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HomeMy WebLinkAbout96-01737 I J\ ':t . ~ '1 q ~ , . 'I " I i I ~ i , J , J " I' " I i' , I J , \ I i I ~ I ;) I " ~j I' " NOTICI 0' APPIAL C_WIAUH or P1NNIYLYANIA CQUI' or COMMON PLlAI .... 'ROM IUDICIAL DIII.'CY DISTRICT JUSTICI JUDGMINT COMMON 'UAI No. <)6-1737 Clvi.J 'l'!!XI1l NOTICI 0' APPIAL Nolie. i. g1_ that the appellant h,,, filed in lhe obov. Court of Common Ploo. on appeal from the judgment ,end",.d by the Di.I,ict Ju,tiu on the dat. and In the c.... mentioned below. ~._-_..__...... '["iG'liiIlNli'/llIlAMlOIbJ ./J,..,7"",::fh.J1;:;-0 . tjlt'::;'~'1.d.E..:!/L/1,~CC-tcn\' /)':;,I(6f.~l'tY)-';'i v:' '/ ~.,(?~p'.' ..!~I<-~'~'f.,\;CA!;;""';il; (/lr~,I... ~I ,,.,..,,.., ./;'<'-'/..!.. 4'1' ~ ,;-.;='~~'> !~',^'I' ]~._,,~.t'~~;'::Y'A- ThI. bloc\ will ~~ ~ ONLY ~~~~. ';';;~ti';;~; required und.tr Po. R:tP.f{ri.#-';::;:"~t was ~LAi~Atfcsee Pa, RCPJP, No: 10088. Thi. Notie. of Appeal, when received by tho Di,t,ict Ju,"co, will operot. o. 0 1001 (6) In action belore District Jus/Ice, he MUST SUPERSEDEAS to the judgment /01 po"..~on in Ihi. cooe. FILE A COMPLAINT wilhm twe,,'y (20) days al/er Iillng hiS NOTICE 01 APPEAL. -----,- --u-.SiijmJrIJro--o/-'iici;hl)(i,>tm-y OIOIIfJlIf'l ........ "'RAECIPETO IENTER RULE TO PILI COMPLAINT AND RULI TO FILl (This section ollorm 10 be used ONLY whe" /lppell"'" WIlS OfJENDANT (,el' p" HCPJP No IF NOT USED, detach from copy 01 notice of ilppeal to be SCIVed upon ilppe/lC'tJ I 'RAICIPI. To Ptotllonotory E_ NIe upon.,....Ll~!.~!', .~.. 1.J~)I<'"...~"/I..t!!J..~. ". . Nlw''''I)'j~)IIt.''H~J '00 1( 7) '" acllon bl.!fom D'stJict Just/co. , appellee('I, to fil. 0 comploint in !hi. appeal (C_ Plea. Nc,.96 -1 7 37_ Ci vll......'.rerl!l...............) within lwenty (201 day. after .""ice of rule 01 .uffer ent,y 0/ judgment of non pro. ...-t:c..i~.-'.!.L"--,'~_~~e'."-. . SI{}flUlUfe 01 fIWt'/IW1t Of hIS illtumey U' agent /) t:' 011/ ni, '-" 64- Ie J!.:" j..!..~ D J. ~, appell.e('I, NBmc of ~lloo(s) IULII To (11 You ant noijfied that 0 ,ule i. hereby en"'ed upon you to file 0 cc,nlploint in thi. appeal within twenty (20) day. oft", lhe dolt of letvrce of !hi. ",Ie """" you by p....anal ."vie. 01 by certified 01 regi.tered moil. (2) H you da not file 0 comploll1t within thi. time, 0 JUDGMENT Of' NON PROS WILL BE ENTERED AGAINST YOU. (3) The dotw of letvlc. of thi. ,ule if ."vie. wo. by moil i. the dote of moili~ DaM: ADril 1st ,1996 . ~~\'<\~" nk, ~~-"""'rCII~1lY /It11'C312." '0- j ~ ~ """ <") ::to r!. N , ~p .. i. - .!~ t"l :1: .J..,;1 t y~ .l::-. ~ ..c:: .,;] ffi~:., en N 'f;l ~ t-. ':r)J 0 ~.~~ c.." j(11 ~ I'. (;:.> . ~ t.)... L; .." :3 "- c... , , , ' .' C_lIItIAUN Of '_I"VANIA ----..cOull OfC_MilN .LIAI NOllCI OF APPlAL fllOM NOICIAL D11111C1 DIIl.ICl JUSTICI JUDOMINl COMMON fiLiAl N. '1,,-171" ('ivll Term "-------- NOYlCI O' APPIAL Noli.. i. lli_ that tho appellant "'. filed in the aba.. COIMt of Common Plea. on _01 Irom the Judgment ,.nder.d by the Oi."ict lu.ti.. on tho daM and In tho co.. .....liall.d below. /1~~' . ~."..",~~'~~ j'-- ~~'~~~~' ...-.. .- .--. .. - .. - T:O.t.~;~-OI~~;o j';z-", ;7. ; :~..,7: h) .......401AmlUNI - "-~fY-'" ..- ....... ..hmli..J--. ...- zn~ ..~.~/ /, . ""dCA!/";~"""'- (/h" "-m..---..-..--..-.....-....-..--......:.~t..!..-;=...T--. 'r,I.1 ;;L..,,;.://.-~ ....!.~,_._:!..~,~-_.' -!.-~_I--'; ( .J) V1 .;.