MedResources, LLC, PO Box 54520, Cincinnati, OH 45254

03/03/2014
12: 01 Robert K I i ckov i ch PLLC
(FAX)859 282 6208
P,001/001
Future Medical Care Form
Supplemental Questionnaire
MedResources, LLC, PO Box 54520, Cincinnati, OH 45254
Tele 513.233.9300 Fax. 888.380.3434
Re: Herschel T. Moore
DOB: 6/13/1972
February 18, 2.014
FROM: ROBERT KLICKOVICH, M.D., Paradigm Pain & Spine Consultants
Please provide supplemental answers regarding this patient's future medical and rehabilitation care
related to the injulY sustained on 9/1112008. Your original responses were provided on Februal)' 6, 2013.
In your original response, you indicated that Mr. Moore would need "Complex Long Term Care". Do
you anticip e that Mr. Moore will require follow-up pain management appointments for the remainder of
his lifetim as a part of his complex long term care?
Yes--",--
No _ __
Comment:
In your original response, when asked if you supported the need for home assistance for activities of daily
living that Mr. Moore has difficulty performing due to his injUl)'," you indicated that Mr, Moore would
need "ongoing assistance", Would you agree that it is reasonable to expect Mr. Moore will need a home
health aide for at,least two hours per day, five days a week from the present day to age 60, and then need
a home health de for at least two hours per day, seven days a week from age 60 through the remainder
of his lifeti ?
No _ __
Comment:
Signature:
Printed Name:
~1.W<:!..!iL.J._~!.-:..-L.ll.u.;;.t..;I..5!:..';!.!.
27E
MOORE 002169
Future Medical Care Form
Supplemental Questionnaire
MedResources, LLC, PO Box 54520, Cincinnati, OH 45254
Tele 513 .233 .9300 Fax 888.380.3434
February 18, 2014
Re: Herschel T. Moore
DOB: 6/13/1972
FROM: JOSEPH HARTIG, M.D., PRlMARY CARE
Please provide supplemental answers regarding this patient's future medical and rehabilitation care
related to the injury sustained on 9/ 1112008. Your original responses were provided on March 12, 2013 .
In your original response, you agreed that Mr. Moore would need future physical therapy, but indicated
that you were unsure of the frequency of future visits . Would you agree that it is reasonable to expect that
Mr. Moore will need a minimum of one course of physical therapy every five years (with six visits per
course) for the remainder of his lifetime?
Yes
/
No _ _ _
Comment:
Would you agree that it is reasonable to expect that Mr. Moore will need a borne bealth aide for at least
two bours per day, five days a week from the present day to age 60, and then need a home bealth aide for
at least two bours per day, seven days a week from age 60 througb the remainder ofbis lifetime?
Yes
/
No _ __
Comment:
Signature:
Printed Name:
Date: _
..::...
) .1.1 ,17....:../',1-,'1
' --_ _ __
Joseph Hartig. M.D.
S!. Elizabeth Physicians
520 Violet Rd.
Crittenden. KY 41030
(859) 428-1 610
MOORE 002170