HomeMy WebLinkAbout98-07011
\.
\l
t-
......
VI
.11)
...
~
(!)
'1
:>
<
, . ()
...
;1--
i .......
-
: ....
'~
, It
i~
'V
,~
"t
~
::!: )
'... i
. \J
':t
'"
"-\I
-. U
~ '-
oJ :;)
:) ~
\I \l
'~ L:J
(
~
-
. -
.::l
..
\:)
-
.......
~
,
~
'"
,
~
SAMUEL B. FINEMAN, Esquire
Identification No. 75717
CAPOZZI AND ASSOCIATES, P,C,
3109 North Front Street
Harrisburg, PA 17110
(717) 901- 5795
Attorney for Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
BEVERLY HEALTH AND
REHABILITATION SERVICES, INC.,
d/b/a WEST SHORE HEALTH and
REHABILITATION CENTER
770 POPLAR CHURCH ROAD
CAMP Hill, PENNSYLVANIA 17011
Plaintiff,
CIVil ACTION - LAW
v,
DOCKET NUMBER: 'I' f - 701 / L~.J .~
VERNA GRISSINGER
313 lEWISBERRY ROAD
NEW CUMBERLAND, PA 17070
Defendant.
COMPLAINT
AND NOW, comes Plaintiff, Beverly Health and Rehabilitation Services,
Incorporated, d/b/a West Shore Health and Rehabilitation Center (hereafter
"West Shore Health"), by and through its attorneys, Capozzi & Associates, P.C.,
and avers as follows:
1, Plaintiff, West Shore Health, is a corporation organized under the
laws of the State of California with its registered office located at
770 Poplar Church Road, Camp Hill, Pennsylvania 17011.
2, Defendant, Verna Grissinger, is an adult individual residing at 313
Lewisberry Road, New Cumberland, Pennsylvania 17070.
3. West Shore Health provided nursing home care and services to
Leila Savilla Kochenour, now deceased, for whom the Defendant
served as legal representative and Power of Attorney, from
September 20,1997, through January 13,1998,
BREACH OF CONTRACT
4. Plaintiff hereby incorporates 11111 through 3 of this Complaint as if
set forth in full.
5. On September 20, 1997, Defendant, Verna Grissinger, admitted
Leila Kochenour to West Shore Health for nursing facility care and
services,
6, Upon admission, Defendant signed an Admission Agreement
(hereafter "Agreement") as Leila Kochenour's "Agent" and Legal
Representative. A true and correct copy of the Short-Term
Admissiob Agreement is attached hereto and marked as Exhibit
"A,II
7. Through signing the Agreement, Defendant agreed to arrange for
payment of her mother's nursing home care and services,
Specifically, Defendant agreed (1) at her option to pursue Medical
Assistance benefits for Leila Kochenour or (2) to pay for Mrs.
Kochenour's nursing home care and services directly from her
assets.
8. Through signing the Agreement as "Agent," Defendant obligated
herself "to pay the account of the Facility for services/items
rendered." The Agreement further states that: "Signing this
agreement as Agent obligates that individual to distribute to the
Facility, from the Patient's income or resources, payment when due
for services/items provided to the Patient. The Agent does not
assume responsibility for payment of the cost of the Patient's care
out of the Agent's personal funds. The PatienUAgent is expected to
settle the account in full or make arrangements for payment prior to
discharge. All delinquent accounts shall bear interest at a legal rate
not to exceed the maximum allowable by state law,"
9. Under the Agreement, Defendant's obligations included her
obligations to act on behalf of Leila Kochenour.
10, On information and belief, Defendant had access to Leila
Kochenour's financial information, including the latter's income and
assets.
11. Defendant advised West Shore Health that she would pursue
Medical Assistance benefits to pay for Leila Kochenour's nursing
home care and services
....
