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IN TilE LUUH'l' OF l..:lH..tr.tUN PLE..\S
CUtoHU.:rn,i\ND L'UlJN'l'Y PENNSYLVAN [A
POL.YCLINIC Ml~I)IC^r. CEN'rCR,
PLlintiff
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OALic OAHHICK one!
BETTY ~I. B,\HH ICK,
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Complaint
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Ii J, 07~07
ARTHUR A. KUSIC
AHORrlEY AT LAW
4~~Ol CHJ~F; M1LL ReAD
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POLYCLINIC MEDICAL CENTER,
Plaintiff
IN THE COURT OW COMMON PLEAS
CUMBBRLAJlD COUNTY, PDOISYLVAJlIA
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CIVIL ACTION - LAW
NO. 9(, /5-~7 (!,,,;j -r;.~
DAtB BARRICK an4
BBTTY M. BARRIC.,
Defan4ant..
I
COM P L A I N T
AND NOW comes Plaintiff by and through its attorney,
Arthur A. Kusic, Esquire, and respectfully represents the
following:
1. Plaintiff, POLYCLINIC MEDICAL CENTER, is a hospital
facility organized and existing under the laws of the Commonwealth
of Pennsylvania located at 2601 North Third street, Harrisburg,
Dauphin County, Pennsylvania.
2. Defendants, DALE BARRICK and BETTY M. BARRICK, are
adult married individuals residing at 51 Gasoline Alley, Carlisle,
CUmberland County, Pennsylvania 17013.
3. On or about May 12, 1994 through May 16, 1994,
Plaintiff, at the request of Defendants, did provide health care
services to Defendant, Betty M. Barrick.
4. Plaintiff in good faith provided the necessary
health care services to Defendant Betty M. Barrick and thereafter
billed Defendants for those services and expenses incurred. As
evidence whereof, a copy of the billing for services rendered to
the Defendant, Betty M. Barrick is attached hereto, made a part
hereof and marked Exhibit "A".
5. Plaintiff's charges to the Defendants for services
rendered to Defendant, Betty M. Barrick are its usual ~nd customary
charges.
6. Any and all monies received have been credited to
the account of the Defendants, thereby reducing the balance due and
owing to $1,301.99.
7. Defendants did execute Insuarnce Assignment Forms,
whereby they agreed to assume financial responsibility for the
charges not covered by insurance coverage.
As evidence thereof, a copies of the Insurance Assignment Forms are
attached hereto, made a part hereof, and marked Exhibit "B".
COUNT I.
(Plaintiff v. Dale Barrick and Betty M, Barrick)
(Breach of contract)
8. Plaintiff incorporates herein by reference thereto
the averments hereinabove set forth in paragraphs 1 through 7.
9. Pursuant to the Insurance Assignment Form,
Defendants agreed to be financially responsible for the charges not
covered by insurance and further agreed to authorize their insurer
to pay Plaintiff directly.
10. Plaintiff has made demands upon Defendants for
payment of the balance due of $1,301.99, which demands remain
unheeded.
COUNT II I .
( Plaintiff v. Dale Barrick
(Doctrine of necessaries)
13. Plaintiff incorporates herein by reference thereto
the averments hereinabove set forth in paragraphs 1 through 12.
14, Plaintiff believes and therefore avers that the
health care services rendered, upon request, to Defendant Betty M.
Barrick, wife of Defendant Dale Barrick, were necessary for her
benefit and welfare,
15. Plaintiff believes and therefore avers that pursuant
to the "doctrine of necessaries", Defendant Dale Barrick, as spouse
of the recipient of health care services, is liable to Plaintiff
for the balance due,
16, Should Defendant Dale Barrick not be held liable to
Plaintiff for payment of services rendered his wife, he would be
unjustly enriched as the services were necessary to benefit the
health and welfare of his wife and their marital union.
17. Plaintiff has made demands for payment upon
Defendant, which demands remain unheeded.
WHEREFORE, Plaintiff prays your Honorable Court to enter
JUdgment in its favor and against Defendant Dale Barrick in the
amount of $1,301.99 along with interest at the rate of 6% per annum
and the costs of this proceeding.
~t1NT IV~
l Plaintiff v. Dale BarricK)
lstatute)
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,b. .v.,..n'. h.,.'nabOV. ..' ,o,'h 'n .a,.g,..h' , 'h,ough ".
". ..,.u.n' '0 " ,..c.s... .",. ..",.. ..,.on. .,.
liaDle for the support of each other.
". "",...n' '0 " ,a.C's." "". vh.'. ..bts ".
con,r.c'" '0' n......r,.. by ."'" ....... a cr.."or ..y
,..,,'u,. .u,' .,.'n.' 'h. hU..... .n' v,'n '0' 'h. .r'c. 0' 'h.
necessaries,
". .,,'n'''' ...".v.. .n' ,..,.'0'. oV.r. tJ>a'. ...
