HomeMy WebLinkAbout02-6095MOFFITT HEART & VASCULAR
JACQUELINE BEERS
WILLIAM BEERS
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
:
: CIVIL ACTION - LAW
NOTICE TO DEFEND
You have been sued in court. If you wish to defend against the claims set
forth in thc 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 writing 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.
CUMBERLAND COUNTY BAR ASSOCIATION
2 LIBERTY AVENUE
CARLISLE, PA 17013
1-800-9108
MOFFITT HEART & VASCULAR
V$o
JACQUELINE BEERS
WILLIAM BEERS
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
:
: CIVIL ACTION - LAW
:
:No.
COMPLAINT
AND NOW, this __ day of December, 2002 comes Moffitt Heart &
Vascular, above-named Plaintiff, by and through its attorney, Gall Guida Souders, Esquire, and
respectfully avers the tbllo~ving:
1. Plaintiff is a corporation having offices at 1000 North Front Street, Wormleysburg,
Pennsylwtnia 17403.
2. Defendant Jacqueline Beers is an adult individual residing at 6603 B Carlisle Pike,
Mechanicsburg, Pennsylvania, 17055.
3. Defendant William Beers is an adult individual residing at 6603 B Carlisle Pike,
Mechanicsburg, Pennsylvania, 17055.
4. At the specific instance and request of Jacqueline Beers, Plaintiff provided medical
services to Defendant at the times, amounts, and the prices for these services are
indicated in PlaintifFs Statement of Account, a true and correct copy of which is
attached hereto, marked Exhibit A, and made part thereof.
5. The prices charged by Plaintiff were fair, reasonable, and market prices that
prevailed at the times of the transactions.
6. Defendant William Beers was married to Defendant Jacqueline Beers at the time
services were rendered.
7. Although Defendant Jacqueline Beers was the PlaintiWs patient, Defendant
William Beers is also responsible for payment of said services pursuant to 23
Pa.C.S.A.~4102.
8. Plaintiffavers that the balance due amounts to $8,576.00, which is above the limit
for mandatory arbitration.
9. As of November l, 2002, the interest at the legal rate of six percent a year is
$605.46.
l 0. Although repeatedly requested to do so by Plaintiff: Defendant has willfully thiled
and refused to pay the aforesaid balance or any part thereof to Plaintiff.
WHEREFORE, Plaintiff respectfully requests that.judgment be entered in favor of
Plaintiff'and against Defendant in the amount of $9,181.46 with interest and costs.
Respectfully submitted,
Gall Guida Souders. Esquire
Guida Law Offices
503 North Front Street
Harrisburg, PA 17101
717-236-6440
Attorney for Plaintiff
Supreme Court ID #68740
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--~ MEDICARE E~ MEDICAID E~ CHAMPUS E~ CHAMPVA C'~GROuPHEALTH PLAN ~FECABLK LUNG 0THER la. INSURED'S ,.D. NUMBER (FOR PROGRAM IN ITEM 1)
(Medicare ~) (~dicaid ~) (Spon~r's 8SN) (VA File ~) (~SN ~ ID) (~N) ~ (/D)
2. PATIENT'S NAME (Lasl Name, First Name, Middle Initial) 3. PATIENT'S BIR~ DATE 4. INSURED'S NAME (~st Name, Fir~ Name, Middle tnitla0
5. PATIENT'S ADDRESS (No., Street) 6. PATIE~ RE~TIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street)
CITY STATE & PATIENT STATUS Cl~ STATE
ZIP CODE
TELEPHONE (Include Area Cede) ZIP CODE TELEPHONE (INCLUDE AR~ COD~
FulFTIme P~.~me 7
9, OTHER [NSURED'S NAME (Last Name, Fimt Name. Middle Initial) 10, IS PATIENT'S CONDITION RE~TED TO: 11. [NSURED'S POLICY GROUP OR FECA NUMBER
a. OTHER INSURED'S POLICY OR GROUP NUMBER a, EMPLOYMENT? (CURRENT OR PR~[OUS a. INSURED'S DATE OF BIRTH
YY M~ S~ F~
b. OTHER INBURED'S DA~ OF BIRTH b. A~O ACCIDENT? P~CE (~e) b, EMPLOYER'S NAME OR SCHOOL NAME
c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER ACCIDENT c. INSURANCE P~N NAME OR PROGRAM NAME
~YES ~NO
d. INSURANCE P~N NAME OR PROGRAM NAME 10d. ~HVED FOR LOCAL USE d, IS THERE ~OTHER HEALTH BENEFIT P~N?
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13, INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12. PATIE~S OR A~HOREED PER~N'S SIGNATURE I auth~ze the mle~e ~ ~y m~lce~ ~ ot~er I~o~atio~ n~a~ payment of medical ~nef~s to the undemlgn~ ph~iclan or supplier
14.MMDATEi OFDDCURRE~:i YY ~ I~URY (~ldent) oRILLNE~ (Flrlt 8yrripiOi.) OR 15, GIVE FIRST DATEIF PATIENT HAS H~ MM~MEi ORDDSIMIBRi YY I~ESS. 16, DA~S MMPA~ENTDDUNABLEyyTO ~RK IN CURRENTMM OCCUPATIONDD yy
~ I PREGNANCY (LMP) I i ~OM I I ~ I
17. NAME OF ~Fc~RING PHY~IOIAN OR OTHER 8OUROE 17a. LD. NUMBE~ OF ;;g; gH~lN~ PHYSIO~N 18. HOSP~ALI~TION DA~8 RE~TED TO CURRENT SERVICE8
19. RESERVED FOR LOCAL USE 20, OUTSIDE ~B? $ CHARGES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY, (RE'TN ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) I ~' MEDICAID RESUBM~SSION
~.14.14,,~ ISCFfEM[C HERRT ;DJ s,I '785.~ TRCHYCRr~)]R CODE ~ ORIGINALREF, NO,
23, PRIOR AUTHORI~T~ON NUMBER
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~4. A B C D E F K
Place ~ PROCEDURE 8ERV ES, OR SUPPLIES G H I J
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2z~.5 PARKE'IR STRE]ET 1000 IqORTH F'RONT c."'~ ........
CAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-1500 (12-90), FORM RRB-/500,
APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS)
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1, MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM
(Medicare #) (Medicaid #) (S~onsor's S~N) (VA File #) LJ (SEN or ID) L~ (SEN) XL~j (ID)
2, PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH DATE 4, INSURED'S NAME (Last Name, First Name, Middle Inllial)
5. PATIENT'S ADDRESS (No,, Street) 6, PATIENT RELATIONSHIP TO INSURED 7, INSURED'E ADDRESS (No., Slmet)
CITY I STATE 8, PATIENT STATUS CITY STATE
I1E:CI.,,IA'II',IZCS:[]URGI PR SlngleF~ MarrledF-1 OlharI PIECFIFiNICS:I:IUIRG
TIp CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE)
Full.Time
9. OTHER INSURED'E NAME (Lasl Name, First Name, Middle Initial) 10, IS PATIENT'S CONDITION RELATED TO: 11, INSURED'S POLICY GROUP OR FECA NUMBER
a, OTHER INSURED'S POLICY OR GROUP NUMBER 'a, EMPLOYMENT? (CURRENT OR PREVIOUS a, INSURED'S DATE OF BIRTH
b, OTHER INSURED'E DATE OF BIRTH b, AUTO ACCIDENT? PLA~E (St~te) b, EMPLOYER'S NAME OR SCHOOL NAME
MM t ''YY i []sEx r-i
o. EMPLOYER'S NAME OR SCHOOL NAME c, OTHER ACCIDENT? o, INSURANCE PLAN NAME OR PROGRAM NAME
[~YES ~"] NO
d, INSURANCE PLAN NAME OR PROGRAM NAME 10d, RESERVED FOR LOCAL USE d, I$ THERE ANOTHER HEALTH BENEFIT PLAN?
F~YES F'~NO Ify~.relumtsandssmplsteltemEa,d,
READ BACK OF FORM BEFORE COMPLETING &EIGNING THIS FORM, 13, INSURED'E OR AUTHORIZEC PERSON'S SIGNATURE ~ authorize
12, PATIENT'$ORAUTHOR~ZEDPERSON'SSGNATURE auh~zatherelaaaeofanymedt~alo~othsrlnf~rmatlannecaeeary
~os~ro~, ss this claim, I sled request payment of govemmant beneflt~ either to myself or to Ihs party who ~apt~ assignment payment of madlaal benefits to the undersigned physician or supplier 1or
sewlssa described below.
SIGNED S:I:GI',IA'r'URE: ()lq F:':LE DATELt 29 0."L SIGNED .,SZGNA'TLJr-~E: O1',t F'ILE:
14, DATE OF CURRENT; ~ ILLNESS (Flint symplam) OR 1~, IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, 1 e, DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM IDD I YY~1 INJURY (Acsldent) OR GIVE FIRET DATE MM j DD I YY MM DD Yy MM DO YY
, i PREGNANCY (LMRI ~ , PROM I I TO
17, NAME OF REFERF[iNG PHYSICIAN OR OTHER SOURCE 17a. I.D, NUMBER OF REFE~HiNG PHYSICIAN 18, HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
19. AE~I::HVED FOR LOCAL USE 20, OUTSIDE LAB? $ CHARGES
E YEE F NO I
21, DIAGNOSIS OR NATURE OF iLLNESS OR INJURY, (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) 22, MEDICAID RESUBMISSION
23. PRIOR AUTHORIZATION NUMBER
24, A E C D E F G H I J K
DATE(S) OF SERVICE Ploa~e T~fPe PROCEDURES SERVICES, OR SUPPLIES DIAcGoND(~EiS GAYS
MM F~rn '*fY MM To (Exalel~ 0'nuaual Clmumetancae) RESERVED FOR
DD YY Servl~e 8er~l:! CPTIHCPCS [ MODIFIER $ CHARGES OR Family EMG COS
s?. ACCEPT ASS GNMENT~ $ (:iI, ,,
25. FEDERAL TAX I.D, NUMBER SEN EIN 26. PATIENT'S ACCOUNT NO. (For govt. claims see beck) 28, TOTAL CHARGE 29, AMOUNT PAID 30. SALANCE DUE
8~ 51,, O0 0O
3~. S~GNATUBE CE PHYSiCiAN OR SUPFUER .
32, NAME AND ADDRESS OF FAC L 'FY WHERE SERV DES WERE ~3, PHYSICIAN'S, SUPPLIER'S SlLLING NAME, ADDRESS, ZiP CODE
INCLUGING DEGREES OR CREDENTIAL8 RENDF~flf other than home or office) & PHONE #
24.6 fDRRKEIR S'T'F~E]'_:~T 10O0 NORTH FROI',IT
SIGNED 1 .'.{, 2!~ [ii. DATE PIN#
, COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-1500 (12-90), FORM RRB-15OE,
APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS)
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. MEDICARE MED[CAtD CHAMPUB CHAMPVA GROUP FECA OTHER la. INBURBO'S I.D. NUMBER
~ HEALTH PLAN F'--I ELK LUNSr'"'~-'-~
3. PATIENT'S BIRTH DATE 4. INBURED'S NAME (~t Name, First Name, Middle initial)
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E. PATIENT'8 ADDRESe (NO., 81mt0 8. PATIENT ~E~TIONSHIP TO IN~U~ED 7. INSURED'8 ADD,E88 (No., Street)
C[~ [ STATE 8. PATIE~ STATUS Cl~ STATE
ZIP CODE TELEPHONE (Inolude Area Co~e) ZIP CODE TE~PHONE (INCLUDE AREA CODE)
g, OTHER IN~UHBD'8 NAME (Lair Name, Firm Name, Middle I~lflal) 10, IS PATIENT'8 CONDITION RE~TED TO: 11, IN~URED'~ POLICY GROUP OR FEOA NUMBER
~. OTHER INSURED'8 POLICY OR GROUP NUMBER ~, EMPLOYME~? (CUR~E~ OR PREVIOU~ n, INSURED'$ DATE OF BIRTH
.1 [51 3 4 2 7 D 6 Y~s NO 0 ~ O ~ .1 ~ 4 2 ~ ~
D. OTHE~ INgUHED'8 DATE OF ~IRTH b. AUTO ACCIDENT? P~E (~ b. EMPLOYER'8 NAME OR SCHOOL NAME
MM , DD YY
c. EMPLOYER'8 NAME OR SOHOOL NAME c. OTHER AOOIOE~ ~. INSURANCE P~N NAME OR PROGRAM NAME
~YES ~NO
d, INSURANCE PLAN NAME OR PROeRAM NAME 10d. R~h~ED FOR LOCAL USE d, IS THERE ANOTHER HEALTH BENEFIT P~N?
~YES ~ NO Bye, return to and complete Item 9 a~,
~EAD BACK OF FOR~ BEFORE COMPLETING & S GNING TNIS FORM 13, INSURED'8 OR AUTHORIZED PE~ON'S SIGNATURE I authorize
12, PATIENT'S OR AUTHORIZED PER~N'SSIGNATURE aut~Hzetheml~ym~lcalor~herlnfo~a~on n~a~ payment of medlealbenefltstotheundemlgn~ physician or suppller for
bel~.~ p~ this claim. I also ~u~ paym~t of government ~n~ either to ray,If or to the ~ ~o ~p~ ~lgnment ee~lces described below.