}/"..../'.., .', /; "../1 _;;....l.//\, a~ ",_ ~~i:.. 3_"~'~~';:;,~~~~=.... . ..!~;'(~=:~~~~:::~':.~:N~~V~~~ ~_... ..._.._.... TN. block wiN be Iigned ONLY when thi. r<>lolion i. required undo< Pc> R.cP,JP, No. /I appellant was CLAIMANT (see Pa, R,C.P,JP. No, 10081. ThI. Notic:. of Al'flOal, when receh,.d by the Di.trict Ju.tice, will operate o. 0 lOOI(6) In action belore Dlstricl Justice, he MUST SUPERSEDEAS 10 tho Judgment lot po.....on in this co... FILE A COMPLAINT wlthm twenty (20) days alter filing hiS NOTICE 01 APPEAL. -s/fi1iiiuro-"lirPrOlhOn0i,j,-yc'/"-OiiptllY'- _____.____.__..,.._.~_.,.._ ...."_ _n__._ ---"PltAICr'l TO IINT.RaULI TO Fill COMPLAiNT'AND IU.iLI TO fill (TIlls section 01 101m 10 be used ONLY when appel/anI Wi'S DEFENDANT ('c'C Pa. R.CP.JP. No 1001(7) In acllon belore D'S/lIel Justice. IF NOT USF.D, dolBch lrom CcyJY 01 nollce 01 appcilllo be sc!Vm! upon appcl/c'C) 'IAICI'I. To Prothonotary Em. Me upon I)'" '.r/'.. - ,. /lj..;. ,'I I.J{J' . .~=-__.._..~.~,.,..,~._..~.., appell"('I, to fil. n complaint in thi. appeal Nomt1 oIl~IIf.'f!(sl (CommonPleo.No.'16-173'l Civll Term IULII To " I ), ,'I/l'V,..j, , /'~}.,r.. ) within lwenly (20) day. allet ...vic. of rule 01 .uller .nlry of judgment of non P'O' ) , '1' . ,~. ~. - ,. /.("'.... ~,...., " ':-.-' , 'I' "-I',:'.--A- ~ at ~t or hIS attomey Of agent """'01_'1 ).". jt '?/..J" ...___~____.. , appelle.('I, (I) you.... nolified that 0 rule i. heteby enleted upon you to file 0 complaint in thi. al'flOoI within lwenty (20) day. oflet the dote 01 ...vIc. of tN. Me upon you by petsonol.etv~. 01 by cettilied QI relli.1eted moiL (2) H you do not file 0 complaint within thi.lime, 0 JUDGMENT OF NON PROS WILL BE ENTERED AGAINST YOU, (3) The dot. of ...vlc. of thi. rule il ....~. wo. by moil i. the dot. of moiling. Dolo: Anrll l!lt ,I9.2&., LJ,a.-~ \\\6.\iN\oN'I Q..,..f.. ~PfdA.~'IOI~ , . AOPC 312." COURT FILE ----..--_._._-~.-....~-,--.. .....--.....-...... --- PAOOF OF SERVICI: OF NOTICE OF APPEAL AND RULE TO FILE COMPLAINT {rtJi.'J }!rd':.! t)I,~tJ/\I'II~1/ MUS r nr f 11.1 [) WI ""f~N 'TN (10) n,t y',''; .\1 Tt_I1IIi:"~} /lit! U(l/,U.' 1)1 olPI',',1I CII"Ol ,fppl,CJ/ll03 tJIJ)/IS} COMMONWEAL TH OF PENNSYLVANIA COUNTY OF Cl./ h? b~ K/ -'9Y? cL . II AFFIDA VIT: I t1Pr~'hy sWOllr or Ilfflrm thAI r 5trfV*"j I ZV;-, "I'Y <lllh" ~J <I,. ,. "~y I' <I , ,,,,,,,,,,,, 1'1"", N"f 1-/ 7.3.?""""-"",, ll',IJlf . "",c" ,1"'I(Jn,"",j ",,""", on fdollo "I ,""nr,,,) 7"1 :2-. Ig 9. -'. l.J l,ly.J'C!"]o",,' ""IVI';" l'hT 0""'''') ('''.\Ilst"""I) molll, """iuI', '~WI'I,t (d'llr~lI'" tWI.!I0, .Ill j .rpnn 011' IlppPlh I' 'flill1lfJ! {./r!"'h ."'1.\ ~ ~.~u ~c. (. ., ',.)__?~. .._... 011 ~_l\ f.~ 111 9 (, I J hI' P'II',uII.l1 '11'1 ~I(l! riJ..hy 11\.'111111'<1) ""'JI~ih''''dl l!lat!, 'd'Il.j{~I\ 1I'II'lp\ dllddll.'d hl1fet/) r~"<I '11111"'1 II.,,, I .".",.;01 ";0,11111, '" L\I'.\;! C';I!lPltlIIIIIlUJ.lIII!)'I'lYI~'(ljlt-ll; ,1I)'Y'I,' N,)II' P Ijf /'I"I:t.'.'II.IJPlJ~~IIil) i1P~ljll(!tJ.O.) IOW.horn 1I!1~ FiI)II' Wilf, i1,jdll.'~.,I'd "II , - .\. I'} __ ,(. r ] Ly p"r~,'Hldl 'il'IVI,,'1' 1.% (l'fl/llfll~d) (rl'gt"ilOrt'tl) nlwl. "I'tlrlcr"j II'!Cl1Ipl nlt;ld'l:d "('f(llo , SWORN IA,rIflM[ III AND c"JII1"CflIIIlIJ Of I I JIll MI, THIS "1..;L ,"L IlAV()P" d..:..i d:... 1~9G ,..Jtt"llJA.~", ~7.-') J ~..// S!)nilll"fJ,Jt~!,..1;tll"I"l'.lj n,.I/"/J'lw".,,"'t' V.V'--' _:.1 '~'"~"~"-"J'" -- "-" -- " 71/1t 01 t)"I<I,'I._~_- f'........ ------ Ml' COf11/-,t,~IQf\ '.'l'p:ll~11 on M_..UlJJ.AEIlA1...SL.\!... ___, llL ~"'~,!NU~ l' r:ur:- NtJT:VlV FUGUe 1 '-.1.'1 :"Ll ,~')I:(J ,UI,:OmI.MIO COUN! Y I' ':.. :::";',1":"(11. F..iPIRtS llOVEMRER 15. 1990 -'. -- a:";.--../;"';'L-~ /" .. ,J~"-== S'OlliIfLJfU O/lJ/f,iffl, ~., - ,;',! :l:':it~;: " :iocnipt for Certified lVlail , ., , '- , ,j " . .1 -r . "J I. I. : , , I 'r, \? , ) '. ~. :-, it " , :i.J , " 'I, J " , I n . ~"') -- -, -. LJLJD "be d'( N., 11.'.ldoll'" ,'",,"1.;11" h, ',"'<'.'<1 I)" P,)l II",. 1"1 lid, rrl,II''-'''oIl '\1,).1 '" m m ~ '''.r,J'"", , ..._-_.._-~ h j').I." t[C') ~;2 " " I:, ., liil '1' './ :I"i II I'. , I , I , , , I ,. \i , , I .;,:! II I' /! .1 , l, 'I I I , , ,. , I I: '!:I. , ,. " , " , I ,. I I Ili II" , , , , , , I , , 'j: 1;' , , I , " , Iii. I . I,'." ~ I , I. "i " "Nod, 9(, ~tA.. C, nki.~, ~ ~ 'I' 'I' " I, I rId "'1 " j I, I,:.j; ill; 'II'!I ','1 I I' ,Ii " " ,:1, ,,' :1 ',I ..""".f"'-' h"" r. ~.,. ~r;.~~ I" ,r;t~ II &/~~ Ju ."OUJO" ClIL...OY . HOUeTON. ,.. C. ATr'ORHWV. It" LoAw ,. HORTM MANOW" .T....... ' . C."U.ur. ,.IENN.VI.,VANIA ''701~ 17'''. .48-4_74 "'.'..0 DENNIS BURKETT, DDS Plaintiff :IN THE COURT OF COMMON PLEAS OF :CUMBERLAND COUNTY, PENNSYLVANIA . . . . v :NO. 96 - 1737 : ALEXANDRIA A. SEEK Defendant : :CIVIL ACTION NOTICE TO PLEAD You h~ve been sued in Court. If you wish to defend against the claims set forth in the following pages, you must take action within (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defens~s or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. COURT ADMINISTRATOR CUmberland County Courthouse Carlisle, PA 17013 (717) 240-6200 OFFICE 2 PATIENT TRANSACTIONS INQUIRY Thursday March 21, 1996 ~~~~~~~~ijij~~I~~~~~~ijl~~6116011~ijlijijlijijllllijijllllllllllIIAlllllllllijijII16~I&IIII' CPATIENT:2629 SEEK, ALEXANDRIA A oCODE:M OFEE PLAN n:OaAAAAAAAAAAA6641 cOOCTOR : 2 BURKETT O,iaaaAAAAaeaaA4UAUAAAa,1Aeaa,liiaaaAaaaAi INS TOTAL 1 cHYGIEN.:5 RUDGE 0 CURRENT OVER 30 OVER GO OVER 90 PORTION BALANCE 1 CNEXT APPT. :--/--/-- 0 0.00 0.00 0.00 '/033.70 1880.00 7033.701 uAA48A44AAAAAoaAA8A4aaaaaeaaaaA4AaaaaaAAAAAAAAAaoAAoadoaaA4AoAAAA4AA48A44A44444i cCYHo DATE oDOcoCODE DESCRIPTION oUNOTuoSURF 0 AMOUNT 0 BALANCE 1 uA446A44AA4AAeAA464AA4aaaAaaaaAAaaaaAAAAAAAAAa4aeaaeaaeaa4aaeaAAAAAAAeAAAA44464i CCHGo08/03/9302 0130 EMERGENCY. ORAL EXAMINATI01 0 0 0 38.000 38.001 CCHGo08/03/9302 0330 PANCRAMIC FILM 00 0 0 0 46.000 84.001 CCHGo08/03/9302 09910 AP>>r, DESENSITIZING MEDICoO 0 0 0 12.000 96.001 CCHGo08/03/9302 06930 RECEMENT BRIDGE 03 06.011 0 88.000 184.001 CCHGo08/06/9302 0240 INTRAORAL-OCCLUSAL FILM 00 0 oMAX 0 24.000 208.001 CCHGo08/06/9302 03950 CANAL PREP & DOWEL/POST 01 010. 0 114.000 322.001 CCHGoOB/06/9302 02710 TEMPORARY CROWN 05 05 0 0 225.000 547.001 CCHGo08/06/9302 02710 TEMPORARY CROWN 05 06 0 0 225.000 772.001 CCHGoOB/06/9302 02710 TEMPORARY CROWN 05 07 0 0 225.000 997.001 CCHGoOa/06/9302 02710 TEMPORARY CROWN 05 08 0 0 225.000 1222.001 CCHGo08/06/9302 02710 TEMPORARY CROWN 05 09 0 0 225.000 1447.001 CCHGo08/06/9302 02710 TEMPORARY CROWN 05 0100 0 225.000 1672.001 CCHGo08/06/9302 02710 TEMPORARY CROWN 05 0110 0 225.000 1897.00[ CCHGo08/06/9302 02710 TEMPORARY CROWN 05 0120 0 225.00" 2122.001 Aij~~Q~~~I@I@@QII@Q~~ijAAI@A0~111~~AIAlijAllllijijll@QIIQIIQIAII@QIII@AAAIQAIAI~~ij~Al PgOn Cant inue End Exit OFFICE 2 