",." car' ..,.,c.. r....'.. '0 ,",...an' .."y M. ..r,'" ve"
......arv '0' h.r heal'h .nd v."". and 'hU' .1.0 .,n."".' ,h.
marital union.
". ,'a'n"" ha' .... ....... '0' .aye.n' upan
oefendant, which demands remain unheeded,
.....'0... "a'n"" .ray. your Monorab'. cour' '0 .n'"
'u....n, 'n ". ,avor an' aga'n" ,.f.o.ao' oa'. .ar"c' 'n 'h'
..oun' 0' ".""" .100' v,'h '0'.'..' a' ,h' ,a'. of .. .., ann"
and the costs of thiS proceeding.
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COUNT V.
(Plaintiff v. Dale Barrick and Betty M. Barrick)
(Total)
23, Plaintiff incorporates herein by reference thereto
the averments hereinabove set forth in paragraphs 1 through 22.
24. Any and all monies receive have been credited to the
account of the Defendant, thereby reducing the balance due and
owing to $1,301.99.
25. Plaintiff has made demands for payment
Defendants for the balance due and owing of $1,301. 99,
demands remain unheeded.
26, The purpose of this communication is to collect a
debt, Any and all information obtained will be used for that
purpose.
upon
which
27. Plaintiff avers that the amount due and owing does
not exceed the jurisdictional amount requiring arbitration referral
by local rule.
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BETTY II BARRICK
51 GASOLINE ALLEY
CARLISLE,PA 170.13
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'13 o.1CREATlNE KINA 0.1170.155 52,90. 52.90.
'u o.1PSH-SiRU.. 0.1170.30.9 84.80. 84.80.
'13 o.1PART THO/llBOPL 0.120.112 27.90. 27.90.
'U D1PHLESaTo.MY 0.150.0.0.15 9,70. 9.70.
'1] D1ESTRAOIOL 0.161434 164.50. 164.50.
'1] D1PARTlAL THRO.. 0.173196 52,10. 52,10.
'13 D1ICG ROUTINE 0.3110.0.1 114.80. 114,80.
'13 o.2NACL-Io.,9 10. 0.70.46391 1. 75 1. 75
13 D1ATENOLOL~T 50. 0.70.310.1 1,0.0 1.0.0.
13 D28ACTRIII OS 1 0.70.4280. 1.0.0. 1,0.0.
13 D1PROCAROIA-XL 0.70.5197 4.25 4.25
13 o.1HEPARIN~~" 25 0.70.4839 18.75 18.75
13 o.1NTG-rv 25o.IlL 0.70.5235 15.75 15,75
13 o.1Ro.OM S2D9 30.20.0.0.0.4 750..0.0. 750..0.0.
14 o.1SLIPPERS T T 2510.20.2 8,50. 8,50.
14 o.1SPECIPAN KENO 2510.20.7 6.40. 6.40.
14 D1PROTECTIVE NE 2519192 2.30. 2.30.
14 01UNOERPAD POLY 2519342 2.20. 2.20.
14 D1CREATINE ~INA 0.1170.155 52,90. 52.90.
14 D1CREATINE KINA 0.1170.155 52.90. 52.90.
14 o.1PART THOMBo.PL 0.120.1123 27.90 27.90.
14 o.1C8C/INT DlFF 0.120.7521 37,70. 37,70.
14 o.1PHLEBOTOMY 0.150.0.0.15 9,70. 9,70.
14 a1PHLEBOTaMY 0.150.0.0.15 9.70. 9,70
14 a1PHLE8aTOMY 0.150.0.0.15 9,70 9.70.
14 alPARTIAL THROM 0.1731963 52,10. 52.10.
14 a1ECG Ro.UTINE 0.3110.0.1 114,80. 114.80.
14 a4NITRo.BID-O 1G 0.7047711 3.0.0. 3,0.0.
14 a1ATENOlaL~T 50. 0.70.310.17 1.0.0. 1.00.
14 a3BACTRII'I DS 1 0.70.4280.9 2.0.0. 2.0.0.
