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" '.:\\ ;:. :: j;)i'~ ~:X;!X,{f:~:: '~;'t:~ ~~\/;:~~~: 'i'" 'oJ," ("t)f:,-'ii)lllfl'i'"I:";,,t)'h;h!j :;', ','::':;(j:i,;,~:';i ::j':4:::?'Vi;\;, "'" ,', -' .'1: ,I" "," "!,~ ,'".L/ ".-"','i,"1 ""'.~.. ',""",U! , "/',;:: ,};\i,i,' .', '" :; i:":, '''~41!~ lLL,;/'., ;', "~::I :"!\!,'hi{~I/i;' f'J. , ,1,'1" "" ", "i 1'_'IF~'L(:f};';P. \~~;(;, ,i;, f-'~i" "/':;":','.., ' , j t;,t;J)r.!,:.jL~::k- Ij-,'-'\t';'L''1f1l,t\''tt"" -, , ',~,:' t~h,""f" '. ,; :,:'::;~' ',,'. ,;." ;'"~ ;t.', OF! g'SrPh: "h20 CUM~fRU.,\1o :_~NT.t' P~1IiNS'r"..VANJA' " c. 1 ,f 'I ~ ( " 'f. ' , '...' ""P"!"';:'I';" f.JH:Ulc , ,! r~1:~:"0~ ~ ~ , ,1.1; Ill>!,"", I ,), "\ l:' "1i" 1,'yj!:~:.,r;\'I.r_1 ~'r, (, ,I, . 'I~;!., I,"J. . . 'rJ~~i 'iiM "I~ ,,' II !it' ~.,'i;,kil,itl~,";}il:.t,J' /" , fSol'I' ,,- \e""".,. t"',"', \1. ,_' ,,' '"';,:-:!"~r'; .1,',1",", 'i'::II:",'." lil',' II,"".-';'f";"ii'h/I};,'i.,i'!': ','.'/; , .} Ct, 'I ,',l:; ,( i ',:I t, . 'I ' ~' I, ' 11.':;," 'Ii ,,' "I't , j'l' i; CARLISLE HOSPITAL AND HEALTH SERVICES. Plainti ff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA v. CIVIL ACTION - LA W NO. 97- .$'OIJ...., CIVIL TERM SYLVESTER S. ANDERSON, JR, and ROBIN L. ANDERSON, husband and wife, : Defendants JURY TRIAL DEMANDED COMPI.AINT AND NOW, comes the Plaintiff, Carlisle Hospital and Health Services, by and through its attorneys, Martson, Deardorff, Williams & Otto, and hereby avers as follows: I. Plaintiff is Carlisle Hospital and Health Services, a Pennsylvania non-profit corporation with its principle place of business at 246 Parker Street, Carlisle, Cumberland County, Pennsylvania 17013. 2, Defendant Sylvester S. Anderson, JI', is an adult individual residing at 419 Factory Street, First Floor, Carlisle, Cumberland County, Pennsylvania 17013. 3. Defendant Robin L. Anderson is an adult individual residing at 419 Factory Street, First Floor, Carlisle, Cumberland County, Pennsylvania 17013, 4. On or about September 19, 1993 through December 6, 1996, Defendants were provided with reasonable and necessary medical care by the Plaintiff and the Plaintirrs agents, servants and employees, 5, The outstallding balance of$23,042,00 represents the reasonable and necessary value of the services provided to the Defendants for which Defendants have yet to pay, (A copy of the invoices and printouts are attached hereto as Exhibit "An) COUNT I BREACH OF CONTRACT FOR PROVIDING NECESSARY CAAF. 6. Plaintiff hereby incorporates by reference the averments contained in paragraphs I through 5 of this Complaint. 7, Defendants have breached an expressed or implied agreement to pay the reasonable value of the services rendered. exhibit A f '~IIIi~'IlAIAttII.I!IIIIlSI'I'I,o\l. Ulk'll1 !tl!M 1'lIlt n'IllN lJJ'12I\1111414~/lPM kOIN\l 0"1)...,1 IN 41211 ^'" JII410111 SUMMARY OF ACCOUNT DATE OF SERVICE PATIENT AMOIJNT DUE 09/19/93 Sylvester S, Anderson, Jr, 104.60 05/04-05/15/96 . Robin L. Anderson 10,874.00 06/30/96 Sylvester S. Anderson, Jr, 221.00 08/08/96 . Robin L. Anderson 45.00 08/21-08/22/96 Sylvester S, Anderson, Jr. 398.00 08/22/96 Robin L. Anderson 161.00 08/22-08123196 Sylvester S. Anderson, Jr. 11.00 09/01-09/10/96 Robin L. Anderson 11,218.00 12/06/96 Sylvester S. Anderson, Jr. MIl TOTAL $23.042 00 EXHISIT "A" 0111/111 eF .