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Home My WebLink About02-5050REMIT CORPORATION, Assignee of : IN THE COURT OF COMMON PLEAS THE BLOOMSBURG HOSPITAL, : CUMBERLAND COUNTY, PENNA. VS. L. SHAUN BRYAN Plaintiff Defendant : CIVIL-LAW : r)oc T NO.: NOTICE TO DEFENDANT TO THE DEFENDANT: YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served by entering a written appearance personally or by attorney and filing in whting with the Court your defenses 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. Pennsylvania Lawyers Referal Service 100 South Street, P.O. Box 186 Harrisburg, PA 17108 717-238-6715 Cumberland County Bar-Association 2 Liberty Avenue Carlisle, PA 17013 717-249-3166 REMIT CORPORATION LAURINDA VOELCKER, ESQU1RE Attorney for Plaintiff REMIT CORPORATION, Assignee of : IN THE COURT OF COMMON PLEAS THE BLOOMSBURG HOSPITAL : CUMBERLAND COUNTY, PENNA. VS. L. SHAUN BRYAN Plaintiff Defendant : CIVIL-LAW : DOCKET NO.: ~5) ~,~ - ~5jo -9~O COMPLAINT The Plaintiff, the Remit Corporation, by and through its attorney Laurinda Voelcker, Esquire, hereby files this Complaint of which the following is a statement: 1. The Plaintiff, the Remit Corporation is a Pennsylvania Corporation doing business at 36 West Main Street, P.O. Box 7, Bloomsburg, Columbia County, Pennsylvania 17815 and is the assignee of The Bloomsburg Hospital. A copy of the document assigning all relevant fights with reference to the present action to the Remit Corporation is attached hereto, incorporated herein and referred to hereafter as ExNbit A. 2. The Defendant, L. Shaun Bryan, is an adult individual residing at 50 South 22nd Street, Camp Hill, Pennsylvania, 17011. 3. On or about July 24, 2001, L. Shaun Bryan was admitted lo The Bloomsburg Hospital for medical treatment of Depressive Disorder and Recurrent Manic Depressive Disorder and did receive various services from The Bloomsburg including, but not limited Emergency Room services, Psychiatric services for twenty days, medical supplies, and laboratory services, as set forth on the attached bill. The aforementioned bill is attached hereto, incorporated herein and referred to hereafter as Exhibit B. COUNT 1 BREACH OF EXPRESS CONTRACT 4. The preceding paragraphs are incorporated herein by reference and made a part hereof as if fully set forth herein. 5. In consideration for the services and materials supplied by The Bloomsburg Hospital, the Defendant L. Shaun Bryan agreed to pay all reasonable charges and expenses related thereto. 6. On 7/24/01, the Defendant signed a Treatment Authorization and Assignment of Benefits form which states in part, "I agree that I am responsible for payment of that portion of hospital and/or physician expenses not covered by my insurance. If my hospital and/or physician(s) charges are not covered by my insurance, or, ifI am uninsured, I will be responsible for payment of the entire hospital and/or physician(s) bill. I undersatnd that I am financially responsible for any balances, a copy of this statement and signature is as valid as the original. 7. The charges for all services provided to the Defendant, L. Shaun Bryan is $17,418.48. 8. The Defendant, L. Shaun Bryan, accepted all services for which he was billed w/thout complaint, object/on or dispute as to the services provided or as to the prices charged for the same. 9. In breach of the Agreement between The Bloomsburg Hospital and the Defendant, L. Shaun Bryan failed to make payment on the outstanding sums and the same is now due and owing. 