1. CONFIDENTIALITY NOTICE: This letter is intended only for the use of the individual or entity to which it

2. is addressed and may contain information that is privileged, confidential and exempt from disclosure

3. under applicable law. If you have received this letter in error, please do not distribute. Please notify the

4. sender by e-mail at gstezzi@aol.com. Thank you for your compliance.

 

 

5. DUE DILIGENCE: Gloria Stezzi calls to the attention of Kenneth Fody, Esquire, Keystone Legal

6. Department manager, Independence Blue Cross,  the fact that the documents contained in this

7. presentation provide evidence of negligence and wrongdoing by the University of Pennsylvania Medical

8. Center and its Penn Health system, which includes its in-house Department of Orthopaedic Surgery,

9. which must be prosecuted.  Otherwise, Keystone would be guilty of  "willful blindness".

 

 

10. Gloria Stezzi

11. 2442 South Mildred XXXXXXXXXXXXXX Street

12. Philadelphia, PA 19148

 

13. September 3, 2002

 

 

14. Keystone Health Plan East

15. Patient Care Management Department

16. Post Office Box 7890

17. Philadelphia, PA  19101

 

 

18. Attention: Internal First Level Grievance

 

 

19. SUBJECT: Patient, Gloria Stezzi, grieves the Keystone Health Plan East's Explanation of Benefits' denial

20. of payment to Dr.Salvo of Philadelphia Orthopedic Associates.

 

 

21. RE: Explanation of Benefits

 

22. Date    06/27/02

23. Claim Number   21752770500

24. Patient Name   Stezzi, Gloria, J.

25. Provider Name    Philadelphia Orthopedic Associates

 

26. Member ID Number XXXXXXXXXX

27. Group Number 600180

 

28. NOTE: All documents referenced are attached.

 

29. Dear Keystone Health Plan East:

 

30. Gloria Stezzi, under the direction of Rocco Stezzi, submits the following grievance necessitated by the

31. receipt of the above referenced Explanation of Benefits statement metered on July 8, 2002 in Harrisburg.

 

32. GLORIA STEZZI contests the Keystone Health Plan East denial of payment for services by

33. Philadelphia Orthopedic Associates, hereinafter referred to as DR.SALVO, with the Reason Code

34. A003 "SERVICE NOT AUTHORIZED BY PCP: MEMBER NOT BILLABLE"

 

35. DR.SALVO is entitled to payment for services.

 

 

36. Both GLORIA STEZZI and DR.SALVO on 5 December 2001diligently requested a written referral from

37. GLORIA STEZZI's Primary Care Physician, Dr. Mignott, hereinafter referred to as PCP, of the Penn

38. Health system, after the in-house Department of Orthopaedic Surgery, of the same Penn Health system,

39. unilaterally terminated the treatment of GLORIA STEZZI on 4 December 2001.

 

40. The Penn Health Care system PCP on 5 December 2001, after the in-house Department of Orthopaedic

41. Surgery of the same Penn Health system unilaterally terminated the treatment of GLORIA STEZZI on 4

42. December 2001, refused requests from both GLORIA STEZZI and DR.SALVO to write a referral until

43. after the Nationwide medical benefits were exhausted.

 

44. At the time Keystone Health Plan East, hereinafter referred to as Keystone, was not the primary insurer.

45. GLORIA STEZZI under the Pennsylvania Auto Insurance Law, Act 6 had to use Nationwide Mutual

46. Insurance Company as the primary insurer not Keystone up to the medical liability limit of the policy.

 

47. The Penn Health system PCP on 5 December 2001 attempted to evade the referral rules of Keystone

48. Health Plan East with a sham promise to write a referral when Keystone became the primary insurer.

49. GLORIA STEZZI and DR.SALVO had no way of knowing when that time had arrived.  Keystone's benefits

50. processing department rules apparently required the PCP to write a referral dated 4 December 2001, the

51. time that the in-house Department of Orthopaedic Surgery of the same Penn Health Care system

52. unilaterally terminated the treatment of GLORIA STEZZI.

 

53. But when GLORIA STEZZI started treatment with DR.SALVO Keystone under Pennsylvania law was not

54. the primary insurer.