12. On January 29, 1998, the Cumberland County Assistance Office
notified West Shore Health that, between January 1, 1998 and
January 13, 1998, it would consider Leila Kochenour eligible to
receive Medical Assistance benefits. Conversely, Mrs. Kochenour
was found ineligible for benefits from her admission date 10
December 31, 1997. A copy of said notice is attached hereto and is
marked as Exhibit "8."
13. On information and belief, Leila Kochenour received a Social
Security check, each and every month, in the amount of nine
hundred and sixty dollars ($960.00) between September 1997 and
January 1998, Defendant never forwarded said check to West
Shore Health,
14. On information and belief, Defendant failed to liquidate an
insurance policy held by Leila Kochenour which resulted in the
Cumberland County Assistance Office's finding that ivirs.
Kochenour was not eligible for Medical Assistance benefits until
January 1998.
15. As a result of Defendant's failure to provide the Cumberland County
Assistance Office with the required financial information for the
Medical Assistance application in a timely manner along with
Defendant's withholding of Leila Kochenour's monthly Social
Security check, Leila Kochenour's outstanding balance with West
Shore Health, to date, is seventeen thousand three hundred and
eighty-eight dollars and forty-four cents ($17,388.44). Said amount
reflects Leila Kochenour's private pay charges from September 20,
1997 through December 31, 1997, during which time she was
ineligible for Medical Assistance benefits. Photocopies of the
outstanding invoices reflecting this balance are attached hereto and
are marked as Exhibit "C,"
16. West Shore Health repeatedly requested that Defendant forward
payment for Leila Kochenour's care and services. A true and
correct copy of West Shore Health's Medicaid eligibility log,
documenting attempts made to contact Defendant, is attached
hereto and marked as Exhibit "0,"
17. West Shore Health has demanded payment for the care and
services it provided to Leila Kochenour on many occasions, but to
date has not received payment.
18. The Agreement provides that in the event that West Shore Health
initiates and prevails in litigation against Defendant in an action
arising from Defendant's failure to comply with the Agreement,
West Shore Health shall be entitled to receive reasonable attorney
fees.
WHEREFORE, Plaintiff respectfully requests that this honorable Court
enter judgment in favor of Plaintiff and against Defendant in an amount in excess
of $17,368.44, plus interest, attorney fees and court costs from the date of the
COUlt'S judgment.
BREACH OF IMPLIED CONTRACT
19, Plaintiff hereby incorporates,m 1 through 18 of this Complaint as if
set forth in full.
20. West Shore Health agreed to provide Leila Kochenour with nursing
home care and services, and Defendant agreed to pay West Shore
Health for the nursing home care and services provided in
accordance with the terms of the Admission Agreement.
21, West Shore Health provided Leila Kochenour with the agreed upon
services, as set forth in this Complaint.
22, Plaintiff and Defendant have an implied contract for Plaintiff's
provision of nursing home care and services.
23. Defendant has failed to pay Plaintiff the agreed upon compensation
for the care and services provided to Leila Kochenour.
WHEREFORE, Plaintiff respectfully requests that this honorable Court
enter judgment in favor of Plaintiff and against Defendant in an amount in excess
of $17,388.44, plus interest, attorney fees and court costs from the date of the
Court's judgment.
QUANTUM MERUIT
, ,
24, Plaintiff hereby incorporates '11'111 through 23 of this Complaint as if
set forth in fu II.
25, With the Defendant's full knowledge and agreement thereto,
Plaintiff provided Leila Kochenour with nursing home care and
services.
26, Defendant knew or should have known that Plaintiff expected
payment for its care and services.
27. Plaintiff had a reasonable expectation of payment for provision of
its care and services.
28. Defendant was unjustly and unconscionably enriched through its
use of Plaintiff's nursing home care and services without providing
Plaintiff with proper and agreed upon payment.
WHEREFORE, Plaintiff respectfully requests that this honorable Court
enter judgment in favor of Plaintiff and against Defendant in an amount in excess
of $17,388.44, plus interest, attorney fees and court costs from the date of the
Court's judgment.