>60610.1 >AliENI NO 16101H P .. f l F. N r N A fiI t ANOERSO~,. RO~I~ L. soe SEe . l00\4a.~9 NR~ eHG QTY no no l50 BO no n8 n8 l58 l58 n8 HO HO HO HO HO HO HO HO lIO HO HO HO HO HO HO HO HO HO HO HO HO HO HO HO HO HO HO HO HO HO Hl Hl 114 101 101 101 101 LI 101 FLU06 AUGO l LITO! FLU06 80110 80346 80154 80118 80 H8 lH59 lano 7844) lallO 19010 11401 19016 19444 79095 80060 79531 790H 1940) 80OdO lH04 1940) 800al 79444 19404 19451 79401 7950l lOO58 79458 81011 laU) 81017 1811) 798lO 81013 18865 lUI5 1SlOd BOOO seoO) 51lS1 14115 "'~ou"'r ) 6 -I -) -6 I I I I l I I I I I l I I I I I I I I I I I I I I I I I I l I l I I I I I 4 I I I l l.OO l.oo 15.00 l.OO l.OO B.OO B.OO H.OO H.OO H.OO 8.00 8.00 5.00 lO.OO 5.00 8.00 lO.OO 5.00 5.00 5.00 15.00 20.00 8.00 5.00 5.00 8.00 8.00 5.00 5.00 8.00 B.OO 11.00 14.00 14..00 5.00 8.00 5.00 8.00 11.00 11.00 8.00 21.00 5.00 1.00 )6.00 21.00 98.00 CAH ISLE HOSPIIAl PRINT PAlIiNI HAS.TER JAN ll, 1991 09.1. PAGE ) AM I OUE 10814.00 e HARGEl PR~V eAL 10814.00 PAYMENIS NEI eHGS ROO_ CHGS .00 .00 H81.00 OIS INS .00 ... HECIROl\leALLY BILL,D ... EXl AHI SRV 01 PSI 01 ,JA' REFERENCE DEseRIPIlON 0.00 011496 051690 e 10 Il.OO 011496 051696 e 10 -45.00 051596011606 ell .6.00 U5I506 051696 ell -ll.OO 051596 Oll696 C II l).OO 050406 050696 R6a l).OO 050496 050690 R6a 12.00 050496 050606 R61 H.OO 050196010696 ell 64.00 010596050696 ell 8.00 010496 050696 R68 8.00 050496 010696 R68 1.00 050496 050696 R68 10.00 050496 010696 R68 ~.OO 050496 050696 R68 16.00 050496 010696 R68 lO.OO 050406 050696 R68 5.00 050496 050696 R68 5.00 050496 050696 R68 5.00 050496 050696 R68 15.00 050496 050696 R68 10.00 050496 050696 R68 8.00 050496 050696 R6B 5.00 050496 010696 R68 5.00 050496 050696 R61 8.00 050496 050606 R61 8.00 050496 050696 R61 1.00 050496 050696 R61 1.00 050496 050696 R61 8.00 050496 050696 R61 15.00 050496 050696 R61 11.00 050496 010696 R61 14.00 050496 050696 R61 14.00 050496 010696 R61 10.00 050496 050696 PHO 8.00 050596 050596 PHO 10.00 050596 050696 PHO 8.00 050696 050696 PHO 11.00 050696 010696 PHO 11.00 050696 050696 PHO 8.00 050496 050696 R68 ll.00 050496 050696 R61 lO.OO 050496 050696 R61 1.00 .50496 050696 C U J6.00 "0496 050696 C 11 ll.00 050496050606 Cll 196.00 010496 010696 PHO I NIFCf CHG LI IHIUH CARBONATE CAPSULE INHCE CHG FLUPHENAZINE TABLET INIFCE CHG AHO'leILLlNICLAV TABlET I NIFeE eHr, L1IHIUH CARBONArE CAPSULE INTFCE CHG FLUPHENAZINE TABLET Iv SOl. DE XlROSE INJ 5' 50 I~ SOL SOD CHl o.n 100 Hl I~ SOL SOD CHL 0.9' 1000 t NTFC E eHG IV SOL DE' 5~ & SOD CHL .4 INTFeE tHG I~ SOL DEA n S SOD CHL .4 SEI IV SOL SECONDARY HED IRAP SPECIHEN IV ACCESS INTERLINK CANNUL IV ADHIN CHECK VALVE SET GRADUAlE DISP CANNISIER SUCTION 1500Ml CUFF ADULT OISP YANKAUER SUCTICN I,STRUHEN LI NEN lAVE RS PG/6 TUBE CONNfeTING L' TU8E SALEM SUHP H/VAlVE CUFF ADUL T 01 SP CANNISIER SUCTION ISOOHL TU8E CONNECTING L' NSS IRRIG. BOTTLE 250 Hl l CANNISIER SUCTICN 1S00Hl lUBE NON-CONouer IVE U' YANKAUER SUCTICN I.STRUMEN CANNULA NASAL C'YGEN HOlOER PH E T TUBE SAG RESUSCITATION ADULT IU8E [NOD 1.5 HM CUHED NA SAt