 

55. The Penn Health system, which includes the University of Pennsylvania Medical Center's in-house

56. Department of Orthopaedic Surgery, scammed both GLORIA STEZZI and DR.SALVO.

 

57. It deliberately created an impossible "catch 22" situation for both GLORIA STEZZI and DR.SALVO.

 

58. The PCP on 5 December 2001 refused to issue a referral because Keystone was not the primary insurer,

59. Keystone requires a referral from the PCP written on 4 December 2001 when Keystone was not the

60. primary insurer.

 

61. Furthermore, the University of Pennsylvania Medical Center's in-house Department of Orthopaedic

62. Surgery unilaterally terminated the treatment of GLORIA STEZZI on 4 December 2001with written

63. notification that GLORIA STEZZI was to seek treatment immediately.

 

64. Gloria Stezzi will prove with well-documented facts that the PCP, under instruction from Penn Health

65. system in-house Department of Orthopaedic Surgery, on 5 December 2001, refused to write a referral to

66. evade accountability for the Department of Orthopaedic Surgery's missed diagnosis and inappropriate

67. treatment and for the Department of Orthopaedic Surgery's  unprofessional and unlawful conduct.

 

68. Thus the Department of Orthopaedic Surgery on 4 December 2001 avoided a certain complaint to

69. Keystone from GLORIA STEZZI.

 

70. Nationwide Mutual Insurance Company, of course, can only pay the valid bills submitted up to the

71. medical liability limit of the policy. There is no provision for reporting bad medical service.

 

72. WHEREFORE, GLORIA STEZZI requests that DR.SALVO be paid for services grieved. 

 

 

 

 

 

73. DISCUSSION OF THE CASE

74. The Auto Accident and Insurance

 

75. GLORIA STEZZI suffered injuries to the right foot and ankle on 24 October 2001 when struck by a motor

76. vehicle insured by Nationwide Mutual Insurance Company.

 

77. At the time GLORIA STEZZI  was employed by Mellon Bank, but its retail banking business had been

78. sold to Citizens Bank.  GLORIA STEZZI was covered by Keystone Health Plan East group health

79. insurance through December 31st 2001.  GLORIA STEZZI  had been scheduled to be covered by

80. Highmark group medical health insurance from the new employer Citizens Bank on 1 January 2002. 

81. Keystone Health Plan East is an HMO which uses a primary care physician referral system. Highmark is

82. not an HMO and does not use a primary care physician referral system. 

 

83. As a result of the accident GLORIA STEZZI immediately went on short-term disability.  The Pennsylvania

84. Auto Insurance Law, Act 6 dictates that the auto accident medical bills of GLORIA STEZZI first be paid by

85. the auto insurance company until the limits of the medical liability coverage is reached.  When the auto

86. accident medical liability coverage is exhausted, under the law, GLORIA STEZZI's health care insurer,

87. Keystone must then take over payment of the medical bills.

 

 

88. DETAILED SUMMARY OF MEDICAL EVENTS THROUGH 9 NOVEMBER 2001

 

89. Gloria Stezzi was struck on the left side, turned around, and landed on her back in the street crosswalk.

90. Her right lower leg was struck.  Her foot was hyper-extended and crushed as the pickup truck wheel ran

91. over it. Within the hour she received an emergency diagnosis and stablization of the injury at Methodist

92. Hospital on 24 October 2001.

 

93. The treatment consisted of an uncertified x-ray, a posterior splint, crutches for non-weight bearing and

94. instructions to consult with an orthopedic surgeon. 

 

95. There was no licensed radiologist available to read the x-ray.

 

96. The cost-cutting hospital policy was not to have an orthopedic surgeon involved unless the injury was life

97. threatening.

 

98. On 25 October 2001 at the University of Pennsylvania School of Medicine, Hospital of the University of

99. Pennsylvania, Department of Orthopedic Surgery Ernest J. Gentchos, MD prescribed a cast. No x-rays

100. were taken that day. Dr. Gentchos used only the crude Methodist Hospital x-ray.

 

101. On the follow-up visit on 1 November 2001 Dr. Gentchos ignored the foot pain complaints of Gloria Stezzi

102. and did nothing with the cast.

 

103. On Friday, 9 November 2001 Gloria Stezzi scheduled an emergency visit with Dr. Gentchos to investigate

104. the pains that she was experiencing in the now very loose cast.