BREACH OF FIDUCIARY DUTY
29. Plaintiff hereby incorporales 'Il'll1 through 28 of this Complaint as if
set forth in full.
, ,
30. By signing Leila Kochenour's Admission Agreement as her "Agent,"
Defendant indicated and entered into a confidential, fiduciary
relationship with Leila Kochenour.
31, As Leila Kochenour's agent, Defendant had a fiduciary duty to act
in Leila Kochenour's best interests, including a duty to timely file an
application for Medical Assistance benefits and to disclose financial
information which would enable the County Assistance Office to
make an eligibility determination, as well as forward any Social
Security income to West Shore Health.
32. As Leila Kochenour's Agent, Defendant had a fiduciary duty to use
her Leila Kochenour's income and assets to serve Mrs,
Kochenour's best interests,
33. Defendant violated her fiduciary duty to Leila Kochenour by failing
to liquidate certain assets required by the County Assistance Office
for Medical Assistance eligibility and by failing to forward Social
Security checks.
34. As a result of Defendant's breach of fiduciary duty by failing to
liquidate certain assets required by the County Assistance Office,
Leila Kochenour was denied Medical Assistance benefits between
her admission on September 20, 1997 and December 31. 1997.
35. As a result of Leila Kochenour being denied Medical Assistance
benefits, West Shore Health was not paid for the care and services
it provided to Mrs, Kochenour.
WHEREFORE, Plaintiff respectfully requests that this honorable Court
enter judgment in favor of Plaintiff and against Defendant in an amount in excess
of $17,388.44, plus interest, attorney fees, and COUlt costs from the date of the
Court's judgment.
Date: iJk/ir-
Respectfully,. submitted, "
CAPOzp:AND AS/~OCIATES, P.C.
/, ~'
/.,,//,,. ./f~
,Samuel B. Finernah, Esquire
#75717
3109 North Front Street
Harrisburg, PA 17110
(717) 233-4101
Attorneys for Plaintiff
Beverly Health and Rehabilitation Services,
Inc., d/b/a West Shore Health and
Rehabilitation Center
Dee 09 19 11:~~a
west Shore Health & Rehab 17171 730-9361
p,2
SHORT-TERM ADMISSION AGREEMENT .
@~l'iIQ.'Ii'
~
1. CONSENT FOR TREATMENT: The undersigned consenlS 10 Ihe rouline nursing and olher health care services which may
be performeel by this Facility as directed by Ihe aneneling physician's in,trnclions. The Patient also consentS Co cre>tment by
health care trainees under supervision as required by Jaw. The Palienl has Ihe right to refuse treatmenl and to revoke consent for
Ireatment at any time.
2. CONSENT TO PHOfOGRAPII: The Patient agrees to allow Ihe Facility to photograph or videotape the Patienl as a means ~
of identifieotion in ea.e of emergency or for he:llth-related purpn<e<. The pholoBraph or videolape will be kepi confidential, and o'
a
advance written permission must be obtained from the Palicnt if used for purposes olher than Ihose slaled above,
z
S
3, IUiLEASE OF INFORMATION: To the extent necessary 10 delenniJleliabilily for paymenl and to obtain reimbursement, the n
Facility may disclose ponions of the Patienl's rerord, including hisiber mediC<l1 records, 10 any person or corporation whicb is or
may be liable, for all or any portion of the Facility's charge, including but not limited 10 insurance companies, health C<lfe service
plans, Medicare, Medicaid, or worker's compensation carriers, '.