10. By virtue of the assignment of The Bloomsburg Hospital's fights to the Plaintiff, The Remit Corporation, the Defendant L. Shaun Bryan, is indebted to the Plaintiffin the amount of $17,418.48. WHEREFORE, the Plaintiff, The Remit Corporation, Assignee of The Bloomsburg Hospital, demands judgment against the Defendant in the mount of $17,418.48, together with interest, costs and such further and additional relief as this Honorable Court deems just and equitable. COUNT H BREACH OF IMPI,11~B CONTRACT 11. The preceding paragraphs are incorporated herein by reference and made a part thereof as if fully set forth herein. 12. It is averred, in the alternative, of the paragraphs set forth above, if an express contract between Plaintiff and Defendant did not exist, that a contract implied within the law exists. 13. At all times relevant hereto, the Defendant was aware that The Bloomsburg Hospital was providing medical services to L. Shaun Bryan and that The Bloomsburg Hospital expected to be paid for these services and materials. 14. The Defendant received the services rendered and received the same to her benefit. 15. The total value of the services and materials provided to the Defendant, L. Shaun Bryan by The Bloomsburg Hospital is $17,418.48. 16. In breach of implied contract the Defendant has failed and refused to pay medical services rendered and the same is now due and owing. 17. The Defendant has failed and refused to pay the aforementioned sum despite frequent demand to do so. 18. By virtue of the assignment of The Bloomsburg Hospital's rights to the Plaintiff, The Remit Corporation, the Defendant L. Shaun Bryan, is indebted to the Plaintiff in the amount of $17,418.48. WHEREFORE, the Plaintiff, The Remit Corporation, Assignee of The Bloomsburg Hospital demands judgment against the Defendant in the amount of $17,418.48, together with interest, costs and such further and additional relief as this Honorable Court deems just and equitable. ,COUNT HI QUANTUM MERUIT/UNJUST ENRICHMENT 19. The preceding paragraphs are incorporated herein by reference and made a part thereof as if fully set forth herein. 20. The Bloomsburg Hospital provided the medical services set forth above with the expectation of receiving payment for such services and materials provided. 21. The services and materials provided to the Defendant by The Bloomsburg Hospital benefited the Defendant. 22. The Defendant will be unjustly enriched if he is allowed to retain the benefit resulting from services and materials produced by The Bloomsburg Hospital to the Defendant without having to make a reasonable payment for the value of the benefits received by the Defendant resulting from The Bloomsburg Hospital's provision of services and materials. 23. The Bloomsburg Hospital was not a volunteer in providing the services and materials set forth above and the Defendant understood that The Bloomsburg Hospital was entitled to compensation based upon the amount of services and materials provided. 24. The reasonable value of the services and materials provided to the Defendant is $17,418.48. 25. By virtue of the aforementioned assignment, the Plaintiff the Remit Corporation is entitled to $17,418.48 from the Defendant and frequent demand for said sums has been made and the Defendant has failed and refused to pay the same. WHEREFORE, the Plaintiff, The Remit Corporation, Assignee of The Bloomsburg Hospital, demands judgment against the Defendant in the amount of $17,418.48, together with interest, costs and such further and additional relief as this Honorable Court deems just and equitable. Respectfully submitted, Laurinda Voelcker, Esquire PA ID #82706 Remit Corporation 36 West Main Street Bloomsburg, PA 17815 570-387-6470 VERIFICATION I verify that the statements made in the foregoing Complaint are true and correct. I