AlRW'Y STYLI"E 14 FR. BLOOD G.s KI I IV PUHP INFUSICN SIRVICE BLOOD G.s KIT IV PUHP INFUSION SERVICE HUHIOIFIR EXCH'NGIR VENT CIRCUIT TR.Y IRRIG.TION HIIH PISTO CA THE TER nAY 'OllY 16 'R NSS IRRIG. SOTTLE 1000 ML INTFCI CHG PHLE8010MY FEE INTFCI CHG ALCOHOL ITHYL INHCI CHG HI TABOllC PRO' ILl ARIIRIAL BLOOD GA5 AN.LYSI QllZ Z 197 C'.PH610.1 PATIENT _a 16I~I8B P~TIE" N~.E .,"OE~SCN" ~OBIN 1... IJe SEC' Z00588499 ~dV Ct'+\:I Qrv ISO eHG09 -I 210 eLlB -I ZIO DEX94 -I 2\0 eHG09 -I 210 aAMI -I 210 eHG09 -I 210 AeE02 I 210 AUG02 I ISO AUGO 2 I 210 AUG02 I 210 LI TOI I 250 AUG02 I ZIO AUG02 I 210 AUG02 I ZIO LITO! I ZIO AUG02 -I 210 FLU06 Z ZIO LI TOI I ZIO FL U06 2 210 AUG02 I 250 L1TOI I ZIO FLU06 6 210 FLU06 6 250 FLU06 -Z ZIO AUG02 I ZIO L1TOI I ISO FLU06 6 210 IBUOl 4 210 AUG02 J ZIO LI 101 , 250 FLU06 6 ISO ACE02 I ISO SAL SI I ZIO ACE02 I ISO AUG02 I ISO UTOI , ZIO FLU06 6 ISO AUG02 , ISO L1TOI I 210 FLU06 6 250 AUG02 , Z50 L ITOI , ISO FLU06 6 ISO AUG02 , ISO L1101 I ISO FLU06 6 ZIO AUG02 I A/'40U"'f '.00 15.00 1'.00 '.00 15.00 1.00 .00 11.00 15.00 15.00 2.00 15.00 15_ 00 1 'S. 00 2.00 15.00 2.00 2.00 2.00 11.00 2.00 Z.OO 2.00 z.oo IS.OO 2.00 2.00 2.00 15.00 2.00 2.00 .00 8.00 .00 1 S.. 00 2.00 2.00 15.00 2.00 2.00 15.00 Z.OO 2.00 15.00 2.00 Z.OO 15.00 C~RLI5LE HOSPITAL pal"'! PAT IENI .ASIEQ J~N 22, 1997 09'14 P~GE 2 ~"r DUE 10874.00 CHARGES PREY B~L 10874.00 OIS INS .00 ,'AV"ENTS .00 NO eHG SHOO" eHGS .00 17H.00 "to fLECrRONIC'-lLY BIllED 000 !XT ~.r SRY ar PST DT BAT IIEFERE"E DEseRIPIION -1.00 OSOl96 OS0e96 CIa INTFeE eHG PH~R"ACY CHARGE IY SERYleE -11.00010196011096 cIa INTFeE eHG eLlNOA"yeIN INJECTION 600" -1'.00050596011096 elo INIFeE eHO DOTROSE S~ INJ AOO-YANTAG -'.00010596 OIlOH elo INTFeE eHO PHAR"~ey eH~RGE IY SERYleE -11.00050196051096 CIa INTFeE (HG R~NIIlDINE INJECTION 50"G -1.00050196011096 elo INTFeE eHG PHAR"~ey CHARGE IY SERYleE .00 010696 050896 PI' INTFeE eHG ~eET~"INOPHEN TABLEr 610"G 15.00 050696 050896 cia INTFeE eHG A.OXleILLI""eLAY T~BLEI 45.00050696050896 cIa INTFCE eHG ~.OXlelllINICLAY TABLEI 41.00050696050896 cIa INTFeE eHO ~.OXleILlINICL~Y TABLE! 6.00010696050896 elo INTFeE eHG lITHIU. CARBONATE CAPSULE 15.00050696011096 etO INTFeE eHO AHOXlelLlINICLAY TABLET H.OO 010696 OSl096 elo INTFeE eHO ~.oueILlI"'ICLAY TABLET H.OO 010696 011096 elo INTFCE eHO ~.OXleILlIN/CL~Y TABLET 6.00050696051096 elo INTFeE eHG lITHIU. e~RBONATE e~PSULE -15.00050696 OSl096 ell INTFCE eHG ~.OXIr.rLlINICLAY TABLET 4.00 050796 050896 PI4 INTFeE eHG FLUPHENAZINE TABLEI 6.00 010/96 051096 ell INTFeE eHO LITHIU. eARBONAIE e~PSULE 4.00050/.6 OSl096 ell INTFeE eHG FLUPHENAZINE TABLE! 41.00050796 011096 ell INTFeE eHG A.OXleILlINICLAY TABLET 6.00050796 OSl096 ell INIFeE eHO lITHIU. CAR80NATE CAPSULE IZ.OO 050796011096 ell INTFeE eHO FLUPHEN~ZINE TABLEI IZ.OO 050796 OSl096 ell INTFeE eHO FLUPHENAlINE TABLEr -~.OO 050796 011096 ell INTFeE eHO FLUPHENAlINE TABLEI 41.00050896 01l0?6 elZ INTFeE eHG AHOXlelLlINICLAY TABLET 6.00050896051096 elz INTFeE eHG LITHIUH CARBONATE C~P5ULE 12.00 050896 011096 elZ INTFeE eHG FLUPHEN~lINE TABLE! B.OO 050896 011096 elz INTFeE eHG IBUPROFEN TABLET 41.00 050996 OSlO.6 ell INTFeE eHO ~.OXlelLlINICLAY TABLET 