SmN~m SIGNATURE O~ F'ZLE DAT~.i 29 01 S~aN~D S~tqCq'T'URE[ OIq F'IL..E;
14.MMDATEi OFDDCURRE~:i ~ ~ INJURY (A~cldent) oRILLNE~S (Fl~ myi~p[u..) OR 16. GIVE~F PATIE~FiRST DATEH~ HAD MMSAMEi ORDD61MI~Ri YY ILLNES6. 16. DATES MMPATIENTDDUNABLEyyTO WORK IN CURRENTMM OCCUPAT~ONDD YY
, , I PREGNANCY (LMP) I I FROM ~ ~ TO ~ I
17. NAME OF f~; ~;;~Na PHYSICIAN OR OTHER 8OURCE 17a. I.D, NUMBER OF R~PmHmlN~ PHYSICIAN 18, HOS~ITALI~TION DATES RE~D TO CURRENT SERVICEB
~, ~E~E~VED FO~ LOOAL U~E EO, OUT~IDE ~B? ~ OHA~GE8
21. DIAGN081~ O~ NATURE OF ILLNE~ O~ INJURY, [~E~TE ITEM~ 1,a.a O~ 4 TO ITEM 24E BY LINE) E2, MEDIOAID ~ESUBMI~ION
a~.P~IO~ AUTHO~I~TION NUMBE~
~.~,,,[~1 CORONARY RTHEROSC <,1
24, A S O D E F ~
Place T~ PROCEDURE~ 8ERVCES, OR SUPPLIES G H I J
Fro~ATE(S) OF SERVICE TO of (Explain ~nusual Clmum~an~) DIAGNO818 DAYS EPSDT
UNITE Plan LOCAL USE
' ~ ' ' ~ 3000J,, 0 [) ],
0].~0z,~01 ', ', 21 O1 ~g3555 J59~ 1,2 2E, l~,,00 1
-
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25. FEDERAL T~ I.O. NUMBER SSN EIN 26. PATIENT'E ACCOUNT NO.
27. ACCEPT ASS GNMENT? ~
(For ~. claims see back) 28. TOTAL CHARGE 29. AMOUNT PAID 3~. BALANCE DUE
3F/OHZIqSKY, WIL.L. IRi~ '.B, HP~RRISBURG, PF/ l'S].01 WORI'q._IEYS~URG, PR .1. 7043
SIGNED ]..l 2~9 [)1 DATE PIN~ IGRP~
~L SERVICE 8/88)
PLEASE PRINT OR TYPE
iD OMB.0938-0008 FORM HCFA-1500 (12-901, FORM RRE-1500,
APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMS-0720-0001 (DHAMPUS)
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1. MEDICARE MEDICAID CHAMPU8 CHAMPVA GROUP FECA OTHER la. INSURED'8 I.D, NUMBER (FOR PROGRAM N ITEM
~ (Medl~re ~) ~ (Medlcald ~) ~ (Sponsor's ~, ~ (VA FIle ~) ~H~LTHP~N~BLKLUNG~
2, PATIENT'S NAME (Last Name, First Name, Middle Initial) 8, PATIE~'8 BIRTH DATE 4, INSURED'8 NAME (L~t Name, First Name, Middle Inltl~)
8. PATIENT'8 ADDRE88 (No., tltltl) 8. PATIENT RE~TIONSHIP TO INSURED 1. INSURED'8 ADDRE88 (No.,
C~h[..I S[...E PZKE
CiTY STATE 8, PATIENT STATUS CI~ STATE
MECHAIq:[CS3L)RG : ~-~ 81ngle~ Marrled~ Ot.er~ IIECHF:INICS:BURG
ziP CODE TELEPHONE (include Area Co~e) ZIP CODE TELEPHONE (INCLUDE AREA CODE)
1 F [] .... ':4 ';; ( 717~ -'766- 1103 Employed ~8tudentFUlI-Tlme ~PamTIme
9, OTHER INSURED'S NAME (L~t Name, First Name, Middle Initial) 10, IS PATIENT'S CONDITION RE~TED TO: 11, INSURED'S POLICY GROUP OR FECA NUMBER
8. OTHER INSUREB'B POLIOY OR ~ROgP NUMBER ~. EMPLOYME~ (OURRENT OR PREVlOU8) ~. INSUREO'8 ~ATE OF BIRTH
BIRTH ~. AUTO ACCIDE~? P~CE (~e) b. EMPLOYER'8 NAME OR SCHOOL NAME
OTHER
INSURED'8
DATE
OF
c, EMPLOYER'S NAME OR SCHOOL NAME ¢, OTHER ACCIDENT? c, INSUBANCE P~N NAME OR PROGRAM NAME
d. INSURANCE P~N NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d, IS THERE ANOTHER HEALTH BENEFIT P~N?
~YES I ~ NO Ify~, return to and complete item 9
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORI~D PERSON'S SIGNATURE I authorize
12. PATIE~'S OR AUTHORBED PERSON'S SIGNATURE I ~thodze the miens of ~y m~lcal or ~her Info~atlon n~ pa~ent of medical benefits to the undersigned physician or supplier for
14. DATE OF CURRENT: ~ IELNES8 (Firm symptom) OR 18. IF PATIE~ H~ H~ ~E OR 81MI~B ILLNE88. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITALI~TION DATES RE~TED TO CURRENT SERVICES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RETIE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) ~ ~. MEDICAID RESUBMISSION
/ ' C ' v" ~ '"~' N C' D:' ~ C'/ CODE ORIGINALREF. NO.
23. PRIOR AUTHORI~TION NUMBER
2. L4.].Z,..01 COIRONARY FITHEROSC
MM DD YY MM DD YY 8e~i~ ~ CPT/HOPO8 J MODIFIER CODE $ CHARGES UNITsOR FamilYplanEMG COB LOCAL USE
ol:og~ol ', ', 2].ol ]3508 i2E~ i,2,3 6[]oi..(:)c].].
-
'
INCLUDING DEGREES OR CREDENTIALS RENDE~flf other than home or officcJ & PHONE ¢
apply o his bill and are made a p~d here~,
]~tF:IC;HZNSt<Y, LIII_.I..ZF)M :B, HAIRR]:SBURG, PR iT101 bJORMLI~iYS:BUR(5, I:~f:t ].7043
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8188)
PLEASE PRINT OR TYPE
APPROVED OMB-0938.0008 FORM HCFA-1500 (12-90), FORM RRB-IS00,
APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS)
PLEASE
DO NOT
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AREA
II I ~P~CA I b 1 3 Z,. 2 ? 8 I!i HEALTH IN~UPIANI;E CLAIM FORM
PICA~
1, MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FEGA OTHER la, INSURED'E I,D, NUMBER (FOR PROGRAM IN ITEM
'~ (Mecll~ere #) [~ (M~dk~etd #) [~ ($poneor'$ $$N) [] (VA FI/a #) ~H~LTHP~N~LKLUN~
2, PATIENT*S NAME (La~l Name, Flier Name~ Middle Initial) 3, PATIENT'S BIRTH DATE 4, INSURED'S NAME (Last Name, First Name, Middle Initial)
~ ~ ~ 8EXF~x~ ............ ~ ..
MM ,DD,
YY
]3E:IEI:~S ::)RCOUEL..I 0511 [J211 :[.94.~~ BE:E:RS;,.)R(.,OL)Iz.L.[.Ill::. R
& PATIENT'S ADDRESS (No., Street) 6, PATIENT RE~TIONaHIP TO INSURED 7. INSURED'S ADDRESS (No,, ~tmel]
..... .....