understand that false statements herein are subject to the penalties of 18 Pa.C.S. sec. 4904 relating to unswom falsification to authorities. Philip W. Zeafla, Remit Corporation ASSIGNMENT OF CLAIM PURSUANT TO PENNSYLVANIA ACT 219 OF 1990 For value received, the undersigned, The Bioomsburg Hospital assigns to: The Remit Corporation doing business at: 36 W Main Street PO Box 7 Bloomsburg, PA 17815 a debt due to the undersigned from: L Shaun Bryan #217787 for the sum of $17,418.48 arising from unpaid medical services. The said sum is justly due to the undersigned without offset or defense. The undersigned neither transfers to The Remit Corporation, nor expects The Remit Corporation to assume, any obligation or any liability of the assignor to the said debt. The undersigned has done nothing and will do nothing to discharge the debt or hinder its collection and hereby grants to The Remit Corporation the full power and authority, to bill and collect the aforesaid claim, in accordance with Pennsylvania Act 219 of 1990, Section 2, as it amends Title 18 regarding Section 7311, including to sue for, (in its own name, through an attorney licensed in Peunsylvania) and discharge the assigned debt or to sell and assign it again. The Remit Corporation specifically agrees to comply with the Pennsylvania Act of December 17, 1968, P.L. 1224, No. 387 (known as the Unfair Trade Practices and Consumer Protection Law), and with the regulations promulgated under that Act pursuant to this assignment. Dated this C~ ~)'-~t day of Authorized Signature The Bloomsburg Hospital EXHIBIT ! C ..~N FaC !;~.~ ;.: :~.~ .~ ~ ....... J .,~', CD M ~.,'IRLT ,4p~T O. O0 PER ...... · ' ~ ~;~, ""~T'¢'" ~.~ u"u.:oo oUF. L -' <;':>~ '" ~ 3, ~: ~: '773 I-.ABORA-rORy ..... ~I.~. :< -~: : --r:~-, , ,,...,. , ' O OO ,.ii Fd ,-"~-mc~ F~ NURSEiRY O"FHER IqISCELJ_.ANEOUS 1:;() :' "':" G, O() :. 5FI OO 900. O0 ....... · ' ..... :.~ ()O I3 UN~L O O') ~' t~¥~ ................... ;7-;7; ..... ...... dNB.[L,L=D O. OO CURRENT B~LANCE ; :,;i ;' ::',~'~ ', ,., ................ 17, :7 .,' O. rjo ~ :.! O. O0 ~ ' ~ O. O'D O. O0 TOT' CURR ' ., -~Id. 48 17, ~.i8 "2 :~ Ai. Ah!C i-t ~C¢ Ci:NDY f,'~,o DIqC .... u. -I.:: i "l'iT) .......~ -" ....... ' "i0 O. ,.~E. PR~o~ Z VI DISORDER DS(tH r) i76. 3:::~ RECURRENT MDD-SEVERE ,.,-,. B:/:iIt:iD CAL.LED FROM MA OFFICE L..~ ....... WANTS BILL FAXD 'TO HZH AND H,:.' [-,.!~ L )'NCLJ.~DE IN APPL THEY ~RE FOR - ,~ · FAXD '!"Ct 717.-=H=: '56~1 DNC , :~ ....... ',,',~ TF , 76 77 AC'2f?lm, i'f' ,,.~ cr~ '-'- ..,. .I c' ,' ..... (~, . ~.:~5.,* OFF']:CE CAI.-L. ED "f'C} ¢' '"" ' ....... INFO dE: HAV~ -'- TOLD Fh:R RE: AIH3VE I'1A APP POSSIBLE -"PSH T'O DMC 1'~05mI ..... ¢' liiJT%l CfNDY HRo, NOTHZNG 'FFT' DP1 ', AI',!z:WALT', CUMBERLAND CTY DE,,.,.ED · ............ ",~ DID NO I FlEE f2OOO TAX r(;':T'UF':fq C]:NDV '(:HECI<ED AblD ~rff].;: .[~ , , J..l COUNTIES D~.., NOT "! i(::~ d:,S ,:; :" :: 'iA¢ I~t)'i' 'rHr:y CAN. ' .... <'()F'V G :"~:NIAL 'TEl ME DMC ~ I ]. 90 J EXHIBIT :r(]).':i(:~Ti!"'7.-.!i~ N 3 000 ': )) [," ~.:: ~.'?~ i P I" ]: ,ri Fl ~D_~Fi"~I]' Oh! ]H].S ONE ,~:':]OU~t~9 'RETURNED FROM ~CI X TO I]D "*' .... "~ KOrflO LAST AMOUNT ~J AI.,.AI'4C E DMC 1130 0 :t 1 '7, 4. 1 ¢, .4-8 17, 4~ 9 4B PATIENT NAME PATIENT NUMBER ADMISSION DATE DISCHARGE DATE CO.t3 INSURANCE COMPANy NAME I GROUp NUMBER POLICY NUMBER GUARANTOR PLEASE RETURN THIS PORTION WITH YOUR PAYMENT. I' ^MOU.T OF PAYMENT CATE OF DESCRIPTION OF I SERVICE TOTAL EST COVERAGE EST COVERAGE ESE COVERAGE EST~ COVERAGE PATIEN1 SERVICE HOSPITAL SERVICES CODE CHARGES INS. CO NO1 INS. CO NO 2 ~NS CO. NO.: INS. CO. NO. 4 AMOUN '. ,; PHYSICIAN'S BILLING SERVICES 549 East Fair Street, BIoomsburg, PA 17815 ~ 50 S ~2~0 ST ¢~P r~ILL PA 17011 F )7 )07048 12/09/196), , ~ ~,,~/01 ,*l PSt' 41~' I r t U ........... A L ,t TREATMENT AUTHORIZATION AND ASSIGNMENT OF BENEFITS The patient, or person acting for the patient (hereinafter 'T' or "Patient"), agrees to the following terms of admission: AUTHORIT.,ATION FQP~HOSPITAL TREATMENT: I hereby authorize the h sician ' , .x~ ¢-..