6.00 050996 OSl096 e II I NIFeE eHO 1I THIU. CARBON.,E CAPSULE 12.00010996011096 ell INTFeE eHG FLUPHEN~2INE TABLE I .00 050996 OSl,96 PIO INTFeE eHG ACETAHINOPHEN IABLEr 650"G 8.00 050996 011396 PIa INTFeE eHO SOOIUH CHLORIDE INJECTION .00 050996 051'96 PIO INTFeE eHO AeET~HINOPHEN TABLE I 610HG 41.00 OSlO?6 051496 CIa INTFCE eHO ~HOXleILlINICLAY TABLET 6.00011096011496 cIa INIFeE eHG LITHIU. CARBONATE C~PSULE 12.00 OSlO?6 OSl496 CIO INTFeE eHG FLUPHENAZINE TABLEr 41.00 OSll96 011496 ell INTFeE eHG A.OXlelllINICLAY T~BLE! 6.00 051196 051496 ell INTFeE eHO LIIHIU. e~R80NATE e~PSULE IZ.OO OSll96 011496 ell INTFeE CHO FLUPHENAZINE TABLEI 41.00 OSlZ96 051496 el2 INTFeE eHG ~HOXleILlINICLAY "BLET 6.00 OSl2?6 011496 CIZ INTFeE eHG lITHIUH CARBON~TE CAPSULE IZ.OO 011296 051496 CIl INTFeE eHO FLUPHENAZINE TABLEr H.OO OSll96 011496 ell INTFeF. eHG ~HOXleILlINICLAY TABLII 6.00 011 196 OSl496 e II I NHe; eHG 1I THIUH CARBON~TE e~PSULE 11,00 OSl'96 OSl496 ell INTFCE eHG FLUPHENAZINE lABLEI H.OO 011496 OSl696 elo INTFCI eHO ~.OXICILlIN/ClAY "BLII 01//IIH CF .p'jO~IO.1 PAIIENI NO 1610H P411E~1 NA"r A,~O"RSON, "O~IN L. SOC SEC' 200S8d4'1I hRV C Nu H Y 124 16500 1 114 16500 1 124 16S00 I 124 16500 I 114 16500 I 114 16500 I 124 16500 I 124 16500 I 124 16S00 I 200 19500 I 200 19500 1 2S0 SUC59 I 250 PAN50 I no CNA20 2 250 LUB70 I 250 FEN50 I 250 VEOO I 250 HL56 I 2S0 CLlB I 2S0 OEX9A I no CNu09 I 250 RAN5I I 250 CNu09 I 250 CLl51 I 250 RAN51 I 250 POT51 I 250 Clta05 1 250 CLl53 3 250 0094 3 250 C NG09 3 250 RAN51 2 250 CNG09 2 250 POTSI 2 250 CHG05 2 250 FEN50 I 250 vEOO I 250 FEN50 I 250 VH50 I 250 FEN50 I 250 VEOO I 250 HL56 I 250 FEN50 I 250 VEOO I 250 CLIB -I 250 0094 -I 250 CHG09 -I 250 RAN51 -I A,~OUhl 465.00 465.00 465.00 465.00 46 I. 00 465.00 465.00 465.00 465.00 800.00 800.00 4..00 8.00 21.. 00 2.00 5.00 64.00 8.00 15.00 13.00 3.00 15.00 3.00 15.00 15.00 4.00 6.00 15.00 13.00 3.00 15.00 3.00 4.00 6.00 5.00 64.00 5.00 64.00 5.00 64.00 8.00 5.00 64.00 15.00 13.00 3.00 15.00 CARLISLE HOSPIIAL PRINI PAIIENI ~ASIER JAN U, 1991 0'/:\4 PAGE 1 AMT DUE 10"74.00 CHARGES PREV eAL 10874.00 0/5 INS .00 PAYMENIS .00 NE I CHG 5 ROOM CHGs .00 5731.00 ... ELECIROhICALLY elLLEO ... 01 AMI SRV 01 PSI 01 I\A' REFERENCE DESCRIPTION 465.00 010696 050696 RBO 05070 1240 ROOM-BED/55 461.00 050/96 050796 RBO 01070 1240 ROOM-BEO/5S 465.00 050896 050896 R~O 05070 1240 ROOM-BED/55 465.00 010996 050996 RBO 05070 1240 ROOM-REO/5S 465.00 011096 051096 RBO 05070 1240 ROOM-BEO/55 465.00 051196 OSII96 RBO 05070 1240 ROOM-8EO/55 461.00 051296 051296 HBO 01070 1240 ROOM-BED/55 465.00 051396 051396 RBO 05070 1240 ROOM.REO/5S 465.00 ~IIH~ 051496 RBO 05070 1240 ROOM-BEO/5S 800.00 050496 010496 RBO 0003A 2000 ROOM-REO/leu 800.00 050596 050596 RBO OOHA 2000 RJOM-BEOIICU 4.00 050496 050896 PII INIFCE CNG SUCCINYLCHOLINE INJECTION 8.00 050496 050B96 P[I INIFCE CHG PANCURONIUM [NJECTION 42.00 050496 050896 PII INIFCE CNu CHARCOAL ACTIVATED ORAL 30 2.00 050496 050896 PII INTFCE CNG LU8RICANT. STE~ILE 5.00 050496050896 Pll [NIFCE CHG FENTANYL I"lJECTlON 64.00 050496 050896 PII INIFCE CHu VECURONIUM 8RO~IO( INJ. I 8.00 050496 050896 PII INIFCE CHG POTASSIUM CHLORIOE 20MEQ/D 15.00050596 