876921 Ind	02/23/08	Hurten, Ima		$445.00
346487 Med	02/18/08	Orthoquest	12/04/07-12/04/07	$72.00
378988 Ind	01/25/08	Hurten, Ima		$445.00
451321 Rx	01/08/08	Prime Rx		$3,750.00
898997 Ind	12/23/07	Hurten, Ima		$445.00
979888 Ind	11/24/07	Hurten, Ima		$445.00
048777 Exp	11/13/07	Magnum P.I.		$278.00
797654 Ind	10/30/07	Hurten, Ima		$445.00
668376 Ind	09/28/07	Hurten, Ima		$445.00
735153 Med	09/20/07	Orthoquest	06/05/07-06/05/07	$80.00
123548 Ind	08/28/07	Hurten, Ima		$445.00
673677 Ind	07/23/07	Hurten, Ima		$445.00
879575 Ind	06/24/07	Hurten, Ima		$445.00
487311 Rx	06/09/07	Prime Rx		$3,750.00
365768 Ind	05/26/07	Hurten, Ima		$445.00
778792 Ind	04/29/07	Hurten, Ima		$445.00
131727 Med	04/18/07	Orthoquest	12/05/06-12/05/06	$72.00
114586 Ind	03/27/07	Hurten, Ima		$445.00
548763 Ind	02/24/07	Hurten, Ima		$445.00
965321 Ind	01/30/07	Hurten, Ima		$445.00
132569 Ind	12/23/06	Hurten, Ima		$445.00
154351 Med	12/11/06	Orthoquest	06/06/06-06/06/06	$150.00
456489 Med	12/08/06	Orthoquest	06/06/06-06/06/06	$135.00
548673 Ind	11/29/06	Hurten, Ima		$445.00
464593 Ind	10/29/06	Hurten, Ima		$445.00
356468 Ind	09/27/06	Hurten, Ima		$445.00
245487 Ind	10/29/06	Hurten, Ima		$445.00

Continued on next page

PRESCRIPTIONS R US PHARMACY SERVICES

Patient: Ima Hurten Date Prepared: 12/31/08
Drug Description	Strength	Qty	DS	Service Date	Amount
Zolpidem	10mg	30	30	12/4/2008	$110.00
Tizanidine	4mg	180	30	12/4/2008	$250.00
Hydrocodone/APAP	10/325mg	120	30	12/4/2008	$50.00
Gabitril	4mg	30	30	12/4/2008	$130.00
Zolpidem	10mg	30	30	11/7/2008	$110.00
Tizanidine	4mg	180	30	11/7/2008	$250.00
Hydrocodone/APAP	10/325mg	120	30	11/7/2008	$50.00
Gabitril	4mg	30	30	11/7/2008	$125.00
Zolpidem	10mg	30	30	10/2/2008	$110.00
Tizanidine	4mg	180	30	10/2/2008	$242.00
Hydrocodone/APAP	10/325mg	120	30	10/2/2008	$50.00
Gabitril	4mg	30	30	10/2/2008	$125.00
Zolpidem	10mg	30	30	09/11/2008	$110.00
Tizanidine	4mg	180	30	09/11/2008	$242.00
Hydrocodone/APAP	10/325mg	120	30	09/11/2008	$50.00
Gabitril	4mg	30	30	09/11/2008	$125.00
Zolpidem	10mg	30	30	08/15/2008	$103.00
Tizanidine	4mg	180	30	08/15/2008	$242.00
Hydrocodone/APAP	10/325mg	120	30	08/15/2008	$50.00
Gabitril	4mg	30	30	08/15/2008	$125.00

(Account transferred from old computer system on 8/13/08)

Endnotes

1 If there are no rated ages, enter "None." The median (not mean) rated age shall be used where more than one rated age is obtained. The median is the value at the center of an ordered range of numbers. (E.g., 67 is the median where the values are 62, 65, 67, 72, and 77.) If there is an even number of values, the median is the average of the two middle values, rounded down (e.g., 61 is the median for rated ages of 61 and 62 because the life expectancy will be computed using the table for someone who is 61 but not yet 62.)

2 The CMS computes the claimant's life expectancy as of the date carrier responsibility is expected to end and claimant responsibility is expected to begin for medical expenses related to the work injury, using CDC Table 1 (see www.cdc.gov/nchs/products/life_tables.htm). There may be a lag time between publication of a life table by CDC and its use by CMS in case processing software.

3 Cases with a YES answer to B.1 should not be submitted for review unless the total settlement amount exceeds $25,000.00. Nevertheless, Medicare's interests must be considered even if a case is not eligible for review.

4 Cases with a YES answer in B.2 should not be submitted for review unless the total settlement amount exceeds $250,000.00. Nevertheless, Medicare's interests must be considered even if a case is not eligible for review.

Includes, but is not limited to, indemnity (lost wages), attorney fees, set-aside amount, non-Medicare medical costs, payout totals for all annuities rather than cost or present values, settlement advances, lien payments (including repayment of Medicare conditional payments), amounts forgiven by the carrier, prior settlements of the same claim, and liability settlement amounts on the same WC injury (unless apportioned by a court on the merits), but excludes prior contested awards by a court on the

The calculation method should be the method the claimant will use to pay for medical items and services after the

The seed money for the WCMSA shall include an amount equal to the cost of the first surgery/procedure, plus the cost of the first durable medical equipment replacement, plus the cost of any extraordinary short-term medications, plus two years of the remainder of the set-aside. In this sample case the seed money is equal to: $1,200 (first surgery/procedure) + 0 (first durable medical equipment replacement) + 0 (extraordinary short-term medications) + [(95,891 - 1,200 - 0 - 0)/17 (life expectancy) x 2 years = 11,140] = $12,340.

Venue is where the workers' compensation hearing will be held. Venue will be used for pricing. Show state, District of Columbia, or U.S. protectorate. If federal or Longshore case, also provide a

ix There is no official consent form; an example of an acceptable form is attached

x If a rated age is submitted, the submitter must also include a statement that all rated ages obtained on the claimant have been included. All rated ages must be by an insurance company, must be independent of the submitter, carrier, and claimant, and must be on insurance company or settlement broker letterhead. Letterhead includes the name and address of the insurance company or settlement broker. Do not include any statements or documents in this section if actual age is being used.

xi Include first report of injury, medical records related to major surgeries, and all treatment records for the last two years of treatment. For example, if the carrier's records indicate that the last treatment was in February 2006, then treatment records for February 2004 - February 2006 should be supplied. A statement indicating that "the claimant has not treated in the last two years" is not a substitute for medical records for the last two years of treatment.

Source: The Centers for Medicare and Medicaid Services