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Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

Primary Disability: Traumatic Brain Injury Date of Injury: X/XX/2006 Date of Birth: X/XX/1974

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Life Care Plan Ms. Client

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Harold Bialsky D.C., M.A., C.R.C., C.L.C.P. Comprehensive Medical Case Management, LLC.

Copyright 2000 - 2005, SaddlePoint Software, All Rights Reserved

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Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

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Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

Mr. John Smith Attorney at Law 123 Main Street Anywhere, USA 12345

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January 20, 2007

RE: Ms. Client D/O/B: XX/XX/74 D/A: XX/XX/06 Dear Mr. Smith:

Ms. Client , a 33yr/2 month old female, was referred for a rehabilitation consultation to develop a Life Care Plan. Ms. Client suffers from a traumatic brain injury and the sequelae thereto. The Life Care Plan, which is a comprehensive organized framework of services, recommendations, and requirements for the current and long term rehabilitation needs of Ms. Client, takes into account her quality of life and familial considerations. It is attached as Section A. The Life Care Plan is designed to meet the needs of Ms. Client through her life expectancy. Ms. Client ’s life expectancy is assumed to be 77 years of age.1 Records Review: Medical History: Current Status:

Social Information:

Conclusion: Careful consideration has been given to the interview information and medical data contained within this file. Ms. Client will be dependent on others for her survival through her life expectancy. This Life Care Plan addresses all of Ms. Client’s needs with the goal being to provide the level of care necessary to maintain Ms. Client’s medical stability, quality of life and prevent future complications.

Source: Appendix 1. Life Expectancy and Present Value Tables, New Jersey Rules of Court, 2006.

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It should be noted that the opinions expressed in this Life Care Plan are based on information available to me at the time this Life Care Plan was developed. If any new information were to become available, I reserve the right to review the new information and consider modifying my opinions in this matter.

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

2

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Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

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Sincerely,

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Please feel free to contact me if there are any further questions.

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Harold Bialsky, D.C., M.A., C.R.C., C.L.C.P.,C.B.I.S. Doctor of Chiropractic Master of Arts - Rehabilitation Counseling Certified Rehabilitation Counselor Certified Life Care Planner Certified Brain Injury Specialist

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

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Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

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Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

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SECTION A

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

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Option 1

Frequency

Cost Per Unit

Cost Per Year

# Total Number of Years 1

Cost Per Year Average $477,700.00

Total Cost

Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

# End Year/Age

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Immediate Housing Needs

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HOUSING NEEDS # Start Year/Age

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Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

2007/33

2007/33

1 Time Only

$477,700.00

$477,700.00

$477,700.00

Purpose: Purchase of a home which can be renovated for wheelchair accessibility, roll-in shower, and consideration for emergency exit. Option 1 HOUSING NEEDS Subtotal $477,700.00 Option 1

ARCHITECTURAL RENOVATIONS

Renovations # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2007/33

1 Time Only

$20,000.00 to $25,000.00

$20,000.00 to $25,000.00

# Total Number of Years 1

Cost Per Year Average $22,500.00

Total Cost

$22,500.00

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Purpose: Renovations for wheelchair accessibility, roll-in shower, and consideration for emergency exit. Option 1 ARCHITECTURAL RENOVATIONS Subtotal $22,500.00

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

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Option 1

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HOME CARE LPN / RN

2007/33

Frequency

Cost Per Unit

Cost Per Year

# Total Number of Years 45

Cost Per Year Average $187,842.86

Total Cost

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# End Year/Age

Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

# Start Year/Age

s.

Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

2051/77

16 Hours/ Day

$40.00 to $50.00

$166,971.43 to $208,714.29

$8,452,928.70

Purpose: Daily assessments, administer medications/feedings, maintain and/or improve medical condition, quality of life, and aid in the prevention of potential complications. Note: 2 shifts, 5 days/week (weekdays). LPN / RN # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

8 Hours/ Day

$42.00 to $52.00

$87,660.00 to $108,531.43

# Total Number of Years 45

Cost Per Year Average $98,095.72

Total Cost

$4,414,307.40

Purpose: Daily assessments, administer medications/feedings, maintain and/or improve medical condition, quality of life, and aid in the prevention of potential complications. Note: 1 Shift, 5 days/week (overnight, weekdays). LPN / RN # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