4. PERSONAL FUNDS: The Patient has a righl to manage hi</her own pmonal funds, At the Patient's written request, the
Facility shall hold, safeguard, manage and account for Ihese funds. Atlhe Patient's request, information about how to open a
Patient Trust Fund Account, and haw Ihe funds will be handled, will be provided,
S: PERSONAL VALUABLES: The Facility strongly discourages lhe keeping of valuable jewell)', papers, large sums of money,
or other items considered of value in me Facility. The Facility will make reasonable effortS 10 safeguard the Patient's propenyi
xaluables which Ihe Patient chooses 10 keep in hisiber possession. The Pa~ient agrees to inform the Facility of all valuable
propeny upon admission, and al any lime new items of value arc added to Ole, Palient's possessions. '
6.. FINANCIAL AGREEMENT: The Facility makes no guaran~ee Ihatlhe PalieJlt's care will be covered by MMicare. Medicaid,
or any third pany insurance or other reimbursement source. By signing lhis agreemenl, lhe Patient individually obligates
himsclflherselt to pay Ihe aceoum of lIle fatUilY for service.litem. ",,,deled, Si~ilillg mi. ogrttmen' as Agen' obligates ,ha'
in'dividnal to distribute to the Facility, from the Patient'. income or resources, payment when due for services/items provided
to the Patient. The ARent does not assume responsibility for payment of the cost of the Patient's care out of the Agent's
persona! Cunds. nle Patient/Agenl is cxpeciM 10 seltle the account in full or make arrangemenlS for payment prior to discharge,
All delinquent accounls shall bear interest al a legal rale not co exceed lhe maximum allowable by sUlle law. FEDERAL
AND STATE LAWS PROHIBIT TIlE FACILITV FROM REQUIRING A TIURO PARTY GUARANTF.F. OF
PAYMENT AS A CONDITION OF ADMISSION OR CONTINUED STAY IN TIlE FACILITY,
.
...,
e:.
ii'
2
A list of supplies and s~rviccs Ihat are included in the Facility's priv~te daily rale or Ihat will be paid for by the Medicaid or ~
Medicare programs and a list of supplies and services fOl which the Palient.will be sepatalely charged will be provided 10 the
Patient upon admission. A detailed list, of and cliarges for aU'supplics and services is maintained in tbe Business Office anells
available for review during normal business hours.
,"
.,. ',,' 0':: ".,.
,". .."l:, "
\<.
. .', ',I;"J ',-
....;. .
,-
7, 11::!P.EPENDENT CQNIRl\CTORS:Physicians areindependenl conlractors, nol agenlS of the FacililY. Patien! understarlds
aDd agrees thai each of the professional voups or individual practitioners which render professional sel\'ices to Patient will bill
anel collect for lIlese professinnal s"",i"", seporale and aport flom the Facility'. billinG end colleclions, but cub;ect to the autho-
roUti')ns granted by Patient in accordance wilb the agreement.
,
8. FACILITY POLICY REGARDING 1-"irLE~tErHAiioN -OF PATIENT SELF DEliitMlNATION ACT: ''Tjili F~~iiily-
recognizes the right of cach P~lient to ~Iiliu: advance directives recognized under slate law and will honm adVaIlce diredives
develop~d in acrold.n... wilh <laIc law and ronsisleut Wilh the Icvel of '~are the Facility is licenscd 10 provide, An advance
direclive. is a wrinen dOCUmcnt Ihal M'let choices!or heallh cole andlor llAIIles someone to make those choices, These choiCes
may ill~lude Il.. rcf~sal of cert.ain.I~YllC; of ~c. A Living Will ~;d a Durable Powcr of Anomcy for Ikalth uro a~ cxvnpies of
,
BE 2D1B
r? . 98 lC: .t~
~ ~ '7 7:.~1 53S~
Dee 09 19 11:43~
We~t Shore He~ 1 th l\. Reh~b 17171 730-8361
".2
I
advance directives, The undersigned acknowledges that a copy oC the Fadlily policy regarding implementation of the Patient
Self Determination Act has been provided to the Patient upon admission, The Patient [ J does l ] does not have an advance
directive.