OS0696 CI2 INTFCE CHG CLlNOAMYCIN INJECTION 600M 13.00 050596050696 CI2 INIFCE CHG OEXIROSE 5'1 INJ Aoe-VANTAG 3.00 050596 050696 Cl2 INIFCE CNG PHARMACY C'lARGE IV SERVICE 15.00 050596 050696 C [2 [NIFCE CHG RANITlOINE INJECTION 50MG 3.00 050596 050696 Cl2 INTFCE CHG PNARMACY CHARGE IV SERVICE 15.00 050596 050696 C 12 INTFCE CHG CLlNOAMYC IN [NJECTION 15.00 050596 050696 C [2 [NIFCE CHu RANII[OINE [NJECTION 50MG 4.00 050596050696 CI2 INIFCE CHG POTASSIUM PHOSPHATE [NJ. 6 6.00 050596050696 CI2 INIFCE CHG PHARMACY CHARGE IV AOOITlV H.OO 050596 0~0696 C 12 [NIFCE CHu CLlNOAMYC IN INJECTION 600M 59.00 050596 050696 Cl2 INIFCE CHG DEXTROSE 5'1 INJ AOO-VANIAG 9.00 050596 050696 C 12 [NIFCE CHG PHARMACY CHARGE [V SERVICE 30.00 050596 010696 C [2 [NIFCE CHG RANITIOINE INJH.TlON 50MO 6.00 OH596 050696 Cl2 INTFCE CHO PHARMACY CHAROE IV SERV[CE 8.00 050596 050696 CI2 INIFCE CHO POTASSIUM PHOSPHATE [NJ. 6 12.00 050596050696 CI2 INIFCE CNG PHARMACY CHARGE IV ADOITlV 5.00 050596 050896 P[2 INIFCE CHO FENIANYL INJEerlON 64.00 050596 050896 PI2 INIFCE CNO VECURONIUM 8RO~IOE INJ. I 5.00 05H96 050896 PI2 INIFCE CHO FENTANYL INJEerlON 64.00 050596 050896 P[2 INIFCE CHr, VECURONIUM BRO~[OE INJ. 5.00 050596 050896 PI2 INIFCE CHG FENTANYL INJECTION 64.00 050596 050896 PI2 INIFCE CHG VECURONIUM 8RO~[OE INJ. I 8.00 050596050896 PI2 INIFCE CHG POTASSIUM CNLORIOE 20M(Q/D 5.00 050\96050896 PI2 INIFCE CHG FENIANYL INJECnON 64.00 050596 050896 PI2 INIFCE CHG VECURONIUM BRO~IO( INJ. I -15.00 050596 050896 CIO INIFCE CNO CLlNOAMYClN INJECTION 600M -13.00 050596050896 ClO INIFCE CHO OF.HROSe 5'1 INJ AClC-VANTAO -3.00 0505~4 050896 ero INIFCE CHG PHARMACY CNAHGE IV SERVICE -15.00 050596050896 CIO INrFCI eHO RANIIIOINE INJHIION 50MO I HI2217? CF .?H61O.1 PA IIENT NO 20H5?6 PArIE,r NAME ANOE RSON, SYLVESTER H S. SOC SEC' 184381044 CARL ISL" HOSPITAL PRINr PAIIENI MASIER JAN II, 1997 08.14 PAGE 1 CHARGES AMT DUE PAYMENIS NEr CHr,S ROOM CHGS PREV 9AL 398.00 .00 .00 .00 398.00 0/5 INS .00 NRV CHG ory AMOUNT EXI AMT SRV 01 PSI or 8AT REFERENCE OESCRIPIION 250 tF 119 I 41.00 41.00 082296 082396 PIO I NTFC E tHG CEFTRIAXONE 250MG/VIAL 250 PHE10 I 2.00 2.00 082296 082396 PIO I NTFC E CHG PHENAI0PYRI0INE TABLET 100 250 AllOl 4 29.00 116.00 082296 082396 PIO INIFCE CHG AIIIHROMYCIN CAPSULE lSOMG 305 55032 I 17.00 17.00 082196 082696 C 10 I NIFC E CHG ST AT 305 55032 1 17.00 17.00 082196 082696 C 10 I NTFC E CHG STAT 306 HH3 1 H.OO H.OO 082196 082396 C 10 I NTFC E CHG CHLAMYOIA ANTIGEN 306 55501 1 26.00 26.00 082196 082396 C 10 I NTFC E CHG CULTURE GC 306 55516 I 10.00 20.00 OBl196 081396 CIO INTFCE tHG GRAM STAIN 307 55112 1 16.00 16.00 082196 OB1396 C 10 1 NIFC E CHG URINALYSIS ROUTINE 4S0 26720 1 109.00 109.00 082296 081296 PHO CLASS II VISIT EMERGENCY 0 101 01110 -1 .00 .00 092096 091396 CS4 AUNTS CONN GENERAL INSURANCE PAY .. E NO OF : HARGES .. ~ INSURANCE COMP,lNY aUARANTOR .....llINT NAMI Carlisle Hospital PIllent Financial SONIC" EIN23-2'4."05 Poet CHico Box 177 COIII,'o, PA 17013.0177 Phonol717) 240-e875 PuLU';V NO OAOUPNO ANDERSON, SYLVESTER 419 FACTOR'i ST FIRST FLOOR CARLISLE, PA JR S, 17013 , N~ RIA OIFICI AE'IAlNClt SIAVlCI DATi It-lt........,...