55D3], CRI~LZ...,I...E. I-.I. KE:. self s~ou,, ~ ot~er 5503]~ C(:tRI....:I:SLE~ P:I:I'~E:
CITY ~ STATE 8. PATIE~ STATUE Or~ ~ATE
ZIP CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE)
171355 (717)) *"'756'-'1103 = , ~FulI.Tlme ~P.n*Tlme r
-~,,w--~s~.a..t ~au~,.~ ~ 17055 (( 7.1.'~)....'765-.-:1..1,03
g, OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) ' 10, I~ PATIE~'6 CONDITION RE~TED TO: 11, INSURED'S POLICY GROUP OR FECA NUMBER
]gE:IERS~ 3-COUE.L. 1{,II:, R
& OTHER INSURED'S POLICY OR GROUP NUMBER a, EMPLOYMENT? (CURRENT OR PREVIOUS) a, INSURED'S DA~ OF BIRTH
b, OTHER INSURED'8 DATE OF BIRTH P~OE (~) 'b, EMPLOYER'8 NAME
c, EMPLOYER'S NAME OR SCHOOL NAME ~, OTHER ACCIDENT? c, INSURANCE P~N NAME OR PRO~R~ N~E
d, INSURANCE P~N NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d. IS THERE ANOTHER H~LTH BENEFIT P~N?
~YES ~NO Ify~,mturntoand~mpleteltemOa~.
R~D BACK OF FORM BEFORE COMP~TING & SIGNING THIS FORM. 13. iNSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12, PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I a~e the ml~e of ~y medial or ~her Information n~e~ payment of medical benefi~ to the undemlgned physician or supplier for
to pr~s this claim, I al~ request payme~ of g~mment ~nefl~ either to myself or to ~e p~ who ac~p~ ~signment sewlces described below.
be[~,
SIGNED SI:GNFq'I'[JRE: ON F'II..E DAT~.:[. 29 [):t. SIGNED SIGIqA'I"LJRE C)N F':[:I_E:
14. DATE OF CURRENT: ~ ILLNESS (Fimt sy.~{oi,,) O~ 1~, IF PATIE~ HAS H~ ~ME OR SIBI~R ILLNESS, 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM ~ DD ~ YY ~ I~URY (Accident) OR GIVE FIRST DATE MM DD YY MM DD YY MM DB YY
, , -- PREGNANCY (~P) I 'l FROM
17. NAME OF AEF~HRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REad.mING PHYSICIAN 18. HOSPITAD~TION DATES RE~TED TO CURRENT SERVICES
MM DD ~ MM DD YV
:BOWIdRIqSI)ALE FROM ¢ [ TO J II
19, RESERVED FOR LOCAL USE 20, OUTSIDE ~B? $ CHARGES
~. PRIOR AUTHORI~TION NUMBER
~.L4].1..0 POS"I"I'IYOCRRD:[:f-~L. ZN 4.1 410..2.L IdI RUUII:. Ilq
24, A I B C O E F G H
CATE(S) OF SERV CE To Place PROCEDURES, SERVlOES OR ~UPPUE8 DAYS EPSDT
From of T~ E lain Unu ual Circumstances DIAGNOSIS RESERVED FOR
UNITS Plan LOCAL USE
~}2'r05~01 ~ ~ 11 [}.]. 99215 1251 1,2,3 1O,.h,.0EI
,
27, ACCEPT AS8 GNMENT?
25, FEDERAL TAX I.D. NUMBER S~N ~IN ~, PATIENT'S ACCOUNT NO. (For g~. claims a~ back 28. TOTAL CHARGE 29. AMOUNT PAID ¢0, BA~NCE DUE
31.SIGNATURE OF PHYSICIAN OR SUPPLIER 32. NAME AND ADDRESS OF FAClLI~ WHERE SERV CES WERE ~3. PHYSICIAN'8, SUPPLIER'S SILLING NAME, ADDRESS. ZIP CODE
INCLUDING DEGREES OR CREDENTIALS RENDE~tIf other th~n home or office) & PHONE
8ppJ~Oh.b and .... adeapa, thereof.) FIOFFZ'T'T I"IE:RRT [~ VF:]S(JUL. r-~R I1OF:*F'ZTT HERRT
1. [] O 0 N O R TI'"I F R O N T S T R E:E:T .1. {3 [? 0 N O R"I'I"I F' R O N T
:I~RCHII',ISKY~ DZL. L. IF:iI'fl ~ b)ORHL. EYS]]UI~G, PR 17043 DORHL. E:YS]?URG, PR .].7043
APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-1500 (12-90), FORM RRB*IS00,
APPROVED OMB.1215-0055 FORM OWCP-1500, APPROVED OMB-0720.0001 (CHAMPUS)
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t. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S hD. NUMBER (FOR PROGRAM IN ITEM[
~ (M~lcare ~) ~ (Medl~d ,) ~ (S~naor'~ ~N) ~ (VA FIle ~) ~HEALTHP~N~BLKLUN~
2. PATIENT'S NAME (Lest Neme, First Name, Middle initial) 3. PATIENT'S BIRTH DA~ S~ 4, INSURED'S NAME (Last Name, Flint Name, Middle Initial)
MM
D
~. PATIENT'S ADDRE$8 (No., Street) 6. PATIENT RE~TIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street)
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g, OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RE~TED TO: 11. IN~URED'S POLICY GROUP OR FECA NUMBER
]~)EERS, 3RCOUELZIqE R
a, OTHER INSURED'~ POLICY OR GROUP NUMBER a, EMPLOYMENT? (CURRENT OR PREVIOUS) ~. INSURED'S DATE OF BIRTH
c, EMPLOYER'E NAME OR SCHOOL NAME c. OTHER ACCIDENT? c, INSURANCE P~N NAME OR PROGRAM NAME
d, INSURANCE P~N NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE ;d. IS THERE ANOTHER HEALTH BENEFIT P~N?