24 Hours/ Day

$42.00 to $52.00

$105,192.00 to $130,237.72

# Total Number of Years 45

Cost Per Year Average $117,714.86

Total Cost

$5,297,168.70

Purpose: Daily assessments, administer medications/feedings, maintain and/or improve medical condition, quality of life, and aid in the prevention of potential complications. Note: 3 Shifts, 2 days/week (weekends)

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Option 1 HOME CARE Subtotal $18,164,404.80

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

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Option 1

Frequency

Cost Per Unit

Cost Per Year

# Total Number of Years 45

Cost Per Year Average $140.00

Total Cost

Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

# End Year/Age

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Internal Medicine

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FUTURE MEDICAL CARE ROUTINE # Start Year/Age

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Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

2007/33

2051/77

2 - 3 Visits/ Year

$56.00

$112.00 to $168.00

$6,300.00

Purpose: Required to maintain and/or improve medical condition, quality of life, and aid in the prevention of potential complications. Physical Medicine and Rehabilitation # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

2 - 4 Visits/ Year

$50.00 to $60.00

$100.00 to $240.00

# Total Number of Years 45

Cost Per Year Average $170.00

Total Cost $7,650.00

Purpose: Required to maintain and/or improve medical condition, quality of life, and aid in the prevention of potential complications. Neurologist # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 - 2 Visits/ Year

$182.00 to $198.00

$182.00 to $396.00

# Total Number of Years 45

Cost Per Year Average $289.00

Total Cost

$13,005.00

Purpose: Required to maintain and/or improve medical condition, quality of life, and aid in the prevention of potential complications. Neurosurgeon # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 - 2 Visits/ Year

$182.00 to $198.00

$182.00 to $396.00

# Total Number of Years 45

Cost Per Year Average $289.00

Total Cost

$13,005.00

Purpose: Required to maintain and/or improve medical condition, quality of life, and aid in the prevention of potential complications. Pulmonologist # Start Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 - 2 Visits/ Year

$182.00 to $198.00

$182.00 to $396.00

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2007/33

# End Year/Age

# Total Number of Years 45

Cost Per Year Average $289.00

Total Cost

$13,005.00

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Purpose: Required to maintain and/or improve medical condition, quality of life, and aid in the prevention of potential complications.

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

7

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Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

Frequency

Cost Per Unit

Cost Per Year

2007/33

2051/77

1 Time/ 2 Years

$834.00 to $1,028.00

$417.00 to $514.00

# Total Number of Years 45

Cost Per Year Average $465.50

Total Cost

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# End Year/Age

$20,947.50

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# Start Year/Age

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CT Scan, Head

Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

Purpose: Required to maintain and/or improve medical condition, quality of life, and aid in the prevention of potential complications. Comment: CPT code 70460: Computed tomography, head or brain: without contrast material. X-Rays # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2007/33

1 Time/ Year

$122.00 to $146.00

$122.00 to $146.00

# Total Number of Years 1

Cost Per Year Average $134.00

Total Cost $134.00

Purpose: Required to maintain and/or improve medical condition, quality of life, and aid in the prevention of potential complications. Comment: CPT code 72070: Radiologic examination, spine, thoracic, two views. Lab Work # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 - 2 Times/ Year

$68.00 to $78.00

$68.00 to $156.00

# Total Number of Years 45

Cost Per Year Average $112.00

Total Cost $5,040.00

Purpose: Required to maintain and/or improve medical condition, quality of life, and aid in the prevention of potential complications. Comment: CPT code 80053: Comprehensive metabolic panel.

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Option 1 FUTURE MEDICAL CARE ROUTINE Subtotal $79,086.50

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

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Option 1

Frequency

Cost Per Unit

Cost Per Year

# Total Number of Years 45

Cost Per Year Average $576.30

# Total Number of Years 45

Cost Per Year Average $214.00

Total Cost

Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

# End Year/Age

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Neuropsychological Evaluation

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PROJECTED EVALUATIONS # Start Year/Age

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Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

2007/33

2051/77

1 Time/ 5 Years

$2,007.00 to $3,756.00

$401.40 to $751.20

$25,933.50

Purpose: Assess cognitive skills. Occupational Therapy # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 - 2 Time/ Year