-1tI1 DIICF'II'TJON NRV SUMMARY DE CRIPTION 120 ROOM-BOARD SEMI 2310.00 200 ICU 2520.00 250 PHARMACY 349.00 258 IV SOLUTIO S 192.00 270 MED.SURG S PPLIES Hl.00 272 STERILE SU PL'i 58.00 301 LAB/CHEMIS RY 864.00 305 LAB/HEMOTO OGY 102.00 307 LAB/UROLOG 16.00 320 RADIOLOGY- X 624.00 351 CT SCAN/HE~ 1008.00 410 RESPIRATOR SERVICE~ 458.00 420 PHYSICAL T ERAPY 527.00 430 OCCUPATION THERAPY 208.00 440 SPEECH PAT OLOG'i 317.00 450 EMERGENCY OOM 716,00 460 PULMONARY UNCTION 174.00 621 MED-SUR SU P/!NCIDNh- RA 8.00 730 EKG/ECC 218.00 940 OTHER THEil, PEUTIC Sl.rCS 78.00 TOTALS 11218.00 !'OllC'" HOlDER DETAIL STATEMENT PATIENT N.MII ANDERSON, ROBIN L. NT IT TE P (tvO 207902.8 09/01/96 6 200-58-8499 10lCAL COA08NO 1313010 09/10/96 1 01/20197 ,t.CC()lJNT BALANCE 70 E' 05 QTY ...\"I"~:~ PAnlNTIAI..AACE N, L, """""'NT Nt> ~M" OATI TCiICHAl'03' OATlIIlL4 OATI ACCOUNT'" 207902-9 Q9/01/961 09/10/961 0100197 ACCOlJNT IAI.ANCI 11218,00 Plllent ".e.ole'Ie",lon. P,O. Box 177, C"II.lo, PA 17013.0177 IU',II04IIJ1QtIOH ~OltfAJlItICO"Oll ~ Carlisle Hospital Patl,nt. Financial S'Nlc.. EIN 23.214.1 105 POll OfficI BOM 177 CI,II,II, PA 17013.()177 Phonl (717) 249-6ll76 INBlJAANCE CO"'''ANV QVA,fIANTOA POl~V ".0 GAQuPNO POt,lCV HOlDIiR DETAIL STATEMENT PAn Nl NAME ANDERSON, ROBIN L. NT IT TD 14 NO 207902-8 09/01/96 4 ANDERSON, SYLVESTER 419 FACTORY ST FIRST FLOOR CARLISLE PA 200-58-8499 09/10/96 1 IOICAl.. RiCOAOS NO u T 131340 01/20/971 ACCOuNT BALANCE .. It! "01 ' C FQA OFFICI Al,iRENC& DETAIL OF CURRE 60075 60075 60075 65400 65400 74290 74380 74016 84004 84002 84025 84001 84025 84002 84025 84002 84025 84002 84025 86103 86109 86109 86109 88005 88017 88017 88017 26037 26750 74 3 90 74405 79150 76001 26042 76001 "AnENT NAN' N, ROBIN L, ","". ""","-"1{lJ' SiFlVlCE OATH r CII!\RGE 09/02/96 09/03/96 09/04/96 09/01/96 09/03/96 09/01/96 09/01/96 09/01/96 09/04/96 09/0s/96 09/05/96 09/06/96 09/06/96 09/07/96 09/07/96 09/08/96 09/08/96 09/09/96 09/09/96 09/05/96 09/06/96 09/09/96 09/10/96 09/05/96 09/06/96 09/09/96 09/10/96 09/01/96 09/01/96 09/01/96 09/01/96 09/01/96 09/01/96 09/01/9~ 09/02/96 JR S. 17013 , .~"""'''''''._HIlI O&:8CAlPTION , PAYMENTS AND ADJUSTMENTS CHEST PORTABLE IV CHEST PORTABLE IV CHEST PORTABLE IV CT HEAD T,1NENHANCED CT HEAD UNENHANCED STAT CHARGE ARTERIAL SAMPLING OXYGEN SERVICE DAILY EVALUATION - P.T. PHYS. THERAPY PROCEDURE 21-40 MIN. BEDSIDE P,T. I IS MIN. MINOR P,T, PROCEDURE 0-20 MIN. BEDSIDE P,T, / IS MIN. PHYS. THERAPY PROCEDURE 21-40 MIN. BEDSIDE P,T. / IS MIN. PHYS. THERAPY PROCEDURE 21-40 MIN. BEDSIDE P.T, / IS MIN. PHYS. THERAPY PROCEDURE 21-40 MIN. BEDSIDE P,T. / 15 MIN. NEUROLOGIC/CVA EVALUATION - O,T. OCC, THERAPY SESSION 21-40 MIN OCC, THERAPY SESSION 21-40 MIN OCC, THERAPY SESSION 21-40 MIN SPEECH/LANGUAGE EVALUATION-ADULT SHORT SESSION - ADULT - SLP SHORT SESSION - ADULT - SLP SHORT SESSION - ADULT - SLP ED BLOOD PRESSURE MONITOR CLASS V VISIT EMERGENCY DEP'r. OXIMETRY MEASUREMENT OXIMETRY MONITORING/24 HOURS POUCH TELEMETRY EKG ED EKG MONITOR EKG 70 OS Pllllnl flnanol.1 S.nlto.., P,O, Bo, 177, Clrll,ll, PA 17013,0177 - ,~ QTY PAllENT IIAlANCE 1 156,00 1 156.00 1 156.00 1 504,00 1 504,00 1 17.00 1 9.00 3 432.00 1 95,00 1 65,00 1 15,00 2 82,00 2 30,00 1 65,00 1 15,00 1 65.00 1 15.00 1 65.00 1 15.00 1 102.00 1 62.00 1 62.00 1 62.00 1 131.00 1 62.00 1 62.00 1 62,00 1 27,00 1 689.00 1 60.00 1 114.00 1 8.00 1 81.00 1 56.00 1 81,00 .. .....