9. CONTRAcrTERMINATION A}1ER 60 DAYS: The undersigned agrees thet the Short-Telm Admis.ion AgreemeDI .b.ll
be in effect for the lirst60 days that the Patient resides in the Facility. On the 61 st day, the Patient will be subject to the terms and
conditions of and required to execute the Resident Admission Agreement which meets additionallCquiremenlS for long-term
care. The Resident Admission Agreement will be explained in detail on or before the expiration of the Shalt-Term Admission
Agreemenr, All financial obligations that arise during the first 60 days that the Short-Term Admission Agreement is in effect
"0
shall be subject to the terms set forth in the Short-Tenn Admission Agreement until the financial obligations are satisfied. ~
n'
EO
10. BED HOLDS: The Patient may need to be absent from the Facility temporarily for hospitalization or therapeutic leave, The z
.,
Patient msy request that tho F.eility hold open the Patient's bed dUling thi. lime (bed hold). The Pat;cnt .hall be given notice of S
"
the bed ~Old option ~,~ lhe ,l,~me.of hospitalization or therapeutic leav,. ," ~..
11. lNSURANCE BENEr1TS: Ilthe Facility agrees to file an insUlance claim on behalf of the Patient, the undel~igned authorizes (\)
direct payment to the Facility ofany insurance benefits otherwist' p.y,o>. to or on behalf of the undersiened for this Patient'S stay.
Il is the Facility's policy to verify insurance benefits and review this infon"ation with the Patient: however, final determination of -+
coverage is made by the insurance compaoy. f)
12, NONDISCRIMINATION STATEMENT: The f.cility welcomes all persons in need of its services and does not discrimi-
nate on the basis of age, disability, race, color, national origin, ancestry, religion, or sex, The Facility does not discriminate
among persons based on their source of payment.
13, GRIEVANCES: Patients are urged to bring any grievances concerning the Facility to the attention of the Facility Adminis-
trator, State Licensing Agency, or Ombudsman, The Facility also offers a toll-free "Hotline" through which rJievances can be
registered directly with the corporate offices, This number is 1-800-572-9981. .
..j ..'
'.
::1, '. r''':.~ . '':..
14. ADVANCE BED PLACEMENT NOTICE: If your condition warrants, you may bo pl.c:cd in tho fucilil)"s Medico.re-
Certified Distinct Part Unit. At some point, circumstances may occur which will make residing in another unit more appropriate
for you, In that case, the facility will discuss such a transfer with you, Under law, you cannot be discharged from this fadlity
unless you agree or unless, following an appeal, it is detennined that you may be involuntallly dIScharged or transferred,
The undersigned certifies that he/she has read the foregoing, received a copy [hereof, and is duly authotized to execute the above
and accept its terms. The Patient acknowledges that he/she has been infonned of, has reccived a copy of, and has been encour-
aged to review and ask questions about all appliC3ble Resident Rights and rules and reeulatians governing Patient conduct under ;;p
Feden\ and State Law. Mail and notie.. will b. given directly 10 Ihe patie"l unle~s ~pedfie.lIy directed otherwi~a by p:uienV !;.
Uga! Represenlative/ABenL '. .,;" , , '. .:" i
':.. I,. Th;~:~a~li;l: ~;:ePts:[ ~(I~;e. I ,-rhled,cm, I ~edJCard: [ -vJi' A ?
.;' ,..'
".'
Patient Signature
.,J.'r~...; .
Date
.. ~ :;1"
~ ,..
......,,,
!'
.... "I-
eA-
11~/7 !r7
'Dale / /'. ,
" ,1,",
,
, ,
.h'
wst ~ wo..J4W.I/...d R.f'~
facility Name and Number
"
BEwm
White - BusinC!,~ Otllce
Yellow, ratirnt
Pin. - Mrdir.alll,lI,w,<i\
~,'
DEC e~ 'ge ~C:~~
~".... "''';'-.