PATIENT TRANSACTIONS INQUIRY Thursday March 21, 1996 eijlllllijlAllijijllllllAIIIAleel~IAIAlillllllllllllllliAIeAII~ijllijliIIAIAIIIIAAA~lf cPATIENT:2629 SEEK, ALEXANDRIA A oCODE:M oFEE PLAN #:OaAAAAAAAA4AAA6A~ cOOCTOR:2 BURKETT OaaAa4aAAaeaAaAaAAaAaAaaaAeaaaaaAaAaAaaiINS TOTAL I cHYGIEN. : 5 RUDGE 0 CURRENT OVER 30 OVER 60 OVER 90 PORTION BALANCE I CNEXT APPT. :--/--/-- 0 0.00 0.00 0.00 7033.70 1880.00 7033.701 uAaA844AAAAaA6a4a8AaAaaaAeAaa44AaAaaaAaAaaAaAaAAoaaoaaoaaAaA8aaa4aAA48AA4AaaA44~ cCYHo DATE oOOcoCODE DESCRIPTION oUNOT#oSURF 0 AMOUNT 0 BALANCE I uAaaeaAAAaAAAeAA4eaAAAaAAaaaa44AaaaaaaaaaAaaAaaaeaAeaaeaaaAAeaa4a4AAAe4Aa4a4A64~ CCHGo08/13/9302 u470 DIAGNOSTIC CASTS 00 0 oMAX 0 28.000 2150.001 CCHGoOB/13/9302 0470 DIAGNOSTIC CASTS 00 0 oMAND 0 28.000 2178.001 CCHO"08/13/9302 09951 OCCLUSAL ADJUSTMENT/LIMP3 0 0 0 84.000 2262.001 CCHGo08/13/9302 09000 MISCELLANEOUS 00 0 0 0 28.000 2290.001 CCHGo09/16/9302 027 POST OPERATIVE CHECK 00 0 0 0 0.000 2290.001 CCHGo09/27/9302 09000 MISCELLANEOUS 00 0 0 0 36.000 2326.001 CCHG010/11/9305 01110 ADULT PROPHYLAXIS 03 0 0 0 36.000 2362.001 cCHG010/19/9302 03310 ROOT CANAL THERAPY-ONE C04 0110 0 270.000 2632.001 CCHG010/19/9302 01 RECEMENT TEMPORARY 03 05-012 0 0.000 2632.00[ CADJo12/02/9302 060 Insurance form charge OtAO 0 0 188.000 2820.001 CADJo12/02/9302 0:29 REM STARTING BALANCE o.po 0 0 -188.000 2632.001 cCHGo 12/03 /93 0 2 01 RECEMENT TEMPORARY 03 06.011 0 0 .000 2632.001 CCHGo12/10/9302 02954 POST AND CORE 04 0110 0 142.000 2774.001 CCHGo12/10/9302 02950 CROWN BUILDUP-INCL ANY p04 05 0 0 127.000 2901.001 AijIIQ~lijijlllijQ@I@Q@@ij@II@I@II@@@@@@lijA@II@@II@I@QijAQleQe@@IIQI@@IIIIIQIIIIIIIII\ PgDn Continue End Exit If!} EXHIBIT I._A__._.. OFFICE 2 PATI.ENT TRANSACTIONS INQUIRY Thursday March 21, 1996 e666~11~~~II~I~~~~~~611Ielee~~~~~I~I~~~~~e~ijel~~le~llelelell~eeel~ll~eijI6111~~61 cPATIENT:2629 SEEK, ALEXANDRIA A oCODE:M OFEE PLAN n:Oa~A~AA4~~44AA441 CDOCTOR : 2 BURKETT 6aiijaAAaaA~Aa,U4aAaaAAaaaaeaaaAa~aaaAaAi INS TOTAL 1 cHYGIEN.:5 RUDGE 0 CURRENT OVER 30 OVER 60 OVER 90 PORTION BALANCE 1 CNEXT APPT.: --/--/-- 0 0.00 0.00 0.00 "033.70 1880.00 7033.701 uA~A84~AaaaAaoAa4oAa~Aa:'aeajaaAAAAaaAAaa4aaaaaajoaA6aa6aaaaa6aa4A~~a~5Aa~~Aa~aAI cCYHo DATE oDOcoCODE DESCRIPTION oUNOTuoSURF 0 AMOUNT 0 BALANCE 1 uA~~ea~AAaAaaeA~ae~~~aaaaaaaa~a~~~aa~~Aa~Aaaaa4AeaaeaAeaa~aae~~AAA~4ae~~~AAa~4AI CCHGo12/10/9302 02950 CROWN BUILDUP-INCL ANY p04 06 0 0 127.000 3028.001 CCHGo12/10/9302 06666 RECONSTRUCTION-VARIABLE 00 0 0 0 1285.000 4313.001 CCHGo12/10/9302 06750 CROWN-PORC/HIGH NOBLE ME03 05 0 0 625.000 4938.001 CCHGo12/10/9302 06750 CROWN-PORC/HIGH NOBLE ME03 06 0 0 625.000 5563.001 CCHGo12/10/9302 06240 PONTIC-PORC/HIGH NOBLE M03 07 0 0 625.000 6188.001 cCHGo12/10/9302 06240 PONTIC-PORC/HIGH NOBLE M03 08 0 0 625.000 6813.00' CCHGo12/10/9302 06240 PONTIC-PORC/HIGH NOBLE M03 09 0 0 625.000 7438.00' CCHGo12/10/9302 06750 CROWN-PORC/HIGH NOBLE ME03 0100 0 625.000 8063.001 CCHGo12/10/9302 06750 CROWN-PORC/HIGH NOBLE ME03 0110 0 625.000 8688.001 CCHGo12/10/9302 06750 CROWN-PORC/HIGH NOBLE ME03 0120 0 625.000 9313.00' cCHGo12/30/9302 03 CELIVER BRIDGE 05 05-012 0 0.000 9313.00' CCHGo02/03/9402 027 POST OPEnATIVE CHECK 00 0 0 0 0.000 9313.001 genS" 83/17/91" 2 06759 CRO',o/N PORC/lIIOH4iOBLB liE 0 3 "28"- 0 673. '75. 99131;;. 