+... (l..n~ "'COONT NQ IACMIT OA TI I"BeHA""1 OATil.", 01011 [ACCOUNT.... ACCOUNT ilAl.ANC( 207902 -81 09/01/96109/10/96101/.0/971 U140. 00 U"'IIl'Hlll'O'IO" 'Oill'....IIIICOlllotl ~ Carlisle Hospital Pati.nt Fln.nelll 6'NlclI EIN 23-214.1 '05 POll Offlc. Boll. 177 Carll.'a, PA 17013.0177 Phona 1717) 249-e876 DETAIL STATEMENT INSURANCE CQWPANY POliCY NO QOOUPNO POUt";y HOt.Of - IPA TlENT NAME QUAfV,NTOA 1 ANDERSON, ROBIN L, NT PAO NO 207902.8 109/01/96 2 ANDERSON, SYLVESTER JR S, 200-58-8499 09/10/96 1 70 05 419 FACTORY ST 0ICAl COAOfl NO LL FIRST FLOOR 131340 01/20/97 CIIRLISLE, PA 17013 ACCOllkT BAI ~"l)II.IIIo/I'IIC ""' l'l"'_ .......Il.IlM.IUIo.==. "'" FOA OFFICI REFEMNCI SlR\IICIOATI! DUCRlPnON OTY PATI(NT BALANCE DETAIL OF CURRE T CHARGE ~, PAYMENTS AND ADJUSTMENTS PSY20 09/10/96 PSYLLIUM HYDROPHILIC PWDR IPK 1 -,.00 BIS30 09/10/96 BISACODYL 10MG 1 2,00 80328 09/01/96 IV SOl, DEX 5 \ & SOD CHL .45' 1000 ML 1 32,00 80352 09/01/96 IV SOL SOD CHL 0.9\ 500 ML 1 32,00 80328 09/01/96 IV SOL DEX 5\ & SOD CHL .45\ 1000 ML 1 32 .00 80348 09/02/96 IV SOL SOD CHL 0.45\ 1000 ML 1 32,00 80328 09/02/96 IV SOL DEX 5\ & SOD CHL .45\ 1000 ML 2 64,00 81017 09/01/96 SLOOD GAS KIT 1 3,00 78515 09/01/96 BANDAGE KERLIX DRESSING 1 8,00 79892 09/01/96 SENSOR OXYGEN ADH OXYTIP 1 60.00 79026 09/01/96 CUFF ADULT DISP 1 20.00 79401 09/01/96 BAG RESUSCITATION ADULT 1 60.00 80080 09/01/96 TUBE CONNECTING L' 1 3.00 79444 09/01/96 YlINKAUER SUCTION INSTRUMENT 1 3,00 78320 09/01/96 IV ADMIN CHECK VALVE SET 2B-60-264 1 20.00 78113 09/01/96 IV PUMP INFUSION SERVICE ITEM 1 B.OO 79070 09/01/96 GRADUATE DISP 1 3.00 78113 09/02/96 IV PUMP INFUSION SERVICE ITEM 1 8.00 79404 09/02196 CANNULA NASAL OXYGEN 1 3,00 79070 09/02/96 GRADUATE DISP 1 1.00 78113 09/03/96 IV PUMP INFUSION SERVICE ITEM 1 8,00 80803 09/03/96 OSMOLITE ISOTONIC LIQ NUTR 8 OZ ~ 6.00 78235 09/03/96 FLEXIFLO PUMP SET W/TUBING 71 1 15,00 79510 09/03/96 TUBE FEEDING ENTRIFLEX 8 1 25.00 79403 09/03/96 CANNISTER SUCTION 1500ML 1 8,00 78205 09/03/96 WATER STERILE 250 Ml 2F7112 1 3.00 79510 09/03/96 TUBE FEEDING ENTRIFLEX 8 1 25,00 80803 09/03/96 OSMOLITE ISOTONIC LIQ NUTR 8 OZ 2 6,00 78235 09/03/96 FLEXIFLO PUMP SET W/TUBING 71 1 15.00 78204 09/03/96 NSS IRRIG. BOTTLE 250 ML 2F7122/P 1 3,00 78113 09/04/96 IV PUMP INFUSION SERVICE ITEM 2 16,00 78122 09/04/96 PUMP FLEXIFLO FEEDING SERVICE ITEM 1 8.00 79070 09/04/96 GRADUATE DISP 1 3,00 80803 09/04/96 OSMOLITE ISOTONIC LIQ NUTR B OZ 1 3.00 78235 09/05/96 FLEXIFLO PUMP SET W/TUBING 71 1 15.00 "T NE: T PAOF. P~TlINT NAME ACCOUNT NO IACMIT DATI IOIBCHAHGIE OATIl BILL CATE I~NT""P ACCOuNT IIALANCI ANDERSON, ROBIN L. 207902-8109/01/96109/10/96101/20/971 573". uO Pili... r1n.nol.ll......lon, PO, Box 177, Carlla,.. PA 17013-0177 (tAvln4lll11OnoH 'OI'T.lJlIll'~1 ~ 9~!!~!