'.' '..'to
r'c.GC .C7.-
'JPMMO,.n'I.c.....~;,.. ""r l"C~,.::lI......,.'A
OEPA"TMDlT Of f"\.I&.lC WWA"1
CUMBERJ..AND coUNTY ASSlS'rANCE OFF._.:.
JJ West1Di.n5ter Drive
P.O. Box 599
Carlisle. Peamylnni& 17013-0599
\~\ IlNil
C:C:. ~
I) ;Z~./1~ \)" ^.~.~,
V~r-V;-- r 1/. ~
33 ~-ALJ~ ty
~ ~,,/C)<.^)jYvAf cffi /7070
I ." l
....~
.~
"
~
~ ~
'. ~
~
-fl- f Il Y ')
TELE.-HONl. NUMBlfl
'.600-211I-011:1
(7171 240-1700
,
, (\ o-Jl'-'
~~(~,~-~
()..M.-
tJ oKt:?ft-I~vJ " .4~
.Ll)d'u:> 0 /
\f\'\' I /'
/
"
"
Dear ~ ~r',
We bave received your application for nursing home Medical Assistance.
In order to determine eligibility ve viii need t~e folloying item~s
indic~ P1~dse send the information to I~/~ (J~/J~
by t ,/04 ') . Please call if you bave any ques ions.
~.)
~:~
~
- 4.)
-;-~
Social Security Card(s)
Proof of date of birth
Medical coverage .eabership cards
a.) Medicare (red/wbite/blue card(s)
b.) Blue Cross/Blue Shield card(s)
c.) Any oth~r health insurance planes)
Work histories (if any in tbe past 5 years)
Verification of assets/resources for the past 3 years ~ Iq~ L( -!o
(acceptable types of verifications are: checkbook. bank E~
statetlellt. capies of itelU(s). statetlCnts(s) froe source of t:JJl'f
resoarce/Ulllt). ~
_ 'i a.) Bank accounts (checking/savings/money market. etc.) I~ C-l
~ / h.) Stocks. Bonds. or Certifi:ates of Deposit ~I ,: ~
, // c.) Christaas Club(s). Vacation Club(s). etc. ~~--
~ d.) Trust Funds
_~ e.) IiA or IEOOH 1. IldLuhl.(' -fh,'
s:-tt' Tax returns. including 1099(s) for last 3 years.Au-lft--- - AW'(J
~. Verification of titles. vehicle registration (if ~re than one ~t
,eh1cle proddll nine of each ,eh1cle). r
8.) All life insurance policies (,erification should include
~any's 1IUIIl. poliCY naber. type of poliCY. face ~t of
policy when tuell out. date poliCY vas tuen out, O1IIIership of
~. poliCY. and IltatetRnt on current cub yalue).
~ ~_ Deed to burial plotlsl or state.ent fr~ ce.etary
c:::--roJ Copy of Burial Trust (i!lcludin'l Statellent of Irrevocability)
~rr.) Deed to all property (if transferred or 50ld within the la&t 36
~nths a copy of the new deed and the settleuent sheet for all
50ld property). --<1 'PI{.U-/.k~ l.( ,
12-}-- Title to mobile bailie .
~.) ,Verification of any resource/asset that has been sold. traded.
~ or qiven any over the last 36 llIonths.A/f~.rU..
__' 14.) Any medical bills you Wish to have a det~~(nation made. to see
if Medical Assistance could cover
\ . _ I
, I,
-
~;AME .:--(. '_ (j, '- - .' ~-- /1 ._-~./JU
RECORD ~\,}lBER
~): ---. I -
.. 'f \
INITJ.\L
GROSS SS
/rw.:f-.
Ih~
MO/YR
q 7 ()t'
/).{~,~I.l
---
/n1!t~
;Cf.J-
:. i &/ '-1, ~
MO/YR
MO/YR
~
.--'"
TOTAL GROSS UNEARNED
ESTIMATED INTEREST
TOTAL INCOME USED
_ PERSONAL C.\RE
ALLOWANCE
') .. (,;
,)0 v
_ COMMUNITY SPOUSE/
HOME MAINTENANCE
--
/ 0 I (; 1 )-
It', ,
V ~ JV
!O)-'iq J-.