7St CCHGo03/17/9402 06750 CROWN-PORC/HIGH NOBLE ME03 027" 0 673.750 10660.501 Ae~~Q~le~llelue~~ule~llele6ele~lleijleellllleel~luleuelueleleueijeelllluele~llije~) PgDn Continue End Exit OFFICE 2 PATIENT TRANSACTIONS INQUIRY Thursday March 21, 1996 e~e~~~I~e~~~~~~~~~I~~III~~eee~I~~~~II~I~~llle~I~~elleelee~I~lleijlee~~el~~~I~~~~1 cPATIENT:2629 SEEK, ALEXANDRIA A oCODE:M oFEE PLAN n:OaAAA~AAAAAaA4~Ai CDOCTOR:2 BURKETT 6aaaaa~~~AeAaA44a~aaA~aAaaeaaaaaaAAAaAAiINS TOTAL I CHYGIEN.:5 RUDGE 0 CURRENT OVER 30 OVER 60 OVER 90 PORTION BALANCEI cNEXT APPT. :--/--/-- 0 0.00 0.00 0.00 7033.70 1880.00 7033.701 uA~~oAAAaAAaa6aaa8aAAAaaaea,iaAAAaAA~a~a~a4AaAAAa6aj6aa6aaAaa8AaaaA4Aa5~a~AA4~~4i ~CYHo DATE oDOcoCODE DESCRIPTION oUNOTuoSURF 0 AMOUNT 0 BALANCE I uaA~e4AAaa~aAeaaae~AAAAaaaaaaa~aaAAaaaAa4AaAaAaaeaaeAaeaAA~AeaAA~AAa~eA44A~AA4~i CCHGo03/17/9402 06750 CROWN-PORC/HIGH NOBLE ME03 0260 0 673.750 11334.251 CCHGo03/17/9402 06750 CROWN-PORC/HIGH NOBLE ME03 0250 0 673.750 12008.001 CCHGo03/17/9402 06750 CROWN-PORC/HIOH NOBLE ME03 0240 0 673.750 12681.751 CCHGo03/17/9402 06750 CROWN-PORC/HIGH NOBLE ME03 0230 0 673.750 13355.501 CCHGo03/17/9402 06750 CROWN-PORC/HIGH NOBLE MEO] 0220 0 673.750 14029.25' CCHG"03/17/9402 06750 CROWN-PORC/HIGH NOBLE ME03 0210 0 673.750 14703.001 CCHGo04/04/9405 0120 PERIODIC ORAL EXAMINATIo01 0 0 0 16.000 14719.001 CCHGo04/04/9405 01110 ADULT PROPHYLAXIS 03 0 0 0 36.000 14755.001 CCHGo04/14/9402 03 DELIVER BRIDGE 05 02 0-28 0 0.000 14755.001 CINso05/06/94.5 082 AETNA DENTAL IN 04/04/940 0 0 0 -52.000 14703.001 CCHGo05/10/9402 02 DELIVER CROWN 04 0210-28 0 0.000 14703.001 CCHGo06/02/9402 0330 PANORAMIC FILM 00 0" 0 44.000 14747.001 CCHGo06/02!9402 0120 PERrODIC ORAL EXk~INATIoo1 0 0 0 16.000 14763.001 CINso07/05/9402 082 AETNA DENTAL IN 06/02/940 0 0 0 -44.000 14719.001 Aije~QI~~~ijleluleeQeleeeeleeeeeeel~II~~eeeeeleeeeueeueeueee~IQleee~~~~u~~~~~6~~~\ PgDn Continue End Exit -.......-....... ... -.......~~~~...... .................. ............-......... ........................ , ~. OFFICE 2 PATIENT TRANSACTIONS INQUIRY Thursday March 21, 1996 ~666~66ijIA~AIIIIII1611IAA~A011111111111111IijIIIIIIII00alllllllllllllllijll1666661 CPAT!ENT:2629 SEEK, Al,EXAN[)HIA A oCODE:M oFEE PLAN #:oGaaUUU444U6i CDOCTOR : 2 BURKETT OMlAAA4aMieaAA444AilA4Uaaaea,'iaaa4AA4AaAi INS TOTAL 1 CHYGIEN. : 5 RUDGE "CURRENT OVEIl. 30 OVER 60 OVER 90 PORTION BALANCEI CNEXT APPT.: --/--/-- 0 0.00 0.00 0.00 7033.70 1880.00 7033.701 u"48i1A4AA4AAoaaA8AA44aaaeaaAaaAA4A444AA4AAaA4AA6aaoaaoAAAA404AAAil4468444A44464t CCYHo DATE oDOcoCODE DESCRIPTION oUNOTuoSURF 0 AMOUNT 0 BALANCE 1 u644ea44A444Ae44aeA44Aaa4Aaaa4A4A4AaA4A444AA4AA4e4A~aaeA4A44e444AA444~444AA4464i CINso07/05/9402 02 UNASSIGNED INSU 08/03/930 0 0 0 0.000 14719.001 CINso07/05/9402 02 UNASSIGNED INSU 08/06/930 0 0 0 0.000 14719.001 CINso07/05/9402 02 UNASSIGNED INSU 08/13/930 "0 0 0.000 14719.001 CINso07/05/9402 02 UNASSIGNED INSU 10/11/930 0 0 0 0.000 14719.001 CINso07/05/9402 02 UNASSIGNED INSU 10/19/930 0 0 0 0.000 14719.001 CADJo07/05/9402 029 REM STARTING BALANCE o_po 0 '10000.000 4719.001 CNOso08/30/9406 00 Mi~ued appointment 0 0" 0 0.000 4719.001 CCHG010/1B/9406 0120 PERIODIC ORAL EXAMINATI001 0" 0 16.000 4735.001 CCHG010/1B/9406 01110 ADULT PROPHYLAXIS 03 0 0 0 36.000 4771.001 CCHG010/1B/9406 02385 1 SURF RESIN-ACID ETCH, 02 01400 0 51.000 4822.001 CCHG010/1B/9406 02385 1 SURF RESIN-ACID ETCH, 02 01300 0 51.000 4873.001 CCHG010/18/9406 02385 1 SURF RESIN-ACID