~///lCf/PJ ~-~ P Y In charge of the care of !r~,atme?J dr/to, peJfo'~ rc~tine hospital~erv ces, and/or dia,',nostJc 07o ....... _ to a, dmJnister medical ,n the o,agnos,s and treatment of Patient. I hereby consent ;~ receiv~ ~-~;;i~/~a~r~an.y oe necessary or advisable · 'is as ordered by the responsible physician(s). I agree that the consent to treatment given herein shall be valid continuing discharge, and until AUTHORIzATIoN TO RELEASE INFORMATION: (Not Applicable To Drug And Alcohol Patients--A specific authorization must be completed for release of information) I authorize The Bloomsburg Hospital and/or Physician(s) to release all or any pad of the patient's record pertaining to this account and/or any subsequent accounts and use patient's social security number to verify insurance benefits to persons or entities engaged in the' activities stated below. A. Ins.urance and Quality Rev ew: persons or corporations (including insurance companies, workers' compensation payers, hospital or medical services corporations, welfare funds, governmental agencies, or the patient's employer), or their designees, which may be liable under contract to the provider or any other party, the patient, a familY member, or employer of the patient, for purposes of securing payment for ail or part of a provider's charges and quality assurance, utilization review and peer review committees, accrediting agencies and provider and physician liability insurance carriers to enable them to carry out their functions. B. ~: agents or employees of the Provider that process or duplicate medical records for billing and reimbursement purposes. C. ~: persons or entities authorized by the Provider for purposes of conducting medical audit activities. D. ~: physicians and personnel involved in the patient's care to provide and manage the patient's healthcare. The undersigned further consents to the release of the patient's name and address to entities acting on behalf of the Provider. I understand that I may revoke this authorization at any time, except to the extent the Provider has acted in reliance upon it or the disclosure is authorized by law. ASSIGNMENT OF INSURANCE BENEFITS: I authorize payment directly to The Bloomsburg Hospital and/or physician(s) for all benefits payable under my insurance policies. After the coordination of insurance benefits has been satisfied, any overpayment will be refunded. I/agree that I am responsible for payment of that portion of ho;spital and/or physician(s) expenses not covered by my insurance. If my hospital and/or physician(s) charges are not coVered by my insurance, Or, if I am uninsured, I will be responsible for payment of the entire hospital and/or pHysician(s) bill. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ANY BALANCES. A COPY OF THIS STATEMENT AND SIGNATURE IS AS VALID AS THE ORIGINAL· / · The undersigned certifies that (1) I have rea~ and understand these conditions of admission, and (2) I am the Patient or I am duly authorized by the patient a.s patient's agent to sign this agreement and accept its terms. I~ Patient is a minor El Patient is unable to give consent due to: ~i~ AgeclLq~.c~Representative ~p to Patient Date of Sign~g / / - HITE - M~ical Record YELLOW - The B , Io~,,,o~urg Hospital; PINK - Physician's Billing