 

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.

RESPONSE:

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.

RESPONSE:

REQUEST NO.5: Please admit that from November 16, 2015 to December 3, 2015, Mr.
Foutch was off work.

RESPONSE:

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.

RESPONSE:

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.

RESPONSE:

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.

RESPONSE:

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.

RESPONSE:

REQUEST NO. 11: Please admit that Burkeen Trucking fired Mr. Foutch due to his
workers’ compensation claim.

RESPONSE:

REQUEST NO. 12: Please admit that at the time of this injury Mr. Foutch was over 40
years of age.

RESPONSE:

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.

RESPONSE:

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.

RESPONSE:

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.

RESPONSE:

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.

RESPONSE:

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.

RESPONSE:

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.

RESPONSE:

REQUEST NO. 21: Please admit that the uninsured employer’s fund, T.C.A. §§ 50-6-801
et. seq. is applicable to this case.

RESPONSE:

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.

RESPONSE:

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.

RESPONSE:

REQUEST NO. 19: Please admit that Mr. Foutch was a Tennessee resident on the date of
injury of September 24, 2015.

RESPONSE:

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.

RESPONSE:

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,

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 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

oro 10824b 5392
STMT DATE: 11/04/15

JAMES FOUTCH
79 GRIERS CHAPEL RD
TRENTON, TN 38382-9444

CHARGES APPEARING ON THIS STATEMENT ARE NOT INCLUDED ON ANY HOSPITAL BILL OR STATEMENT

EXHIBIT so

 

 

 

 

 

 

 

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A $5.00 SERVICE CHARGE WILL BE ADDED TO ALL CREDIT CARD PMTS

RADIOLOGY AND IMAGING ASSOC
P O BOX 1178
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1 ALL “Vid 1112284629-P; TO72-2-16 71581-1 7

DUE DATE OFFICE PHONE NUMBER ACCOUNT # AMOUNT DUE
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DATE PROVIDER EXPLANATION OF ACTIVITY CHARGES & =| PAYMENTS & | “BALANCE
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09/24/15 CT LOWER EXT WiO $242.00 $284.0(
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09/24/t§ CT 30 RECONSTRUCTION $75.00 $403.0(
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PATIENT BALANCE
CURRENT | 30-60DAYS | 60-90 DAYS | >90DAYS TOTAL PATIENT BALANCE
$445.00 $445.00 $445.00
MESSAGE: SEND INQUIRIES TO:
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PLAINTIFF'S
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PHYSICIAN SERVICES RENDERED AT: HENRY COUNTY MEDICAL CENTER DO NOT STAPLE OR TAPE YOUR CHECK
OR MONEY ORDER TO THIS COUPON
Oo CHECK HERE FOR CHANGE OF ADDRESS MAKE CHECKS PAYABLE TO:
401
eESGAT EMERGENCY COVERAGE CORP
79 Griers Chapel Rd PO BOX 740023
Trenton TN 38382-9444 CINCINNATI OH 45274-0023

0160002745424§90344015156207948b390015000083
L9ts0d

NorthStar Anesthesia Of Tennessee PLLC
Po Box 610251
Dallas TX 75261-0251

For more information about your statement, contact
Patient Accounts at 1.888-872.5500, or visit our website
at www. patientaccounts.net

lle UU eroded tlysttop tte pty
JAMES FOUTCH
79 GRIERS CHAPEL RD
TRENTON TN 383829444

O7708.13

~ Please check if address or insurance information

 

(MOST MAJOR CREDIT CARDS ACCEPTED
To poy via credit card please call | 3848 872-5500 or

Pay online at www patentaccounts net and use

Access Code: FP918

 

 

 

 

 

Statement Date | Pay This Amount Account #
10/07/2015 $1,192.00 HC1417199
Payment Due Date | SHOW AMOUNT $

\_ 11/4/2015 | PAID HERE

 

NorthStar Anesthesia Of Tennessee PLLC

Po Box 61025]

Dallas TX 75261-0251
WosubelabassElaDD sural MM fecscololsDalsocaltelatecostlelelel

Pay online al www pctienticccunts net and use Access Code: FP918

 

PLEASE DETACH ANR.RETURN.TOP PORTION WITH YOUR PAYMEN]

 

 

 

 

 

 

 

 

 

 

PS a Paitent®

11/4/201

    
 

 

 

 

 

09/29/2015] CPT Cade: 27814 21326438
Billed To Patient bbode? or
3
% If you have insurance, please let us know immediately so that we can
< file o claim with your carrier. You may notify us by logging on to
www. patientaccounts.net or by contacting our billing office at 1-800-
693-3271.
account | CURRENT | 30DAYS | 60DAYS | 90DAYS | 120 DAYS
CONDMONS| $1,192.00 | $0.00 $0.00 $0.00 $0,00
IMPORTANT MESSAGE ABOUT YOUR ACCOUNT Total Balance $1,192.00
YOUR INSURANCE INFORMATION, PLEASE CALL OUR BILLING OFFICE AT 1-888-872-5500 op] Insurance Pending $0.00
LOGIN TO OUR WEBSITE WWW.PATIENTACCOUNTS.NET. IF PAYMENT HAS BEEN MADE " Amount You Owe $1,192 00
\ PLEASE DISREGARD THIS BILL, THA ‘ /

 

Make Checks Payable To: NorthStar Anesthesia Of Tennessee PLLC

loft

yey
=

Call 1-888-872-5500

97708+13

For Billing Questions Call
1-888-872-5500 (En Espaiol 1-888-850-1446)
Mon - Fri 8:00AM to 7:00PM
Billing Summary: FOUTCH, JAMES, SR. R #56269

WEST TENNESSEE
BONE & JOINT CLINIC,
P.C,

WEST TN BONE & JOINT CLINIC, P.C.
P.O. BOX 5483

BELFAST, ME 04915-5400
billing phone: (731) 410-2265

GUARANTOR NAME AND ADORESS

JAMES, SR. R FOUTCH
79 GREERS CHAPEL
TRENTON, TN 38382

Billing Summary

peuntert 0$/03/2016 11:14 AM

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
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; 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
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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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: QUTSTANUING COLIECTIONS | | P3147 Ai
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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

PO BOX 1030
PARIS, TN 38242

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