ETCH, 02 03 00 0 51.000 4924.001 aCHG010/18/9406 02385 1 SURF RESIN-ACID ETCH, 02 04 00 0 51.000 4975.001 CCHG010/18/9406 02385 1 SURF RESIN-ACID ETCH, 02 020"0 0 51.000 5026.001 a616u6ijlij~lllulllullijllleaee~llllllllel~eelllleeueeu~euellllulllleeeeul16116666) PgDn Continue End Exit OFFICE 2 PATIENT TRANSACTIONS INQUIRY Thursday March 21, 1996 e66661lelllllllellleelel~ijeeeellllelllllllllijlllllllllIlijlellleij1611e161161~6661 cPATIENT:2629 SEEK, ALEXANDRIA A oCODE:M oFEE PLAN n:OGa4A4444A446444f CDOCTOR:2 BURKETT OaaaAA4A44eAAAaA4aaaAAaAAAeaaaaaaAaaaAAiINS TOTAL 1 CHYGIEN. :5 RUDGE 0 CURRENT OVER 30 OVER 60 OVER 90 PORTION BALANCE 1 CNEXT APPT. :_./__/u 0 0.00 0.00 0.00 7033.70 1880.00 7033.701 uAa4oAAAAAaaaoaaa8AAAaAaAeaaaaAA4aaAAAAAA4aAaaAaoAaoaaoaaAAaoaAAAA4aa84A4Aa4444i cCYHo DATE oDOcoCODE DESCRIPTION oUNOTuoSURF 0 AMOUNT 0 BALANCE I uAAAeAAaAAAAaeaAae44AAaaaaadaAa4AaaaaaaAAaAAaaaaeAa~aaeaaaAaeaaAaaaaa~aa4444444i CCHG010/1B/940~ 02385 1 SURF RESIN-ACID ETCH, 02 02800 0 51.000 5077.001 CCHG010/1B/9406 02385 1 SURF RESIN-ACID ETCH, 02 029"0 0 51.000 5128.001 CINsoll/17/9406 082 AETNA DENTAL IN 10/18/940 0 0 0 -297.600 4830.401 OCHGo01/19/9506 04910 PERIODONTAL PROPHYLAXIS 04 0 0 0 54.000 4884.401 OCHGo02/08/9502 04260 CROWN LENGTHENING PROCEE04 "18" 0 385.000 5269.401 CCHGo02/0B/9502 02710 TEMPORARY CROWN 05 0180 0 235.000 5504.401 CCHGo03/02/9502 02750 (~OWN-PORC/HIGH NOBLE ME05 0180 0 5B5.000 6089.401 CINso03/03/9505 082 AETNA DENTAL IN 01/19/950 0 0 0 -3.200 60B6.201 CINso03/31/9502 082 AETNA DENTAL IN 03/02/950 0 0 0 -180.000 5906.201 OINso03/31/9502 082 AETNA DENTAL IN 02/08/950 0 0 0 -292.500 5613.701 ClAJ)Jo04/18/95'2 015 correction of Balance O.C"" 0 '235.000 5378.701 OCHGo04/18/9502 oB FINAL IMPRESSION 00 0" 0 0.000 5378.701 CCOLo04/1B/9502 02 Pymt - Check over countrO 0" 0 '125.000 5253.701 OCHGo05/12/9502 01 RECEMENT TEMPORARY 00 0 0 0 0.000 5253.701 ~leeullijIIIIIOlllu611Ieeeee0eijlijijlell~elllijellllule~ee011111u11111666u111166666) PgDn Continue End Exit --.---. ---....- -..-........... -. .. I ... ~ .. ........ . OFFICE 2 PATIENT TRANSACTIONS INQUIRY Thursday March 21, 1996 ~66~~~~~~&&6&~&&&~&&e&lleleleelellele&clelijeellleellleee&e&le&&&le&6&el&e&666e61 cPATIENT:2629 SEEK, ALEXANDRIA A oCODE:M oFEE PLAN n:Oa~~~AAAaAAAAa'41 cOOCTOR:2 BURKETT oaaa~~~AaAeAaaaAaaaaaAaaAAeAAaa~aa~a~aAiINS TOTAL 1 cHYGIEN.:5 RUDGE 0 CURRENT OVER 30 OVER 60 OVER 90 PORTION BALANCEl CNEXT APPT. :--/--/-- 0 0.00 0.00 0.00 7033.70 1880.00 7033.701 ua448~Aa~aA4A8aA~oaaaAAa~eaa~aAaAAa~~~AA~AA~A~AAoA~oa~o~~A~a8A4A~AAA~o~~44~a4"i cCYHo DATE oDOcoCODE DESCRIPTION oUNOTuoSURF 0 AMOUNT 0 BALANCE I uA44e6a4'A~aAeAA~ea'AAaAAAaaA"~aaAAa~~AaaaAaaaaeaae'4eaaAaaea~a~aAAaeaa4aAa~'al CCOLo05/22/9502 02 Pymt - Check over countrO 0 0 0 -100.000 5153.701 CCHGo05/25/9502 02710 TEMPORARY CROWN 05 0210 0 235.000 5388.701 cCHGo05/25/9502 02710 TEMPORARY CROWN 05 0220 0 235.000 5623.701 CCHGo05/25/9502 02710 TEMPORARY CROWN 05 0230 0 235.000 5858.701 CCHGo05/25/9502 02710 TEMPORARY CROWN 05 0240 0 235.000 6093.70( CCHGo05/25/9502 02710 TEMPORARY CROWN 05 0250 0 235.000 6328.701 CCHGo05/25/9502 02710 TEMPORARY CROWN 05 0260 0 235.000 6563.701 CCHGo05/25/9502 02710 TEMPORARY CROWN 05 0270 0 235.000 6798. 70L "~I1gftg[/2S/9S""'2 1)2719 TE~H\QR.