$136.00 to $146.00

$136.00 to $292.00

Total Cost $9,630.00

Purpose: Required to maintain current health status, quality of life, and aid in the prevention of potential complications. Comment: CPT code 97003: Occupational therapy evaluation. Physical Therapy # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 - 2 Time/ Year

$144.00 to $166.00

$144.00 to $332.00

# Total Number of Years 45

Cost Per Year Average $238.00

Total Cost

$10,710.00

Purpose: Required to maintain current health status, quality of life, develop/modify treatment plan, and aid in the prevention of potential complications. Comment: CPT code 97001: Physical therapy evaluation. Speech Therapy # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 - 2 Times/ Year

$181.00 to $224.00

$181.00 to $448.00

# Total Number of Years 45

Cost Per Year Average $314.50

Total Cost

$14,152.50

Purpose: Required to maintain current health status, quality of life, develop/modify treatment plan, and aid in the prevention of potential complications.

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Comment: CPT code 92506: Evaluation of speech, language, voice, communication, and/or auditory processing.

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

9

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Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

Frequency

Cost Per Unit

Cost Per Year

2007/33

2051/77

1 - 2 Visits/ Year

$108.00 to $136.00

$108.00 to $272.00

# Total Number of Years 45

Cost Per Year Average $190.00

Total Cost

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# End Year/Age

$8,550.00

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# Start Year/Age

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Nutritional Evaluation

Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

Purpose: Assess nutritional status. Option 1 PROJECTED EVALUATIONS Subtotal $68,976.00 Option 1

PRESCRIPTION MEDICATIONS

Baclofen # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ 2 Months

$34.19

$205.14

# Total Number of Years 45

Cost Per Year Average $205.14

Total Cost

# Total Number of Years 45

Cost Per Year Average $136.68

Total Cost

$9,231.30

Purpose: Manage spasticity. Clonodine # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ Month

$11.39

$136.68

$6,150.60

Purpose: Reduce high blood pressure. Option 1 PRESCRIPTION MEDICATIONS Subtotal $15,381.90 Option 1

TRANSPORTATION

Auto Insurance / Maintenance / Fuel Allowance # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ Year

$3,600.00

$3,600.00

# Total Number of Years 45

Cost Per Year Average $3,600.00

# Total Number of Years 45

Cost Per Year Average $4,650.00

Total Cost

$162,000.00

Purpose: Auto Expense Allowance.

Wheelchair Adapted Van with Wheelchair Restraint # End Year/Age

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# Start Year/Age

2051/77

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2007/33

Frequency

Cost Per Unit

Cost Per Year

1 Time/ 10 Years

$45,000.00 to $48,000.00

$4,500.00 to $4,800.00

Total Cost

$209,250.00

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Purpose: Community Access. Option 1 TRANSPORTATION Subtotal $371,250.00

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

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Option 1 Electric Hospital Bed Cost Per Unit

Cost Per Year

# Total Number of Years 45

Cost Per Year Average $199.50

Total Cost

# Total Number of Years 45

Cost Per Year Average $37.00

Total Cost

# Total Number of Years 45

Cost Per Year Average $518.00

Total Cost

# Total Number of Years 44

Cost Per Year Average $140.00

Total Cost

# Total Number of Years 45

Cost Per Year Average $70.40

Total Cost

# Total Number of Years 45

Cost Per Year Average $175.80

Total Cost

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Frequency

Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

# End Year/Age

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HOME FURNISHINGS/EQUIPMENT # Start Year/Age

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Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

2007/33

2051/77

1 Time/ 10 Years

$1,995.00

$199.50

$8,977.50

Purpose: Client Comfort / Ease of care for caregiver. Over Bed Table # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ 5 Years

$185.00

$37.00

$1,665.00

Purpose: Client Comfort / Ease of care for caregiver. Power Hoyer Lift # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ 5 Years

$2,590.00

$518.00

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ Year

$140.00

$140.00

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ 5 Years

$352.00

$70.40

Frequency

Cost Per Unit

Cost Per Year

1 Time/ 5 Years

$879.00

$175.80

$23,310.00

Purpose: Client transfer. Hoyer Sling # Start Year/Age 2008/34

$6,160.00

Purpose: Client transfer. Suction Machine # Start Year/Age 2007/33

$3,168.00

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Purpose: Maintain Airway. Enteral Feeding Pump

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# End Year/Age

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# Start Year/Age

2051/77

$7,911.00

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2007/33

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Purpose: Administer Nutrition.

