Dorian Mayhew Rothschild 60 Arthur St.

San Rafael, CA 94901 May 08, 2012 California Peer Review Organization 440 Montgomery St. Los Angeles, CA 93845 Re: Beneficiary's Name: Dorian Mayhew Rothschild Medicare No. T123456789 Dear Sir or Madam: The purpose of this letter is to advise your office of inadequate care received as a hospital patient. On April 08, 2012, the following incident occurred at Marin County General Hospital: The nurse tucked my sheets in too tightly one night, which resulted in chronic ankle pain on both legs which I am still experiencing today. I understand that your office investigates this type of complaint. Please advise me as to the outcome of your investigation. You may contact me at the above address if you have any questions or need additional information. I may be contacted by e-mail at droth@sloth.com. Thank you for your assistance in this matter. Sincerely,

Dorian Mayhew Rothschild Beneficiary

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