105. An x-ray was taken through the original fiberglass cast on the foot. Nothing else was done. 

 

106. Gloria Stezzi called Rocco Stezzi from the telephone in the lobby of the Hospital of the University of

107. Pennsylvania at 12:30p.m.  Gloria told Rocco over the telephone that Dr. Gentchos had given her a letter

108. for her employer dated 25 October 2001 that gave a diagnosis of displaced fracture of the distal right fifth

109. metatarsal. Rocco immediately called Dr. Gentchos and left a message for him.  At exactly 5:12 p.m. on 9

110. November 2001, Dr. Gentchos returned Rocco's call. The telephone number 215 349 8683 was recorded

111. on the caller ID.  Dr. Gentchos set up an informal meeting with Rocco at 1:00 p.m. on 12 November 2001

112. to explain the x-rays and diagnosis. Dr. Gentchos also said that he was scheduled at that time to be at

113. the Penn Towers student clinic.

 

114. Rocco and Dr. Gentchos did meet at 1:00 p.m. on 12 November 2001 but Dr. Gentchos chose not to

115. explain the x-rays and diagnosis.

 

116. At that point, given the seriousness of the previously undisclosed diagnosis sent to her employer and the

117. refusal of Dr. Gentchos to discuss the matter, Rocco and Gloria requested X-Ray proof of the

118. unsubstantiated diagnosis. What occurred next were blatant and outrageous violations of Keystone's

119. Contractually guaranteed Member's rights of Gloria Stezzi and the Pennsylvania Patient Bill of Rights

120. posted in every Hospital for at least the last five years.

 

121. The following are key quotes and basic analysis of the documents generated through November 9th by

122. the University of Pennsylvania School of Medicine, Hospital of the University of Pennsylvania,

123. Department of Orthopedic Surgery, Penn Health System.

 

 

124. Medical Report Documentation

 

125. Report Submitted To Employer For Disability

 

126. The letter dated 25 October 2001, with the signature of Ernest J. Gentchos, M.D., is needed by the

127. employer of Gloria in order for her to receive disability pay.

1. "there is swelling at the dorsal aspect of her right distal foot as well as ecchymosis on the dorsal

128. lateral aspect of her foot as well as her fifth toe and somewhat on the fourth toe as well."

2. -"The x-ray examination demonstrates a displaced fracture of the distal right fifth metatarsal."

3. -"The patient was casted in a short-leg walking fiberglass cast and she will partially bear weight with

129. crutches"

4. -"Six weeks immobilization is planned."

 

130. One Week Re-Evaluation

 

131. The 11/01/01 medical notes, with the signature of Ernest J. Gentchos, M.D., contain a correction. The

132. word  "interspace" was crossed out and corrected with the word  "avulsion" over the top of it. There were

133. no initials and no signature. -"The patient comes in for follow-up evaluation with regard to avulsion

134. fracture of the fifth metatarsal for her right foot"

5. -"She will return in six weeks for cast removal and follow-up x-ray."

 

135. Emergency Appointment For Pain Investigation

 

136. The 11/09/01 medical notes, with the signature of Ernest J. Gentchos, M.D. were written after an x-ray

137. was performed through a cast. -"Ms. Stezzi comes in because she has some pain over the fracture site."

6. -"The patient has a fracture of the fifth metatarsal distal third.

7. -"A follow-up x-ray was performed and the fracture remains well aligned."

 

138. X-Ray Report On 11/09/01

 

139. The 9 November 2001 "film" report, apparently read by Ernest J. Gentchos, M.D. and then approved by J

140. Bruce Kneeland, MD was without signatures. -"The study is performed through a cast which obscures fine

141. osseous and soft tissue detail."

10. -"There is a poorly visualized, nondisplaced traverse fracture through the distal fifth metatarsal shaft."

11. -"I [J. Bruce Kneeland, MD] certify that I have personally reviewed this examination, and agree with

142. this report."

 

 

 

 

143. Comment On Medical Notes Of The Three  Visits

 

144. From an orthopedic surgeon's perspective the medical notes on each of the three days describe three

145. distinctly different injuries. 

 

146. On October 25th the diagnosis of a displaced fracture of the distal right fifth metatarsal is made.

 

147. On November 1st an avulsion fracture of the fifth metatarsal for her right foot is diagnosed. 

 

148. On November 9th a nondisplaced traverse fracture through the distal fifth metatarsal shaft is diagnosed. 

 

149. The physiology of the fifth metatarsal is such that a simple fracture at its base heals faster than at its

150. neck.  The blood supply to the neck is poor when compared to the blood supply at the base of the fifth

151. metatarsal in a healthy foot.