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

11

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Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

Frequency

Cost Per Unit

Cost Per Year

2007/33

2051/77

1 Time/ 5 Years

$11,445.00

$2,289.00

# Total Number of Years 45

Cost Per Year Average $2,289.00

Total Cost

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# End Year/Age

$103,005.00

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# Start Year/Age

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Automatic Turning Mattress

Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

Purpose: Prevention of skin breakdown.

Automatic Turning Mattress - Air Filters # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ 2 Years

$97.00

$48.50

# Total Number of Years 45

Cost Per Year Average $48.50

Total Cost

# Total Number of Years 45

Cost Per Year Average $599.00

Total Cost

# Total Number of Years 1

Cost Per Year Average $995.00

Total Cost

# Total Number of Years 45

Cost Per Year Average $245.00

Total Cost

# Total Number of Years 45

Cost Per Year Average $495.00

$2,182.50

Purpose: Automatic turning mattress maintenance. Automatic Home Standby Generator # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ 5 Years

$2,995.00

$599.00

$26,955.00

Purpose: Backup power supply.

Automatic Home Standby Generator Installation # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2007/33

1 Time Only

$995.00

$995.00

$995.00

Purpose: Backup power supply - Installation Wall Mounted Mat Platform # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ 5 Years

$1,225.00

$245.00

$11,025.00

Purpose: Physical assessment & therapy. Adult Shower Chair # Start Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ 5 Years

$2,475.00

$495.00

Pl

2007/33

# End Year/Age

Total Cost

$22,275.00

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Purpose: Bathing / Hygiene. Option 1 HOME FURNISHINGS/EQUIPMENT Subtotal $217,629.00

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

12

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Option 1 Manual Wheelchair (Adult Tilt in Space) Cost Per Unit

Cost Per Year

# Total Number of Years 45

Cost Per Year Average $550.00

Total Cost

# Total Number of Years 45

Cost Per Year Average $7.40

Total Cost

# Total Number of Years 45

Cost Per Year Average $12.00

Total Cost

# Total Number of Years 45

Cost Per Year Average $7.60

Total Cost

# Total Number of Years 45

Cost Per Year Average $23.00

Total Cost

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Frequency

Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

# End Year/Age

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WHEELCHAIR # Start Year/Age

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Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

2007/33

2051/77

1 Time/ 5 Years

$2,750.00

$550.00

$24,750.00

Purpose: Mobility.

Wheelchair Carrying Bag # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ 5 Years

$37.00

$7.40

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ 5 Years

$60.00

$12.00

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Time/ 5 Years

$38.00

$7.60

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1 Times/ 5 Years

$115.00

$23.00

$333.00

Purpose: Mobility.

Wheelchair Tires # Start Year/Age 2007/33

$540.00

Purpose: Mobility.

Wheelchair Casters # Start Year/Age 2007/33

$342.00

Purpose: Mobility.

Wheelchair Lap Tray # Start Year/Age 2007/33

$1,035.00

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Purpose: Mobility.

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

13

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Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

Frequency

Cost Per Unit

Cost Per Year

2007/33

2051/77

4 - 6 Hours/ Year

$65.00

$208.00 to $312.00

# Total Number of Years 45

Cost Per Year Average $260.00

Total Cost

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# End Year/Age

$11,700.00

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# Start Year/Age

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Maintenance

Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

Purpose: Maintain wheelchair.

Option 1 WHEELCHAIR Subtotal $38,700.00 Option 1

SUPPLIES

Gastrostomy Tube Kit # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

3 - 4 Per/ Year

$158.00

$474.00 to $632.00

# Total Number of Years 45

Cost Per Year Average $553.00

# Total Number of Years 45

Cost Per Year Average $749.84

# Total Number of Years 45

Cost Per Year Average $1,204.50

# Total Number of Years 45

Cost Per Year Average $876.60

# Total Number of Years 45

Cost Per Year Average $1,461.00

Total Cost

$24,885.00

Purpose: Administer nutrition.