14 o.1PROCAROlA.Xl 0.70.51972 4.25 4.25
14 Q2HEPARIN-PM 25 0.70.4839 37,25- 37.25-
4 o.1HEPARIN-PM 25 0.7048394 18.75 18,75
4 a1HEPARIN-PM 25 0.70.48394 18.75 18.75
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CARLISLE.PA 17013
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CENTRAL SUPPLY "'.80 5" .80 I
IV SOLUTION 11,20 ".20
1'1" , THUAPY 427.10 421,10 I
LAIORATORY 1031,40 1038.40
au 602.20 602,20
RAD-ROENTGENOLOGY U'2." 22'2." ,
PHARMACY 117.'0 117.'0 i
TVIPHONE 6,00 , 6.00
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CO~CURRENT GROUPER
ORG 122 !'IDC
OR~-RATE.PER.CASE
OU"LIER VALUE
USED PlC93
OS
5101.77
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POLYCLINIC MEDICAL CENTER
HARRISBURG, PA
UIII[)f" urlW...no I~SUIVJlC[ COVUAGt:,
6.00
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CONSENT TO MEDICAL TREATMENT
I consent 10 the rendering of medical care, which may include routine diagnostic procedures and such medlcallreatment
as my allendlng or consulting physician considers to be necessary. I also understand It Is customary, absent emergency
or extraordinary circumstances, that no substanllal procedures will be performed upon me unless or until I l1ave had an
opportunlly to discuss them with a physician or other health care professional to my satisfaction. If I am a competent adult,
I have Ihe right to consent or refuse to consent to any proposed procedure or Iherapeutlc Ireatmen!. I will not be involved
In any research or experimental procedure without my full knowledge and consen!. I undersland that the practice of medicine
and surgery Is not an exact science and that diagnosis and treatment may involve risks of injury or even death and acknowledge
Ihat no guarantae has been madE! to me as to the results of any examlnallon or treatment In this Hospllal.
'._"__~_ ___~u..__..n.
--.:-.. _.:.'~~.~.,~~.
I understand many of the physicians on the staff of this Hospital are not employees or agents of Ihe Hospllal, but rather
are Independent contr'lctors who have been grantad the privilege of using these laciJIties for the care and treatment of their
pallenls. Further,l realize this Hospllalls a taachlng Hospllal and at this Hospital ani health care personnel In training who,
unless expressly requested otherwise, may participate or may be present during my care as part of lhelr education. SlIlI
o. mOlo' .""~ ",d <,,,,,,.1,,", ..~.orln of patient care may also be used lor educational purposes, unless
I expressly requast otharwlse.
~ r )q . - L Rel3t1on hip
Oat , ) _ ~ Signature . ~ To Patlen
I I ., V -.
RELEASE OF MEDICAL RECORD INFORMATION
I authorize Polyclinic Medical Center to release 10 requesting health Insurance carrler(s), Ihelr representallves and auditors,
such dlagnosllc and therapeullc Information (Including any Information relating to trealment for alcohol and substance abuse
and/or treatment of psychiatric disorders, and/or confidential HIV related Informallon), as may be necessary for them to
determine benefil entillement; and to process payment claims lor health care services provided during this hospltallzallon/
Ireatment episode. This authorization shall be valid for the period of lime necessary to process payment claims pertaining
to the pallent. A photostallc or carbon copy of lhls authorization shall be considered as effecllve and valid as Ihe original.
The undersigned also authorizes Medicare, whan applicable, to release to another Insurance carrier, upon their request,
medlcallnformallon needed 10 make payment upon that claim.
I undersland ard consentlhat Ihe manufacturer of implanlable device Inserted by my physician during the course of
my surgery/procedure may be provided wllh Y.' elltlfl .
oat~ Signature
Information as mandated by Federal ~
.... Relallonshl
To Pallen ~ r-, ~
-
INSURANCE ASSIGNMENT
I authorize paymenl directly to POLYCLINIC MEDICAL CENTER and for physicians of all benefits payable under my Insurance
policies. I understand I am responSible to the Hospital all charges not covered by Ihls asslgnmenl and/or photocopy
of Ihls assignment. %
S}IL..J~~ ~~ Relatlonsh1nll
Oat . Signature .. .~ Tu Pallen! '<.U (fJ (J'{A/':\ ,_
Signature -
4,
.? ~~ 111 q 0 leu 028 C Z 9 ') ~
;i7.;'n-bJ7fJ 194-42-7986 \
[')<010, BETTY H .
'I ';I'i'LltIE ALLEY
(A-LISLe PA 17013
(~/I:lq4 431 09/29/50 r
OAFPHSSC-PltlK PRIVAT
POLYCLINIC MEDICAL CENTER
HARRISBURG, PENNSYLVANIA 17110
PATIENT CONSENT FORM
Patienl Identification
F~n3ll1H.2
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BILLING
-
CONSENT TO MEDICAL TREATMENT
I con88ntlo the rendering of medical care, which may Include roullne dlagnosllc procedures and such medical treatment
II my anendlng or consulllng physician considers to be necassary. I also understand It Is customary. absent emergency
Of extraordinary circumstances. that no substantial procedures will be performed upon me unless or unlll I have had an
.
opportunity to discuss Ihem with a physician or other health care profess/anal to my sallsfactlon. If I am a compe18nt adult,
I have the right 10 consent or rafuse to consantto any'p;oposed procadure or therapeutic traatment. I will not be Involved
In any research or experimental procedura Without my full knowledge and consent. I understand Ihatlhe pracllce of medicine
and surgery is not an exaCI science and that diagnosis and treatment may involve risks of injury or even death and acknowledge
that no guarantee has been made to me as to the resulls of any examination or treatment In this Hospital.