\HY CROUIJ ns n2en n 2JS.een 79))."181 CADJo06/08/9502 060 Insurance form charge O.AO 0 0 585.000 7618.701 CADJo06/08/9502 029 REM STARTING BALANCE o_po 0 0 -585.000 7033.701 CINso09/14/9502 02 UNASSIGNED INSU 12/10/930 0 0 0 0.000 7033.701 CINso09/14/9502 02 UNASSIGNED INSU 03/17/940 0 0 0 0.000 7033.701 CJ 0 00 0000 0 t aij&~u&&elll&eu&elue&&&eeeeeelleijlele&&&&e&leee&eueeu&1ue&&I&u&&ee&eeeu&e&&e&e6el PgUp Current transactions End Exit -.._-~..- -.................--.............. ,........................ ....,. ..--.1.. ......1....... ..,..,..,. (11Ut 04.11.96 Patient History Report T,m.. 0805 06 for Patient #2629 SEEK, MRS ALEXANDRIA A. including transactions starting 04/11/1995 ~ Q!!! IIlI 07107/95 Ill) 07107/9l Ill) 07.'07/9l IIl1 04/ll/9~ IIlI 04/11/96 ~ Ill!! 2 999 2 999 2 999 2 Il 2 Il DeSCriPtiO!! ~ l2!llh ~ Amr)unt ll!!!nf! Pnor balance 50.00 5000 Starting Balan!.:c ,^ $16540 $I6l 40 S18"lOg Balance +^ 53280 $198 20 Slll1mg nalanec +^ 5681110 57033 70 CO"':I.:1I011 or Balance .r 2P> . 6>1'.... . I'm- lit AI $.673 7l 561199l l'orn:..:llun or lIalanc\l -c 1. f, - 7i"'J4Yd"II'r""".... 5.23l 00 5~124 9l PalllmlNR $61249l { 0 .].. (j' t- ,','; ~ r- 0- .,1 8. 4'l ~ f" ~ !: \fl ~ 1\ ::! Cl'. '. ~ .-) I I I' I l. ,,\\ \)"1\ I ~ SAInIS, GUIDO, SHUFF & MAS LAND "I'th'tl "1..".....1 ,,11<1'-.1""11<1"- l\ll1NI. '1.111-1: tl.\lIH'" r ~- \..\Inl\ 1I1\li,^tl.f)L l,UI/:Kl Cf.l.)tflU) \ "'HUH ^IIU:.tl.r II ..,.....'1L""1l I\JI'''''''.'' I DI:II-Y IIMOI H) M ,"'N'IIIM. ,en rr n 'IoKh..llle 'Ill') ~l"ll,"'l r lllq I' 1 P 1..'1 Rl.l\ III CAMP HILL. Pf:NNSYl.VAN1A 17001-()7'17 ..:MJ.lllJ..1lJll'.:J.. .Ill \l,.1\llllt;II'lIIUI.1 l.,,'l,l.I\LL 111\ IIUll Ill/l.'I.\'IJ.'.'.' ....., 1/11) J I ,.(, IMIo 1/1/\ /1/ \ Ill, t"\ 1/1/1/1/' 11\1/ MI!!LI1LC...~MJ~'IU.L July 9, 1996 The Honorable Harold Sheely President Judge Cumberland County Courthouse Carlisle, PA 17013 ReI Burkett Y. Seek "0. 96 - 137 Dear Judge Sheely: I was appoi.nted Chairman of the Board of Arbitra- tors in the above-referenced action. Please be advised that our office has represented the plaintiff in other matters so I should disqualify myself. Bob Saidis is returning the file so that you can name another arbitrator. Very truly yours, JES/McC SAIDIS, ~. , .' I Slike GUIDO, SHUPP" MASLAIID , t Cl -"f) 0 (. en . - "11 .,-; C ; ,..., -;1 tl)t ".. <, :~~ r,.:i' ') I.,': l:'. .l ~ , " ~ .,J") . ~') -Jj , :'r: t , \1) .' C' I. )111 .. " ':") .'. ., In "1 ... December 13.1996 / Dennis Burkett DDS -vs- Alexandria A. Seek No 96-1737 Civil Term Property Claim Determination Dear Sir: Reference is made to Property Claim dated December 5. 1996 entered by Roy E. Seek and pertaining to Execution No. 96.1737 Civil Term, Dennis Burkett DDS vs Alexandria A. Seek. R. Thomas Kline, has determined that the claimant .Roy E. Seek in thl: abovementioned property claim is prima facie the owner of the property set forth therein. So 2~"'"' r/.AI!' ~1."~ ~ R.' omas Kline, Sheriff" AI'6 Byg,t;;~r' h::~ Deputy Sheriff cc: Gilroy atty for pltf A. Seek deft , R. Seek claimant -' I'ROI'I!RTY CI,AIH 111 thtt CQurt of Common PlnllK of C:llmhllrJand Coullty, hlln~ylvnnlft Dennis Burkett DDS ...-- .'....... ~ -- ----- ........... .. ..----.....-...-----......... ... --OT"'''''' -... ..-_. ""'''' ..___.. ..... .._......__ __....... ....._...._ "'rlt No. . 96-1737 Civil VII Alexandria A. Seek --...--- ............ ..... ---..--.........-..-----....-..... ........ .'. ......... ...----..-------.---- ---.....