Feeding Tube Extension Set # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

52 Per/ Year

$14.42

$749.84

Total Cost

$33,742.80

Purpose: Administer nutrition. Feeding Bags # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

365 Per/ Year

$3.30

$1,204.50

Total Cost

$54,202.50

Purpose: Administer nutrition. Suction Catheter # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

4 Per/ Day

$0.60

$876.60

Frequency

Cost Per Unit

Cost Per Year

1 Per/ Day

$4.00

$1,461.00

Total Cost

$39,447.00

Purpose: Maintain patent airway.

re

# End Year/Age

Ca

# Start Year/Age

Pl

Tracheostomy Care Kit

2007/33

2051/77

Total Cost $65,745.00

Al lL

ife

Purpose: Maintain patent airway. Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

14

s.

Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

Frequency

Cost Per Unit

Cost Per Year

2007/33

2051/77

52 Per/ Year

$1.29

$67.08

# Total Number of Years 45

Cost Per Year Average $67.08

Total Cost

ne

# End Year/Age

$3,018.60

ts’

# Start Year/Age

ed

Connecting Tube

Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

Purpose: Maintain patent airway. Suction Collection Jar # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

24 Per/ Year

$9.50

$228.00

# Total Number of Years 45

Cost Per Year Average $228.00

# Total Number of Years 45

Cost Per Year Average $1,459.82

# Total Number of Years 45

Cost Per Year Average $481.76

# Total Number of Years 45

Cost Per Year Average $347.97

# Total Number of Years 45

Cost Per Year Average $525.06

Total Cost

$10,260.00

Purpose: Maintain patent airway. Diapers, Adult # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

18.25 cases/ Year

$79.99

$1,459.82

Total Cost

$65,691.90

Purpose: Personal hygiene. Latex Gloves # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

4.38 cases/ Year

$109.99

$481.76

Total Cost

$21,679.20

Purpose: Personal hygiene. Oral Swabs # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

1.37 cases/ Year

$253.99

$347.97

Total Cost

$15,658.65

Purpose: Oral hygiene. # Start Year/Age

Frequency

Cost Per Unit

Cost Per Year

5.21 cases/ Year

$100.78

$525.06

2051/77

Total Cost

$23,627.70

re

2007/33

# End Year/Age

Pl

Pre-Moistened Wash Cloths

Al lL

ife

Ca

Purpose: Personal hygiene.

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

15

s.

Prepared by: Harold, Bialsky D.C., M.A., C.R.C., C.L.C.P.

Frequency

Cost Per Unit

Cost Per Year

2007/33

2051/77

29.2 cases/ Year

$49.99

$1,459.71

# Total Number of Years 45

Cost Per Year Average $1,459.71

Total Cost

ne

# End Year/Age

$65,686.95

ts’

# Start Year/Age

ed

Underpads, Disposable

Th an is s s a am re ple de is ve in lop ten ed de sp d to ec ific rep all res y t en o ea t for ch ma ind t o ivi nly du . al cli en

Purpose: Environmental hygiene. Peri-Care Ointment # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

0.72 cases/ Month

$29.25

$252.72

# Total Number of Years 45

Cost Per Year Average $252.72

Total Cost

$11,372.40

Purpose: Personal hygiene.

Option 1 SUPPLIES Subtotal $435,017.70 Option 1

MISCELLANEOUS

Case Management # Start Year/Age 2007/33

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2007/33

50 Hours/ Year

$85.00

$4,250.00

# Total Number of Years 1

Cost Per Year Average $4,250.00

Total Cost $4,250.00

Purpose: Assist with implementation of the Life Care Plan, coordination of care, and ongoing resources. Case Management # Start Year/Age 2008/34

# End Year/Age

Frequency

Cost Per Unit

Cost Per Year

2051/77

12 - 18 Hours/ Year

$85.00

$1,020.00 to $1,530.00

# Total Number of Years 44

Cost Per Year Average $1,275.00

Total Cost

$56,100.00

Purpose: Assist with implementation of the Life Care Plan, coordination of care, and ongoing resources. Option 1 MISCELLANEOUS Subtotal $60,350.00

Al lL

ife

Ca

re

Pl

Lifetime Grand Total ....................................................................$19,950,996.00

Life Care Plan for – Ms. Client *LE = Life Expectancy, **U = Unknown, # = All Ages and Dates are Inclusive, e.g. 2000-2006 = 7 Years Copyright 2000 - 2005, SaddlePoint Software, LLC - All Rights Reserved

16