~YES ~ NO Ifps, return to and complete item 9
READ BACK OF FORM ~EFO~ COMPLE~NG & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I euthorize
12. PATIE~S OR A~HORIZED PERSON'S SIGNATURE I autho~e t~ rel~e of ~y m~i~l ~ ether informetion nece~a~ payment ~ medical benefits to the undersigned ph~lcian or supplier for
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SIGNED S~GNRI'URE ON F:'I:L.E: DAT~.]. :~9 [}]. SIGNED SZGNA'TURE ON F'~L.E
14. DATE OF CURRENT: ~ ILLNESS (First s~ptom) OR i8. IF PATIE~ HAS HAD S~E Ob SIMI~ ILLNESS, i6. DATES PATIE~ UNABLE TO WORK IN CURR~ OCCUPATION
17. NAME OF Fill L; ;;iING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF ~e~eHRING PHYSICIAN 18. HOSPFFALI~TION DATES RE~TED TO CURRENT SERVICES
SETZER~I., oC mou ', [ m [
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23. PRIOR AUTHORI~TION NUMBER
24. A B C D E F G H I J K
D
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25, FEDERAL TAX I,D. NUMBER SaN FIN 26, PATIENT'S ACCOUNT NO. I
27. ACCEPT ASSIGNMENT? $ 0~.,
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(APPROVED BY AMA COUNCil ON MEDICAL SERVICE 8/88)
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APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720.0001 (CHAMPUS)
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1, MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la, INSURED'S I,D. NUMBER (FOR PROGRAM IN ITEM
I ~ ~ ~ ~ HEALTH P~N ~ BLK LUNG~
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2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3, PATIE~'S BIRTH DATE SEX 4. INSURED'S NAME (Last Nsme, First Name, Middle Initial)
5, PATIENT'S ADDRESS (No., StreW) 6. PATIENT RE~TIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street)
6(5~3B C~dx[....I..,.LE PZKE
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ZIP OODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INOLUDE AREA CODE)
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]]EEI:~S~ .]RCQUEL-INE R
~, OTHER INSURED'8 POLICY OR GROUP NUMBER a, EMPLOYME~?(CURRE~ OR PREVIOUS) a, INSURED'8 DA~ OF BIRTH
~, OTHER INSURED'8 DATE OF BIRTH b, A~O AOOIDEN~ P~E ~e) ~, EMPLOYER'8 NAME OR 80HOOL NAME
c. EMPLOYER'S NAME OR SCHOOL NAME ~, OTHER ACCIDENT? :, INSURANCE P~N NAME OR PR~RAM NAME
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~YE8 ~NO If y~, return to and complae ~em g a.d.
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S~N~ S[GNRTURE ON FILE DAT~.]. 29 O1 S~N~ S[GNR'T'URE
14. DATE OF CURRENT: j ILLNESS (Fi~ symptom) OR 15. IF PA~ENT H~ HAD SAME OR SlMI~R ILLNESS. 16. DATE9 PATIE~ UNABLE TO WORK IN CURRENT OCCUPATION
MM i DD I ~~ INJURY (~cldent) OR GIVE FIRST DATE MM DD ~ MM DD YY MM DD YY
, , PREGNANCY (~P) I I FROM
17, N~E OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I,D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITAL~TION DATES RE~D TO CURRENT SERVICES
MM DD ~ MM DD YY
SETZER~ W. SC FROM
19, RESERVED FOR LOCAL USE 20. OUTSIDE ~B? $ CHARGES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RETIE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) ~ 22. MEDICAID RESUBMISSION
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24. A B C D E F G H I J K
FroBATE(S)m OF SERVICE To Placeof TYPe~ PROCEDURES SERVICES, OR SUPPLIES DAYS EPSDT
(E~latn ~nusual Clmumstances) DIAGNOSIS RESERVED FOR
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~. S~NATU~E O...VS~O~*N O~ SU."UE~ S~. NAME AND *~SS OF ~*C~L,~ W,E~E SERV CES WErE ~. ,HYS]O,*N'S. SUPPU[R'S ~LL,.~ "*~E, AD~ESS. Z,. CODE
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(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 818B) PLEASE PRINT OR TYPE APPROVED OMB-0938.0008 FORM HCFA-I$00 (12.90), FORM RRB-lEO0,
APPROVED OMB-1215.00E5 FORM OWCP-1500, APPROVED OMB-0720-0001 (CHAMPUS)
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AREA
1. MED CARE MEDICAID ON.PUS CHAMPVA GROUP FECA ~HER la. INSURED'S I.D, NUMBER (FOR PROGRAM IN ITEM
~ HEALTH P~N ~ BLK LUNG~
2. PATIENT'S NAME (Lair Name, First N~me, Middle Initial) 3. PATIENT'S GIRTH DATE SEX 4. IN~URED'8 NAME (L~I N~e, First Name, Middle Inltl~)
'.I] E: E: R E; 3FICOLJIEL,~ [15,I 02*I 194.2Y~ ~ BE. IERS,,JAC,)UEL.:[:IqE R
5, PATIENT'S ADDRE88 (No,, Street) 6, PATIENT RE~TIONSHIP TO INSURED 7. INSURED'S ADDRESS (No., Street)
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ZIP CODE TELEPHONE (Incluee Aree Code) ZIP CODE ~ TELEPHONE (INCLUDE AREA CODE)
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'.BE:ERS, 3RCOUE:I_SNE: R
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1B].34.2786 02'~ 1942
b, OTHE~ INSURED'8 DATE O~ BIRTH b, AUTO AOOIDENT? P~OE (~e) b, EMPLOYER'8 NAME OR 8OHOOL NAME
c, EMPLOYER'8 NAME OH ~OHOOL NAME o, OTHEH AOOIDENT? o, INBUHANOE P~N NAME OH PHOGHAM NAME
~YES ~NO If ~, return to ~d ~mplote item 9 a-d.
R~ GACK OF FORM BEFORE ~MPL~ING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authodze
12. PATIE~'S OR A~HORI~D PER~N'S SIGNATURE r a~hodze the release of ~y m~ic~ or ~her Info~on n~aw payment of medical benefits to the undemigned physician or supplier for
S~GNED S:[:(3Iqf:YT'UF~E ON FZLE D.~.]. 29 0], s~e.~o SZGNFqTURE ON F~ZI,..E
14, DA~ OF CURRENT: j ILLNESS (First symptom) OR 15. IF PATIE~ HAS H~ SAME OR SIMI~R ILLNESS. 16. DATES PATIE~ UNABLE TO WORK IN CURRENT OCCUPATION
17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18. HOSPITAU~TION DATES RE~D TO CURRENT SERVICES
MM DD Yy
19. RESERVEB FOR LOCAL USE 20, OUTSIDE ~B? $ CHARGES
21. DIAGNOSIS OR NATURE OF ILLNESS OR I~URY. (RETIE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) / ~. MEDICAID RESUBMISSION
2& PRIOR A~HOflI~TION NUMBER
L4.1Z,.
PROCEDURES. SERVICES, OR SUPPLIES DAYS EPSDT
DATE(S) OF SERVICE PIg~ T~e P~POS ~ UOOIFIE~ CODE $ CHARGES OR F.mlly EMG COB
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2~. ACCEPT ASSIGNMENT9 S [3 ~P' ac. BALANOE DUE
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:]ONE:S, J"FEVEN, ilL) HRRR]:S'BUIRG ~ PR ].71. D L LdORIflL..EYS:BLJF~G, PF-~ 1704.3
(APPROVED Ely AMA COUNCIL ON MEDICAL SERVICE 8188)
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APPROVED OMB-0938-0008 FORM HCFA-1500 (12-90), FORM RRB-1500,
APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-07E0-00D1 (CHAMPUS)
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MM ,DD,
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5, PATIENT'S ADDRESS (Ne,, ~treel) & PATIENT RE~TION~HIP TO INSURED 7, INSURED'S ADDRESS (No,, Strut)
[5503~
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9, OTHER INGURED'S NAME (Lest Neme, Flrat Neme, MId~le Initial) lO, 18 PATIENT'S CONDITION RE~TED TO: 11, INSURED'8 POLICY GROUP OR FECA NUMBER
~JE:IERS ~ .]RCOUE:L,~IqE R
a, OTHER INSURED'8 POLICY OR GROUP NUMBER a, EMPLOYMENT? (CURRENT OR PREVIOUS) a, INSURED'8 DATE OF BIRTH
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d, INSURANCE PLAN NAME OR PROGRAM NAME 10d, RESERVED FOR LOCAL USE d, 18 THERE ANOTHER HEALTH BENEFIT P~N?