~!l28pital (IN 23.214.1 105 ~O.t OffiCi BOI 177 Carll.ll, PA 17013-0177 Phon. (717) 241l-ll875 DETAIL STATEMENT INSUAANCI COMPN'4Y I'\>.ICYNO """,,,PNO POliCY HOlOl!H GUARANTOR '"1111''' NMlIi ANDERSON, ROBIN L, r 207902'8 09/01/96 ANDERSON, SYLVESTER JR g, 419 FACTORY ST FIRST FLOOR CARLISLE, PA 17013 200-58-8499 09 10 96 I I ,"",COROlI NO LL l'""fi'IT'O 0 1/20/97 1 iCllT 70 OS n_ " . ... IIfFlVlCIl)ATi ICAlPT1QN QTY p,AnlNT DETAIL OF CURRE T CHARG , PAYMENTS AND ADJUSTMENTS 11500 09/04/96 ROOM-BED/MSII 1 38S,00 l1SOO 09/0S/96 ROOM - BED IMS II 1 38S.00 l1SOO 09/06/96 ROOM-SED/MSII 1 38S.00 11500 09/07/96 ROOM-SED/MSII 1 3BS.00 11500 09/08/96 ROOM-BED/MSII 1 38S,00 11500 09/09/96 ROOM - BED /MS II 1 38S.00 19S00 09/01/96 ROOM-BED/ICU 1 840.00 19S00 09/02/96 ROOM-SED/ICU 1 840.00 19500 09/03/96 ROOM-BED/ICU 1 840.00 NALS2 09/01/96 NALOXONE INJECTION IMG/CC 1 15.00 FLUS 8 09/01/96 FLUMAZENIL INJECTION 10ML 1 128,00 ENASO 09/02/96 ENALAPRILAT /VASOTEC INJ 2.SMG/2ML 1 68.00 ENASO 09/02/96 ENALAPRlLAT /VASOTEC INJ 2. SMG/2ML 1 68.00 KCLS6 09/03/96 POTASSIUM CHLORIDE 20MEQ/DSW 0.45' 1 8,00 LUB70 09/03/96 LUBRICANT, STERILE SGM 1 2.00 KCLS9 09/03/96 POTASSIUM CHLORIDE 20MEQ/DSW 0.9'S 1 10.00 KCLS6 09/03/96 POTASSIUM CHLORIDE 20MEQ/DSW 0.4S' 1 8.00 LUB70 09/04/96 LUBRICANT, STERILE SGM 1 2.00 VIT70 09/04/96 VITAMIN A&D OINTMENT 5GM 1 2.00 KCLS6 09/04/96 POTASSIUM CHLORIDE 20MEQ/DSW 0.4S' 1 8.00 KCLS6 09/05/96 POTASSIUM CHLORIDE 20MEQ/D5W 0.45' 1 a.oo KCLS6 09/0S/96 POTASSIUM CH!.ORIOE 20MEQ/DSW O. 4S' 1 -a.oo PHE02 09/06/96 PHENYTOIN CAPSULE 100MG 1 2.00 PHE02 09/06/96 PHENYTOIN CAPSULE 100MG 3 6.00 PHE02 09/06/96 PHENYTOIN CAPSULE 100MG 3 6.00 PHE02 09/07/96 PHENYTOIN CAPSULE 100MG 3 6,00 PHE02 09/08/96 PHENYTOIN CAPSULE 100MG 3 6.00 PHE02 09/09/96 PHENYTOIN CAPSULE 100MG 3 6.00 PSY20 09/10/96 PSYLLIUM HYDROPHILIC PWDR IPK 1 2.00 PSY20 09/10/96 PSYLLIUM HYDROPHILIC PWDR IPK 1 2.00 PHE02 09/10/96 PHENYTOIN CAPSULE 100MG 3 6.00 PHE02 09/10/96 PHENYTOIN CAPSU1,E 100M.G 3 -6.00 PSY20 09/10/96 PSYLLIUM HYDROPHILIC PWDR IPK 1 2.00 PSY20 09/10/96 PSYLLIUM HYDROPHILIC PWDR IPK 1 -2.00 PHE02 09/10/96 PHENYTOIN CAPSULE 100MG 3 -6.00 IIAnlNT NAMI 20 '....nHI....MIaI SO",lo.., P.O. BOI 177, Carll.I., PA 17013,0177 C"'\l1 TWl'ttOTIOJf '~TAX"ICOf'OIJ . ,-,' , . ' .. '. ~~~III'I"'''l.I:'fl'fflf~~ , " ,I, , , "r, " . , '. I, I', , ,,, IN 'fHE COURT OF COMMON PLEAS OF . CUMBIlRLANDCOUNTY, PENNSYLVANIA , CIVIL ACTION. LAW , NO. 97.5012 CIVIL TERM . CARLISLE HOSPITAL AND .HEALTH SERVICES v. SYLVESTER S. ANDERSON. JR. IIIId , ROBIN 1... ANDERSON, buablllld IIIId wife , PRAECIPE " , , , , I " I , , , , I , , , ,. , " '.A'~... !J,.,,/~ *~ 'g.1~ , A ",O.USIONo'lL COP.fOMTlON ' , A~VI AND COU>l'IILLOIII AT LAW l'IN IAIT lIIOH ~TaIlT . , c"aLISU. PIlNNSYLVANIA 1101) . , , ,j -\ ." F'. p>n,:FICE r,'" r:' .".! r ','!"~I''''Y. ,.1 I - ,_11 .n I, "!', (;~i rC'i?j :..1'\ l): 1..9 II" '.! ,,'fy , .. I:: ~!.\ r. /1#y.' " , ' , , , . . 99.00 PeL " 1 , QJ:... dJ.. snr ,~ ~ ~;). '- S7 ,'I" ,. I~! t...L m'Oll 'll\:cL ,r'll,:-' " ,t, , . , ., i'" fI':";, ':' Ii ,'1. ,.' I Iii ;'i , .' , ,I'," I' " 1\; II ''I' , I ,. " , , " i' , , , " ;1 ,j" , , ,. , , , Q >.0 ~ b :J::> \i~:.' ...., J ,r'i1 k'l ,=~n:"; ,:j'} 1'." ,1."--' r,) '~"'l " '-,<',:, '. (,J\ ',I,', '( , F-:~ i: i :> , "\.'" >'1 n::i ,<:,: , -- );., , I, :l'n p _0 1,.,) , , .- ,-1 < " " ;j' ,- "0 -<. '0 =-< , , " , "