 

152. Normal foot injuries are the result of applying too much stress to the foot. The bone breaks and heals.

 

153. In the instant case the foot was crushed under the wheel of a pickup truck. The foot had bone fracture

154. injuries and extensive soft tissue damage.

 

155. Even a person with no knowledge of medicine knows that a displaced fracture is the opposite of a

156. nondisplaced fracture.  The displaced fracture usually requires an operation.  Further, the avulsion

157. fracture occurs at the proximal fifth metatarsal and not the distal fifth metatarsal.  The distal portion of the

158. metatarsal includes the head, neck, and connecting shaft.  The proximal portion of the metatarsal, which

159. may be four to five inches away from the head of the metatarsal, includes the base and two incredibly

160. strong tendons. 

 

161. In certain types of injuries the tendons can actually pull the bone at the base of the metatarsal apart

162. causing a "tuberosity 'avulsion' fracture".

 

163. When the x-rays were taken on 9 November 2001 the cast effectively filtered out all the detailed

164. information about the injury except gross alignment of dense bone structure.  The detailed information on

165. the actual fracture and the extent of the healing progress could not be determined from the x-rays taken

166. through a cast.  In the "clean up state" of the normal bone fracture healing the ends of the injured bone

167. are removed by the body and new bone will grow to bridge the gaps. An x-ray taken at the termination of

168. the cleanup stage will capture the full extent of the fracture.  The analogy to a picture of railroad tracks

169. after the damaged section is removed is applicable.  The doctor only wanted to show that the railroad

170. track bed had not shifted any more. The doctor did not want to document how many miles of rails were

171. missing and had to be rebuilt.

 

172. The patient is not shown the X-ray. The X-ray of Gloria Stezzi at six weeks taken by Dr. Salvo when he

173. removed the cast showed a big empty space where the body had removed all the crushed bone

174. fragments.

 

175. A Cultural of Corruption: The Penn Health System Enronitis.

 

176. A simple internet search of recent newspaper articles reporting on Penn Health Systems turned up many

177. cases of civil and criminal prosecution. These included the Department of Orthopedic Surgery and its

178. administration where surgeons bill for operations they did not perform and managers steal money. In

179. 1995 the figure was a $30 million dollar fine for false billing.  In 2000 it was $12 million. In 2001 it was

180. $1.89 million. The Penn Health Systems lost $198 million dollars in 1999 and $168 million in 2000. In

181. 2001, when Gloria Stezzi was treated, after severe cost cutting, it turned a small profit.

 

 

 

182. The documents generated after 9 November 2001 expose a systemic pattern of corruption at Penn

183. Health system. The writers of the letters deliberately do not conduct due diligence in the accuracy of the

184. statements contained in the letters.  The writers of the letters have no first-hand information of the events

185. contained in a letter. Authentication of the facts is nonexistent.

186. The writers were chosen for their apparent lack of knowledge.  This minimizes the legal liability. The

187. purpose of the letters seems to document unsubstantiated hearsay.  This action is the tactic of an

188. unethical lawyer.  In court the letter writer usually claims that he was misinformed or misunderstood or

189. misled. The letter writer will swear that to the best of his knowledge no report contained a material untrue

190. statement or omitted a material fact necessary to make the report not misleading. 

 

191. A material fact is generally viewed as one that a reasonable juror would want to know.

 

192. In fact the authors of the letters, notes, and reports not only wrote numerous untrue statements of

193. material fact but also omitted to state the material facts necessary to make the statements in the covered

194. documents, in light of the circumstances under which they were made, not misleading.

 

195. A distinction is made between author and writer.  The writer is the person who signs his name.  The

196. author is invariably a lawyer from the legal department.  The writer is little more than a legal department

197. prostitute.

 

198. The Penn Health system employs a literal army of security guards for the buildings and a university police

199. force for the grounds. The university police misrepresent themselves as Philadelphia City police officers. 

200. There is also a special unit of little more than common thugs used to assault and verbally abuse patients

201. who dare to assert their Keystone Member Rights or Patient Rights under Pennsylvania law.