~YE8 ~NO If ~, return to and compile ~em 9 a~.
READ BACK OF FORM B~ ~MPLETING & ~IGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE ~ authorize
12, PATIE~'8 OR AUTHOREED PER~N'S 81G~TURE J aut~ the ml~e ~ ~y m~lcal or ~her Info.on ne~aa~ payment ~ medical benefits to the undersigned ph~el~ or euppfler for
~o pm~ thla claim, I a~ r~ueat peyment ~ g~emment henna either to my~E or to t~e pa~ who ~ep~ ~s~nmenl sewlcea described below.
SIGNED S:[GNR*TL]IRE: ON FILE DA~.]. 2~1 [)]. SIGNED SZGNRTL]RE ON
14, DATE OF CURRENT', ~ ILLNE88 Clot ll~¢~a) O~ 18, IF PA~B~ HA8 HAD SAME OR 81MI~R ILLNESS, 18, DATE8 PATIE~ UNABLE TO WORK IN O~RBENT OCCUPATION
MM IBB I yy~ INJURY (~Ident) OR ~IVE FIRST DATE MM I DD I YY MM I DD I YY MM~ DD~ YY
17, NAME OF REFERRING PHYSICIAN OR OTHER ~UROE 11~, I,D, NUMBER OF R~P¢~IN~ PHYSICIAN 18, HOSPITALI~TION DATES RE~TED TO CURRENT SERVICES
MM DD YY MM OD YY
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RE~TE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) ~ 22, MEDICAID RESUBMISSION
23. PRIOR AUTHORI~TION NUMBER
24. A B C O E F G H I J K
Fm~ATE(S) OF SERVICE To P~¢e T~ PROCEDURES SERVICES OR SUPPLIES DAYS EPSDT
MM DD YY MM DD YY Se~tce ~ CPT/HCPOS / MODIRER CODE $ CHARGES UNITsOR FamilYpl~n EMG COB LOCAL USE
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(APPROVED SY AMA COUNCIL ON MEDICAL SERVICE e/88)
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APPROVED OMB-0938-0008 FORM HCFAd5O0 (12-90), FORM RRB-1500,
APPROVED OMB-1215-0055 FORM OWCPolS00, APPROVED OMB-0720-0001 (CHAMPUS)
PLEASE
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1. MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la, INSURED'S LD, NUMBER (FOR PROGRAM IN ITEM 1)
L~ ($$N or lD) L_.~ ($$N) ~L~ (/D)
2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3, PATIENT'S BIRTH DATE SEX 4, INSURED'S NAME (Last Name, First Name, Middle Initial)
§, PATIENT'8 ADDRESS {No., Straef) E, PATIENT RELATIONSHIP TO INSURED 7. INSURED'S ADDRESS (No,, Slraal)
[)L 0, }~ CF'IF~L. ZSI.,.E: IDZI<E
CITY STATE E, PATIENT STATUS CITY STATE C
ZIP CODE TELEPHONE (Include Area Coda) ZIP CODE TELEPHONE (INCLUDE AREA CODE)
9, OTHER INBUREC'S NAME (Last Name, Firsf Name, M~ddle Initial) 10, IS PATIENT'S OONGITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER .2
~, EMPLOYMENT? (CURRENT OR PREVIOUS) a. INSURED'$ DATE OF BIRTH
b. OTHER INSURED'S DATE OF BIRTH b. AUTO ACCIDENT? PLACE (Slate) ~. EMPLOYER'S NAME OR SCHOOL NAME
c. EMPLOYER'S NAME OR SCHOOL NAME c. OTHER AGCIDENT? c, INSUFb~NOE PLaN NAME OR PROGRAM NAME
LL
F1YSS [].o
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. RESERVED FOR LOCAL USE d, IS THERE ANOTHER HEALTH BENEFIT PLAN?
F~YES I I NO If yes, return to and complete item 9 a-d.
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize
12, PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authedze the release of any medical or other Information r~ecessary payment of medical benefits to the undersigned physician or supplier for
~Oe~:~co~ss this claim, I also request payment of government benefits either to myself or to the party who accepts assignment services descrlpad below.
S~GNED S,['.GNR-FUF~)E: OINI F::[L.E DATL']']' 2CJ [3.1. S~GNED SZGNAYTtJF?E OINI I::'.IL. IE
14. DATE OF CURRENT: · ILLNESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS. 18, DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION
MM ~ DD I YY~ INJURY(Accident) OR GIVE FIRST DATE MM I DD I YY MM DD YY MM DD YY
, , PREGN~CY (LMP) , , FROM ', ', TO I
17, NAME OF REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 1s. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES
MM DD YY MM DD YY
19. RESERVED FOR LOCAL USE 20. OUTSIDE LAB? $ CHARGES
21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) ~ 22. MEDICAID RESUBMISSION
t. L4.1.4.,.8 :[.SCHEt'IIC t"IERF{T I)Z s.[ /+14.,0) CORONF~Y*RT CODE [ ORIGINALREF. NO.
23. PRIOR AUTHORIZATION NUMBER
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24. A B C D E F G H I J K
DAYS EPSDT
DATE(S) OF SERVICE PIoa~e TYo~ PROCEDURES,iE~n SERVICES, OR SUPPLIESs) DIAGNOSIScoDE RESERVEDLocAL FOR
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MM DD YY MM DD YY Service Serv~e CPT/HCPCS [ MODIFIER
UNITS Plan fi'
~ O
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2E. PATIENT'S ACCOUNT NO.
27. ACCEPT ASSIGNMENT? 29. AMOUNT PAID 30, BALANCE DUE
25. FEDERAL TAX I,D. NUMBER SEN EIN (For govt. claims see back) 8. TOTAL CHARGE $ I~f !.
31. SIGNATURE OF PHYSICIAN OR SUPPLIER 32, NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE 33, PHYSICIAN'S, SUPPLIER'S BILLING NAME, ADDRESS, ZIP CODE
INCLUDING DEGREES OR CREDENTIALS RENDERE~flf ether than .hom.e. ~.ofllce) . . & RHONE #
app y o h s bill and are made a part hereof,)
~[, i ;! !~) 0 ;1, DATE PiN#
(APPROVED BY AMA COUNCIL ON MEDICAL SERVICE 8/88)
PLEASE PRINT OR TYPE APPROVED OMS-0938-0008 FORM HOFA. 1500 (12-90), FORM RRB-1500,
APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OUEo0720-000 (CHAMPUS)
11/20/2002 09:38 FAX 2889~;98 @UIDA LAW OFFICES ~004/004
MOFFITT HEART & VASCULAR
JACQUELINE BIEERS
WiLl,lAM BEERS
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
: CIVIL ACTION - LAW
: No.