- I'll '1'1111 SIl~RIn' 010' ClnlRr.RI.^NO C:OllN'I'Y, l'ENN^. Thu llrllpurLy IIKLml lIulll\1 UIIU IllVllld IIpOIl III tlllll ClIllll III lIot tho property of tho ,11Ifllll.lullt \;ut III Ih,' l'wllNly of the ulldeuISlIlld'. A IIRt of the clolmed prorerty Rlld Lhu vlIIIIU thurullr Url'l 1.IS'I' ()II 1'ltlll'l!ll'I'Y VAlII.S 1~ 5t a----------___._____._.._.________~_L 5 'c,.J:..f__ ______. .______/c vtL./~,..,<_::_____.__..______________ ~-,~.; (~_____ .-.----(;M/~.!:.L:.l---__._ _______ (/~.<',r,J (';<709) / h / __c..L&d---_&..rt.L{ig.r;,-L__.._____________._~_. />?, ", _____~ 1f/~:...LJj).-__-_--__ , ~~/>f j-;t1~ /;~~) no -.:f/..~.L':L?F-:-c'_________________.______ 1-'<", ()<" _____ ____Z€'/6' V/'J I ;.:~______________.:..... f>j,' 1<'. t'" _____ J / - -f'/I fc' ,. (' -__. _._.:;;.6./.!..c!____.... ..._n____ ___________ __. _f"': (?=.!:, .!!::.:: _'!':'~~:..~~:~.:.._(;. .('~ . _ _ _ _ _ _____ _____ ~..;.' 7 5 ~ (. C' __ _____ .___ ___A..~_(tf~(._________ _______ _.______ __ _._____ r Ie'. c' ," ____On I'hu C:lillmilllt Ohlal",',1 Tlllll III tIlt' l'rllr,.rty ilK FollOlIRI .__n~!.:":.c: 7"/./.~q.<:_(,<,. .C&,'j_=~:~~_Z~~~J~_ I/..e''d,{' " ,,- ,/ c'~. J ~),':.Aif'l ~~ c:.. _-f-..__ __~~______. ....... --..---------- --_..'-----_.._...~... --...... ...... .--- ..-..--- ----------- -..---- ----- ----....-....... ---...---- -..... -- --.....---.... ......-..-------- ------.. ----.. '"--..... ...--. ---....... ....-.... ---- ....-.. ...-......... ------------..-------...-...------- -...... --- ----.... ....-.. -. .,,,""-" - --- --..... .._~-_.. ............. --- -. ----...---- . ~:----:---L' '---,' -- -----. j" /. I. ,"'\.'4 I -=-_. Uill". __. _:~:.,~/L.---_.-n ___mO. ____.C\.^IIIAN.I._----::'~.; (1 /'10':" ,~O' /<- [$ !~G<f/C. /:.;:;- (~) /';'.<'/-/ /l~.:"/.t /;'~h ~~(.(", .' I' c//~/'/<! r /A'?; ,., pt rn"T '~"';'}; I!', j~~ 7'(/"r;j ~:.;'t', t~ (:"I"-;;"'r/ l-t I/'I\'e .I,,; U', (t;' //c 7i. {o/''' 7' J', .: c /-/r~ {(~j' ,,~,;, f"/ r ~!I-('. u. ,. /.A/<y'l JIM'/< /;{ t"~r' /7/u. ,( ~f: ",' L,tIt-:j1r. ,h1,"t'/':' /'tT '~:"":,, &r ;\~ 7<'#1"'" /J//'-t6..;7t: 7ii~/6 ~c1, ('l(1 {"~"fr:f fjr).., N' ~/'/ ' .' - /" ,C.A'q ~(.''If'< E 7'->, " ~ (j frrt.'J(;lj ..-I';> f: e , /i'/) -r )J., J'.J''''? c', (' c' / ,I / /'-' Ii" .T-;/l'c'I.--' /C, c,' , . ( "..../, 'II .:;r~'~ ""'1'-/ ,P(',!/J, C,' v .f(c rA'I';ii.:J!"'~~~ 'Jr ,>-,1, (1(:.) J;lv';: -f'/!~,(',) " /V;f-J/1"pt'.!. /t., Ce' .fJ/'f'~'< ~~,CV .-- ... - /:>f"::~ 2.G('(. 7'), C,I Y7> . ...,. . ./ // ,.-<;-3,,<:. If, cJ ti .Jl ;;'-rt. elF/'- ~F, V" /1'l~(l,t /r('cA:J''..I',X '?-J,I(I /~ .... ~- ~.l/f'c^ ? ~() /,6 / o//"'/<-c ..I /O'C/" t /f' ,P /~,-,~w/,)tf //'MC',1',:..-.c. /"ftJ. dV _'. ,-r .I ~ t!' ;? "11"'<:';:'...( /,('.,.,(!,f J/t/ It c..L r, (It:? /.//./;i1MQfyf.t'/C- ..f75i. (',I (.$'r A .. ,f'(V'<' .(f (j) ,p~.L 'r?:),C't' !/II"! Jr!, rt' F~ 71'/.' /'fJ';'/";:;'" r ('"c/< 'fF/":" /Y. 7)- - .." " r/./{?i"fft!~ .1/7 7(1('. ('(1 ( ,.</,,~/t' (/) :(;if {>C. . ._t /'< ( /,'/II/'J ..{ 111"11'.1' 5' J1'7>;!.'t' "Y.u t' ].I" "r,~, -r/ / c" ~I " , (/' 1: ~('" " ( .. L ~.1 '-, ~ IP" r,1( /'J~ , _'. - '- ' kif/,#' ;;"- /'-'i;',. t"- /: t C' t't ,.,' ,tI//"""I' )/1/1" t.t ,7J,. C.'l' I'", r,... r,tA.-C _" I. r f.{ ,1/' 't"/'.-.(;'/L <,~t'jl' ./)', c'-' ., " j '" /~. .. ,,/ '/ ( /t ~ I. ~ ,..':; ,(. 4 ,.I^' .I -;' J: (1 (] //~'I A',('tI...' 1/ ',j,'.t', ., I '.f'..." l~ '\,. /(,~ i*: ',$ I" l