 

202. When you are dealing with unscrupulous people who manipulate everything to get there own way nothing

203. you say or do will enable you to receive fully that to which you are entitled.  You cannot deal with a

204. person lacking in honesty and integrity.  Such a person cannot be trusted.  Your rights and your personal

205. dignity should be respected but instead you are subjected to public humiliation.

 

206. Undiagnosed Injury

 

207. Gloria Stezzi documents for the record that ten months after she was treated at Penn Health system she

208. is attempting to avoid surgery by wearing a "premium Walker" shoe boot to hopefully coax the

209. undiagnosed automobile accident injury to heal on its own. 

 

210. The Penn Health System Cover-up from 12 November 2001 to 5 December 2001

 

211. What you are about to ingest is only a taste of the Penn Health system cover-up sufficient to prove the

212. willful denial of a referral for this grievance.  The main dish is in the oven.

 

213. Legal or the lawyers of the Penn Health system risk management department digesting the above

214. medical records surely experienced an acute heartburn attack.The in-house Department of Orthopedic

215. Surgery has failed to make even a definite diagnosis of the injury to Gloria Stezzi from the automobile

216. accident.  In fact, Dr. Gentchos has done nothing but take the obviously limited diagnosis of an

217. emergency room resident doctor based on a crude x-ray and slapped a full lower leg cast on the injury. 

218. The patient, Gloria Stezzi, experiencing intolerable pain, had to make an emergency visit to Dr. Gentchos

219. on 9 November 2001.

 

220. Instead of removing the sixteen day old cast to properly observe and diagnose the source of pain, Dr.

221. Gentchos orders another crude x-ray done with the aggravating cast still on.  Dr. Gentchos just tells

222. Gloria Stezzi to go home.  Gloria calls Rocco, her husband, and complains that the doctor is ignoring her

223. complaints. 

 

224. Rocco, who has taught the design of basic computer logic circuits, and diagnostic decision logic tables,

225. and troubleshooting, after analyzing the situation, including Dr. Gentchos' letter to Gloria Stezzi's Penn

226. Health System Primary Care Physician, Dr. Mignott, determined that Dr. Gentchos has been negligent. 

227. Dr. Gentchos has not gathered sufficient data either through physical observation or instrument testing to

228. make a valid comprehensive diagnosis of all the injuries sustained in the accident.  Gloria Stezzi had her

229. lower leg, ankle, and foot smashed, crushed and stretched but no attempt was made to diagnose the

230. injuries to the soft tissues such as the tendons, ligaments, muscles, nerves, blood vessels etc. You must

231. identify or define the problem before treatment or a solution is possible.

 

232. The primary purpose of this grievance is to supply evidence to justify the payment of benefits by Keystone

233. to Dr. Salvo who was refused a referral from the Penn Health system PCP.  It is sufficient to show that the

234. writing of a referral was denied by the legal department or risk management of the Penn health systems

235. as a desperate attempt to evade accountability to Keystone for violating the contractual Members Rights

236. and to cover-up its misconduct and negligence.

 

237. Therefore the focus of the analysis of the following documents is to be the clear evidence of the

238. unprofessional and unlawful conduct to evade accountability and deny Gloria Stezzi and Dr. Salvo a

239. referral.

 

 

240. The 12 November 2001 Letter

 

241. As stated previously, the "purpose of the letters seems to document unsubstantiated hearsay". The letter

242. violates the rules for medical report writing. A medical chart or incident report does not include

243. inflammatory words or judgmental statements. What is "being extremely difficult and rude" or "was rude

244. and very obnoxious" mean? Where is the statement of facts? Where is the objective description of the

245. subject's actions? Its no wonder the Doctors can not make a valid diagnosis!

 

246. The letter states, "The Patient then through her primary care physician, Dr. Harold Mignott requested a

247. physician here at Penn... ."  This of course could be considered the smoking gun and the proof needed to

248. prove the case. Unfortunately it is hearsay in a letter that contradicts more than it confirms in the

249. previously discussed documents.

 

250. For your own amusement try finding how many medical statements in the 12 November 2001 letter

251. contradict the medical statements in the previous documents. Remember these are not mere mortal men

252. they are the Professors teaching the new interns and residents. Heaven help us!