VERIFICATION
I VERIFY TllAT TIlE STATEMENTS MADE IN THIS COMPLAINT ARE
'I'RUI.~ AND CORRECI'. ! UNDERSTAND THAT I'HE STATEMENTS HEREIN ARE
MADE SUBJECT TO THE PENALTIES OF 1 $ PA.C.S.A. SECTION 4904 RELA'I"ING '['0
UNSWORN FAI,SIFICATION TO AUTHORITIES.
Printed Name
Tille
Date
JACQUELINI
WILLIAM Bi
MOFFITT HEART & VASCULAR
~/S.
r~ BEERS
;ERS
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
:
: CIVIL ACTION'- LAW
:
: NO. 02-6095 CIVIL TERM
CERTIFICATE OF SERVICE
Il hereby certify that on January 10, 2003, I served the Civil Complaint upon
the person an~l in the manner indicated below, which service satisfies the requirements of
Pennsylvania ~ule of Civil Procedure. 403:
] Personal service by James Stamos:
William Beers
6603 B Carlisle Pike
Mechanicsburg, PA 17055
Dated:
January 14, 2003
Guida Law Offices, P.C.
503 North Front Street
Harrisburg, PA 17101
717-236-6440
MOFFITT HEART & VASCULAR
VS.
JACQUELINE BI ~ERS
WILLIAM BEER S
Y~
: IN THE COURT O'F COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
:
: CIVIL ACTION - ]LAW
NOTICE TO DEFEND
u 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 m ~tice are served, by entering a written appearance personally or by
attorney and fili~
forth against yo~
you and a judgm
money claimed
You may lose m~
Y£
YOU DO NOT E
TELEPHONE T
GET LEGAL HI
~g in writing with the court your defenses or objections to the claims set
· You are warned that if you fail to do so the case may proceed without
ent may be entered against you by the court without further notice for any
the complaint or for any other claim or relief requested by the plaintiff.
aey or property or other rights important to you.
IU SHOULD TAKE THIS PAPER TO YOUR. LAWYER AT ONCE. IF
iAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR
HE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN
CUMBERLAND COUNTY BAR ASSOCIATION
2 LIBERTY AVENUE
L CARLISLE, PA 17013
~ 1-800-9108
MOFFITT HEART & VASCULAR
VS
JACQUELINE BEERS
WILLIAM BEERS
IN THE COI~T OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 02-60!)5 CIVIL TERM
TO: Jacqueline and William Beers
DATE OF NOTICE: February 17, 2003
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU H~VE FAILED TO ENTER A
WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING
WITH THE COURT AN ANSWER TO Plaintiff's Complaint. UNLESS YOU
ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY
BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOUMAY LOSE YOUR
PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE
TO A LAWYER AT ONCE. IF YOU DO NOT HAVE ALAWYER OR CANNOT
AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT
WHERE YOU CAN GET LEGAL HELP:
CUMBERLAND COUNTY BAR ASSOCIATION
2 LIBERTY AVENUE
CARLISLE, PA 17013
1-800-990-9108
Gail Guida Souders
Guida Law Offices, P.C.
503 North Front Street
Harrisburg, PA 17101
(717) 236-6440
Identification #68740
Attorney for Plaintiff
MOFFITT HEART & VASCULAR
VS
JACQUELINE BEERS
WILLIAM BEERS
IN THE CO~T OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 02-6095 CIVIL TERM
CERTIFICATE OF SERVICE
I hereby certify that I am this 17th day of February,
2003, serving the Default Notice upon the persons and in the
manner indicated below which service satisfies the requirements
of Pennsylvania Rule of Civil Procedure, 403:
Service by First Class U.S. Mail:
Jacqueline and Williams Beers
6603 B Carlisle Pike
Mechancisburg, PA 17055
Gail Guida Souders
MOFFITT HEART & VASCULAR
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
VS
JACQUELINE BEERS
WILLIAM BEERS
CIVIL ACTION - LAW
NO. 02-6095 Civil Term
PRAECIPE
To Prothonotary:
Please enter judgment in favor of plaintiff, Moffitt Heart &
Vascular and against defendant, Jacqueline and William Beers for
failure of defendants to plead to plaintiff;s complaint as
follows:
$9,181.46 plus costs.
Date:
Respectfully submitted,
Guida Law Offices, P.C.
503 North Front Street
Harrisburg, PA 17101
717-236-6440
Identification #68740
Attorney for Plaintiff
MOFFITT HEART & VASCULAR
VS
JACQUELINE BEERS
WILLIAM BEERS
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 02-6095 Civil Term
CERTIFICATE OF SERVICm
The undersigned certifies that written notice of
intention to file a praecipe for entry of judgment by default
against defendants was mailed to defendants after the default
ocurred and at least ten days prior to the filing of the praecipe
for entry of judgment pursuant to Pa.R.Civ. P. 237.1. A true and
correct copy of the notice is
attached her to as Exhibit A.
Gall Guida Souders f --
MOFFITT HEART & VASCULAR
VS
JACQUELINE BEERS
WILLIAM BEERS
TO: Jacqueline and William Beers
DATE OF NOTICE: February 17, 2003
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A
WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING
WITH THE COURT AN ANSWER TO Plaintiff's Complaint. UNLESS YOU
ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY
BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR
PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE
TO ALAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT
AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT
WHERE YOU CAN GET LEGAL HELP:
CUMBERLAND COUNTY BAR ASSOC~ATION
2 LIBERTY AVENUE
CARLISLE, PA 17013
1-800-990-9108
Gail Guida Souders
Guida Law Offices, P.C.
503 North Front Street
HarrisbUrg, PA 17101
(717) 236-6440
Identification #68740
Attorney for Plaintiff
Exhibit A
MOFFITT HEART & VASCULAR
VS
JACQUELINE BEERS
WILLIAM BEERS
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 02-6095 CIVIL TERM
CERTIFICATE OF SERVIC~
I hereby certify that I am this 17th day of February,
2003, serving the Default Notice upon the persons and in the
manner indicated below which service satisfies the requirements
of Pennsylvania Rule of Civil Procedure, 403:
Service by First Class U.S. Mail:
Jacqueline and Williams Beers
6603 B Carlisle Pike
Mechancisburg, PA 17055
Gail Guida Souders
IN THE COURT OF COMMON PLEAS OF CUMBERI~%ND COUNTY, PENNSYLVANIA
CIVIL DIVISION
PRAECIPE FOR WRIT OF EXECUTION
MOFFITT HEART & VASCULAR :
Plaintiff :
:
VS :
:
JACQUELINE AND WILLIAM BEERS :
6603 B CARLISLE PIKE :
MECHANICSBURG, PA 17055 :
Defendant :
Confessed Judgment
Other
File No. 02-6095 Civil Term
Amount Due $9,181.46
Interest
Atty's Comm
Costs
TO THE PROTHONOTARY OF THE SAID COURT:
The undersigned hereby certifies that the below does not arise out of
a retail installment sale, contract, or account based on a confession
of judgment, but if it does, it is based on the appropriate proceeding
filed pursuant to Act 7 of 1966 as amended; and for real property
pursuant to Act 6 of 1974 as amended.