Se~ices EXHIBIT THE REMIT CORPORATION, Plaintiff VS. · IN THE COURT OF COMMON PLEAS · OF CUMBERLAND COUNTY, PENNA · CIV1L ACTION - LAW L. SHAUN BRYAN Defendant :NO.: 02-5050 Civil PRAECIPE TO WITHDRAW CIVIL COMPLAINT TO THE PROTHONOTARY: I would like to withdraw the civil complaint filed in this matter and request this case be dismissed without prejudice. Respectfully Submitted, THE REMIT CORPORATION LAUR1NDA VOELCKER, ESQUIRE Attorney ID 82706 THE REMIT CORPORATION 36 W Main St PO Box 7 Bloomsburg, PA 17815 Telephone 570-387-6470 Fax 570-387-6474 SHERIFF'S RETURN - CASE NO: 2002-05050 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND REMIT CORPORATION VS BRYAN L SHAUN OUT OF COUNTY R. Thomas Kline duly sworn according to and inquiry for the within named DEFENDANT BRYAN L SHAUN but was unable to locate Her deputized the sheriff of DAUPHIN serve the within COMPLAINT law, says, that he made a diligent to wit: Sheriff or Deputy Sheriff who being search and in his bailiwick. County, NOTICE He therefore Pennsylvania, to On November 6th , 2002 , this office was in receipt of the attached return from DAUPHIN Sheriff's Costs: Docketing Out of County Dep Dauphin County .00 9.00 30.50 .00 .00 39.50 11/06/2002 R. Thomas Klin9/ Sheriff of Cumberland County THE REMIT CORPORATION Sworn and subscribed to before me this ~ day of~ A. D. Prothonotary SHERIFF'S RETURN - NOT FOUND CASE NO: 2002-05050 p COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND REMIT CORPOP~ATION VS BRYAN L SHAUN R. Thomas Kline duly sworn according to law, inquiry for the within named defendant, BRYAN L SHAUN unable to locate Her COMPLAINT & NOTICE ,Sheriff or Deputy Sheriff, who being says, that he made a diligent search and DEFENDANT in his bailiwick. but was He therefore returns the the within named DEFENDANT BRYAN L SHAUN NOT FOUND , as to PER POST OFFICE, HER NEW ADDRESS IS 910 MAIN ST STEELTON. Sheriff's Costs: Docketing 18.00 Service 10.35 Affidavit 5.00 Surcharge 10.00 .00 43.35 Sheriff of Cumberland County THE REMIT CORPORATION 11/06/2002 Sworn and subscribed to before me this ~ day of ~ ~o 2, A.D. r~ary ~ In The Court of Common Pleas of Cumberland County, Pennsylvania Remit Corporation VS. L. Shaun Bryan SERVE: s~ne No. 02 5050 civil Nov~, October 28, 2002 __, I, SHERIFF OF CUMBERLAND COUNTY, PA, do hereby deputize the Sheriff of Dauphin County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. Sheriff of Cumberland County, PA Now, within Affidavit of Service ,20 ,at o'clock M. served the upon at by handing to a and made known to copy of the original So answers, the contents thereof. Sworn and subscribed before me this _ day of ,20 Sheriffof COSTS SERViCE MILEAGE AFFIDAVIT County, PA Mary Jane Snyder Real Estate Deputy William T. Tully Solicitor Dauphin County Harrisburg, Pennsylvania 17101 ph: (717) 255-2660 fax: (717) 255-2889 Jack Lotwick Sheriff J. Daniel Basile Chief Deputy Michael W. Rinehart Assistant Chief Deputy Commonwealth of Pennsylvania : REMIT CORPORATION County of Dauphin : ERYAN ~, $~A~ Sheriff' s Return No. 2462-T - -2002 OTHER COUNTY NO. 02 5050 I, Jack Lotwick, Sheriff of the County of Dauphin, State of Pennsylvania, do hereby certify and return, that I made diligent search and inquiry for BRYAN L SHAUN the DEFENDANT named in the within COMPLAINT and that I am unable to find him/her in the County of Dauphin, and therefore return same I~OT FOUND, November 1, 2002 NEED A BETTER ADDRESS. AS PER JEFF ZERBE SHE MOVED BACK TO PITTSBURGH Sworn and subscribed to before me this 4TH day VEMBER, 2002 SO Answers, Sheriff of Dauphin County, Pa. By Deputy Sheriff PROTHONOTARY Sheriff's Costs: $30.50 PD 10/29/2002 RCPT NO 171081