 

253. (As an aside, Gloria Stezzi sent a certified letter [not attached] to Garry L. Scheib, Executive Director

254. requesting, "The author must certify that the following statements contained in the document are true and

255. correct and not intentionally meant to be false and misleading". He denied the request.)

 

256. The absolute proof of the lack of veracity of the statements contained in the document is in the income

257. statement. Dr. Gentchos never submitted a bill and there is no medical report from him on 12 November

258. 2001 for the evaluation indicated in the letter. It never occurred! Dr. Okereke also never submitted a bill.

 

a. The COMMENTS section on page two are in the same category as Dr. Gentchos' evaluation. But here is

259. a prime example where a report contained a material untrue statement and omitted a material fact

260. necessary to make the report not misleading.

 

261. Gloria requested the cast be removed, that x-rays and an ultrasound be taken, and that she be fitted with

262. a shoe boot. Dr. Okereke refused to take x-rays under any conditions to document the condition of the

263. injury, but told Gloria that he would remove the cast and that she could go elsewhere for treatment.

264. That was a very sadistic comment for a Doctor to make.

 

265. The letter also contains libelous statements that can not be addressed at this time.

 

266. The 4 December 2001 Letter

 

267. Between 13 November 2001 and 30 November 2001 there were many phone calls, letters and faxes back

268. forth which add nothing to the referral issue of this grievance.

 

269. But on November 30th, 2001 Wanda Seamon, patient services representative, called Gloria and told her

270. that she had set up an appointment for her at 9:00a.m. on December 4 with Dr. Heppenstall.

 

271. The resulting 4 December 2001 letter of termination is the final testimony to the Penn Health system

272. culture of corruption.

 

273. True to the modus operandi of "Penn Health 'legal'" the letter is written by Rachelle Little who documents

274. hearsay. Neither Gloria nor Rocco have any knowledge of Rachelle Little.  The relevant statements are

275. flat out lies.  The fabricated first paragraph is as follows:

 

i. This letter will confirm that you have decided not to keep your appointment with Dr.

276. Hepenstall scheduled for 9:00 a.m. today.  You have advised that you do not wish to receive

277. further treatment from the orthopaedic surgeons associated with the Hospital of the University of

278. Pennsylvania and that you intend to seek medical care from another physician.

 

279. In fact, Gloria and Rocco arrived at the 2nd floor sign-in desk at 8:57 a.m.  Gloria printed her name on the

280. chart label because the computer was down.  At 9:03 a.m. two security guards named Jeffrey Harris and

281. Sgt. O'Keefe escorted us down to the lobby.  There we sat until 3:40 p.m. when we were handed the 4

282. December 2001 letter.

 

283. In the interim, at our request, we were escorted by the security guards to visit Wanda Seaman at 9:10

284. a.m. whose office is in the corridor leading from the main lobby. She gave the explanation that "legal"

285. would not permit it. 

 

286. At 11:20 a.m. Eileen Frierson, supervisor of Ms. Seamon, at our request, spoke with us. We were denied

287. a private meeting room and were forced to talk in the open public lobby.

 

288. At 12:22 p.m. A. Glogower, Director of security, tried to pass himself off as a physician with Ms. Frierson.

289. Rocco requested he produce some identification. After 5 minutes he produced his business card.

 

290. At 3:30 p.m. Ms.Frierson came down with old x-ray and requested a signature.  Rocco advised Gloria not

291. to sign anything because "they cannot be trusted". Gloria advised Ms. Frierson that she had sat there all

292. day waiting to be seen by a Penn surgeon.

 

 

293. Letter of Termination Delivered

 

294. At 3:40 p.m. someone came down and delivered the 4 December letter and requested that we leave.

 

 

295. Office of PCP Refuses Request for Referral

 

296. The next day, December 5th, after many phone calls to the PCP office, at 10:04 Linzie the referral person

297. informed us that no referral would be written until the benefits of the automobile insurance were

298. exhausted.

 

 

299. This is the end of the Penn Health system corruption saga and of this grievance discussion.

 

 

 

300. Yours truly,

 

 

 

 

301. Gloria J Stezzi

302. 2442 South Mildred Street

303. Philadelphia, PA 19148-3720

 

304. Prepared by:

 

 

 

 

305. Rocco S Stezzi

306. INTERNAL GRIEVANCE KHPE

307. 01/17/03

308. Page 9 of 9

 

309. Page 9