I understand many of the physicians on the staff of this Hospital are not employees or agents of the Hospital, but rather
are Independenl contractors who nave been granted Ihe privilege of uring Iheso faollllles for the care and treatment of their
pallents. Further, I realize this Hasp/tal is a teaching Hospital and at this Hospital are haalth care personnel In training who,
unless expressly requested otherwise. may participate or may be present during my care as part of thair educallon. SlIIl
or motion pictures and closed.circultlelavlsion monitoring of pallent care may also be used for educational purposes, unless
I expressly request olherwlse.
Dete ~11~J;q4 CJignature'l ../.~'v/? ;..~:?,. N/,,//
Relallonship
To Pallent
RELEASE OF ~EDICAL RECORD INFORMATION
I euthorlze Polyclinic Medical CenlSr to release to requesllng health insurance carrler(sl, their representallves and auditors,
such dlagnosllc and therapeutic in'ormation (including any information relatlrlg to treatment for alcohol and substance abuse
and/or Ireatmant of psychiatric dlsordars, and/or conlldenllal HIV related informatlonl, as may be necessary for Ihem to
determine benellt entitlement; and 10 process payment claims for health care services provided during this hospitalization I
treatment episode. This authorizallon shall be valid for the period of time necessary to process payment claims partalnlng
10 Ihe patient A photostallc or carbon copy of this authorization shall be considered as effactlve and valid a., the original.
The undersigned also authorizes Medicare, when applicable. to release to another Insurance carrier, upon their request,
medical Information needed to make payment upon that claim.
I understand and consent that the manufacturer of any implantable device Inserted by my physician during the course of
my surgery/procedure may be provided with my Idenllllcatlon Information as mandated by Federal Law.
~ I I "" 1Jk-" /J, f Relationship
Date -..J//,J../'1l Signature 'i. /.J", . ,-/,~hU~ ToPatlenl
I
INSURANCE ASSIGNMENT
I authorize payment dlreclly to POLYCLINIC MEDICAL CENTER and for physicians of all benefits payable under my Insurance
policies. I understand I am responsible to the Hospital for alt charges not covered by this assignment and/or photocopy
of this assignment
r.j q(1 '
Date - J. / .:;,./ Signature 1
, '-?(l~ ,~d~,,~A
,/
Relationship
To Pallent
FORM WITNESSED BY )
Date S//J lOLl Signature \l....fUH-l /~/" .
~~77/10
POLYCLINIC MEDICAL CENTER
HARRISBURG, PENNSYLVANIA 17110
PATIENT CONSENT FORM
Pallenl Idenlificallon
'OOWfl241.JI 1'.1)2
BILLlNO
POLYCLINIC MEDICAL CENTER.
Plaintiff
IN THE (,'UURI 01' COMMON PLEAS
CUMBERLAND COUNTY. PENNSYL VANIA
:
CIVIL ACTION - LAW
NO. 96-155a Civil Term
v.
DALE BARRICK and
BETTY M, BARRICK,
Defendants
:
:
CERTIFICATE OF SERVICE
I. Arthur A. KUS 1 c. ESQu ire. do herab.Y cert i f.y that on
thIs
25th
d3.Y 0 f
April
. /996. I placed In the United
States Mail true and correct coplas of
1 O-day Importan~ .!lotic~_._
addressed to following:
Dale and Betty Barrick
51 Gasoline Alley
Carlisle, PA 17013
.
ARTHUR /I IC. ESQUIRE
420/ Crums Mill Road
P.O, Box 1/585
Harrisburg, PA /7//2
(7/7) 540-56/0
Attorne.Y for the Plaintiff
Supreme Court 1.0, 07207
POLYCLINIC MEDICAL CENTER,
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY PENNSYL VAN I A
V.
CIVIL ACTION - LAW
DALE BARRICK and
BETTY M. BARRICK,
Defendants
NO. 96-1558 Civil Term
TO: Dale and Betty Barrick,
Defendants
You are hereby notifIed that on _ _
the followIng Judgment has been entered aga1nst you 1n the ~bove-
caotloned case.
Amoun t :
In the amount of $1,301.99 along with interest at
the rate of 6\ per annum from March 21, 1996, and
the costs of this proceeding.
Date:
Prothonotary
I hereby certify that the name and address of the proper
person(s) to receive this NotIce under Pa.R.C1v.P. Section 236 is:
Dale and Betty Barrick
51 Gasoline Alley
Carlisle, PA 17013
Defendants
.... "