Issue writ of execution in the above matter to the Sheriff of
Cumberland County, for debt, interest and costs upon the following
described property of the defendant(s) all personal property,
including, but not limited to a 1979 Chevy and a 1992 Mercury at 6603
B Carlisle Pike, Mechanicsburg, PA 17055.
PRAECIPE FOR ATTACHMENT EXECUTION
Issue writ of attachment to the Sheriff of County, for debt, interest
and costs, as above, directing attachment against the above-named
garnishee(s) for the following property (if real estate, supply six
copies of the description; supply four copies of lengthy personalty
list)
and all other property of the defendant(s) in the possession, custody
or control of the said garnishee(s).
attached exhibit.
(Indicate) Index this writ against the garnishee(s) as a lis
pendens against real estate of the defendant(s) described in the
Gail Guida Souders
503 North Front Street
Harrisburg, PA 17101
Attorney for Plaintiff
717-236-6440
Supreme Court ID #68740
Jan 22 O! 04:52p 7!77022007
OWNER
PENNSYLVANIA DEPARTMENT OF TRANSPORTATION
VEHICLE RECORD ABSTRACT
6/07/02
PAGE
021581128000059
JACQUELINE R BEERS
CARLISLE PIKE
MECHANICSBURG PA 17050
LESSEE : NONE
00~
TITLE NUMBER
TAG NUMBER
VIM
MAKE
MODEL
RENEWAL
PREVIOUS TAG
LIENS
STOPS
: 48982S20
· ~SP2215 TITLE DATE : I1/01/95
: 2MEPM36XGNB641591 REGISTRATION EXPIRY DATE: 02/03
BODY TYPE : SUN
: MERCURY ODOMETER READING : 54,971'
· TGS *ACTUAL MILEAGE
: 0202911060001~5 001 DUPLICATE TITLE COUNT : 1
: AVLO169 VEHICLE YEAR : 1992
· YES STOLEN DATE ;
: NO
TITLE BRAND INFORMATION
NO TITLE BRANDS EXIST FOR THIS TITLE
ADDRESS CORRESPONDENCE TO:
DEPARTMENT OF TRANSPORTATION
VEHICLE RECORD SERVICES
PO BOX 68691
HARRISBURG, PA 17106-8691
INFORMATION: C7:00 AM TO 9:00 PM)
IN STATE i-800-952-4600
OUT-OF-STATE 717-~91-6190
TDD IN STATE 1-800-228-0676
TDD OUT-OF-STATE 717-391-6191
WWW,DOT.STATE.PA,US
WRIT OF EXECUTION and/or ATTACHMENT
COMMONWEALTH OF PENNSYLVANIA) NO 02-6095 Civil
COUNTY OF CUMBERLAND) CIVIL ACTION - LAW
TO THE SHERIFF OF CUMBERLAND COUNTY:
To satisfy the debt, interest and costs due Moffitt Heart & Vascular Plaintiff (s)
From Jacqueline and William Beers
6603 B Carlisle Pike
Mechanicsburg, PA 17055
(1) You are directed to levy upon the property of the defendant (s)and to sell all personal property,
including, but not limited to a 1979 Chevy and a 1992 Mercury at 6603 B Carlisle Pike,
Mechanicsburg, PA 17055.
(2) You are also directed to attach the property of the defendant(s) not levied upon in the possession
of
GARNISHEE(S) as follows:
and to notify the garnishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) is enjoined from
paying any debt to or for the account of the defendant (s) and from delivering any property of the defendant
(s) or otherwise disposing thereof;
(3) If property of the defendant(s) not levied upon an subject to attachment is found in the possession
of anyone other than a named garnishee, you are directed to notify him/her that he/she has been added as a
garnishee and is enjoined as above stated.
Amount DueS9,181.46
Interest
Atty's Comm %
Atty Paid $82.00
Plaintiff Paid
Date: April 4, 2003
(Seal)
REQUESTING PARTY:
Name Gail Guida Souders, Esq.
Address: 503 N. Front Street
Harrisburg, PA 17101
Attorney for: Plaintiff
Telephone: 717-236-6440
Supreme Court ID No. 68740
L.L.$.50
Due Prothy $1.00
Other Costs
CURTIS R. LONG
Prothonotary
By:
Deputy
WRIT OF EXECUTION and/or ATTACHMENT
COMMONWEALTH OF PENNSYLVANIA) NO 02-6095 Civil
COUNTY OF CUMBERLAND) CIVIL ACTION - LAW
TO THE SHERIFF OF CUMBERLAND COUNTY:
To satisfy the debt, interest and costs due Moffitt Heart & Vascular Plaintiff (s)
From Jacqueline and William Beers
6603 B Carlisle Pike
Mechanicsburg, PA 17055
(1) You are directed to levy upon the property of the defendant (s)and to sell all personal property,
including, but not limited to a 1979 Chevy and a 1992 Mercury at 6603 B Carlisle Pike,
Mechanicsburg, PA 17055.
(2) You are also directed to attach the property of the defendant(s) not levied upon in the possession
of
GARNISHEE(S) as follows:
and to notify the garnishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) is enjoined from
paying any debt to or for the account of the defendant (s) and from delivering any property of the defendant
(s) or otherwise disposing thereof;
(3) If property of the defendant(s) not levied upon an subject to attachment is found in the possession
of anyone other than a named garnishee, you are directed to notify him/her that he/she has been added as a
garnishee and is enjoined as above stated.
Amount DueS 9,181.46
Interest
Atty's Comm %
Atty Paid $82.00
Plaintiff Paid
Date: April 4, 2003
(Seal)
REQUESTING PARTY:
Name Gall Guida Souders, Esq.
Address: 503 N. Front Street
Harrisburg, PA 17101
Attorney for: Plaintiff
Telephone: 71%236-6440
Supreme Court ID No. 68740
L.L.$.50
Due Prothy $1.00
Other Costs
CURTIS R. LONG
Prothonotary
Deputy
R. Thomas Kline, Sheriff, who being duly sworn according to law, states
this writ is returned STAYED, DUE TO BANKRUPTCY.
Sheriff's Costs:
Docketing $ 18.00
Poundage 1.53
Advertising
Law Library .50
Prothonotary 1.00
Mileage 6.90
Misc.
Surcharge 30.00
Levy 20.00
Post Pone Sale
Garnishee
TOTAL 77.93
Advance Costs: 150.00
Sheriff's Costs: 77.93
72.07
Refunded to Atty on 5/12/03
Sworn and Subscribed to before me
this /6 qday of ')~
2003 A D pr~~r~ ~_ - ~-t~.,, ,'t~ ~
eX, e,.