GROSS PATIENT PAY (53)
_ MEDICAL EXPENSES
(See below)
LESS MEDICAL EXPENSES PAID MONTHLY
NET PATIENT PAY (57)
MEDICAL EXPENSES LISTED
I Nt
MO'/YR MO/YR
./ DRUGS (54)
--
it!: KEDICARE (55)
/ BetBS/OTHER MEDICAL INS (55)
--
-- OTHER MEDJCAL (56)
ir. MONTHLY TOTAL
''x//'' , " /'/)
---Ll..- ell ~ 1 ,) d-U:/
SIGNAT~RE I
REMINDER: TIle resource lioit is $~OOO/$:400. See attached Addendu~
,,- -".'
I / 2ft/tit
. DATE
'..
BEVERLY
OfiD\'IUSU
WEST SHORE HEALTH & RI-.IIAB CENTER
770 POPLAR CHURCH RD
CAMP HILL PA 170Il
VERNA GRISSINGER
313 LEWrSBERRY ROAD
NEW CUMBERLAND PA 17070
KOCHENOUR LEILA
DA TElPERIOD COVERED
-IT
: l I I
I I ,!
092097 09iZ497
092097 112097
8~~8~? 8~~8~$
r^r)297 12~997
l397 12:1997
1J9i2527 12[!297
8926::17 09,697
9il797 092897
100197 100197
100897 100897
1011.397 12:1.997
10[697 10il697
l8~!~? lij~~~~
10~997 12B497
11 597 11 597
11 597 110597
11: 197 llU97
11~927 llil997
11 8::17 121997
12 797 l2!'l997
120897 122497
l2~797 12i797
12 797 12~7?7
01 998 "
~6~~~? ~M~~?
110197 113097
120197 123097
123197 123197
01p698 01P~8
,
,
,
NA~! =1
KOCHENOUR LEI I
I
''__.3T~~:OE~/T9D:TE -=---1$
AMOUNT ENCLOSED $
ACCOUNTNU~___
285 97167
AMOUNT DUE
17388.44
Please make check or money order payable to:
WEST SHORE HEALTH & REHAB CENTER
770 POPLAR CHURCH RD
CAMP HILL PA 17011
Be Sure Above Address Appears In Wmdow Of Envelope
Please delqcll lop pel1ion and return with your remittance,
Retain tnis (lomon of the slatement for your records
NAME
DESCRiPTION
BALANCE FORWARD
PHARMACY
PHARMACY NON COVERED 0
ADMISSION KIT
BEDPAN
CURER 4X4 8PLY STERILE
TELFA PAD 2X3A STERILE
GAUZE SPONGE ,,-X2 S
GRADUATE MEASURE.
ATTENDS PAD MODERATE
SYRINGE~ LUER SLIP TB
GRADUATr.MEASURE
KERLIX STERILE 4.5 X 4
5YRINGEA LUER LOK 10 C
SALINE ~OL STERILE 4 0
ATTENDS BRIEFt MEDItn1
BARBER & BEAU rCIAN
ELBOW PROTECTOR
SYRINGE & NEEDLE 22G 1
A & D OINTMENT 4 OZ
COMB
ATTENDS BRIEF SMALL
ATTENDS WASHCLOTH REFI
TELFA NONSTICK PAD 3X4
SYRINGE & NEEDLE 23G 1
TISSUES
PAYMENT
ROOM CHARGE
ROOM CHARGE
ROOM CHARGE
ROOM CHARGE
ROOM CHARGE
ROOM CHARGE
ADJUSTMENT
ADJUSTMENT
ADJUSTMENT
ADJUSTMENT
i
I
I I
r-';c--'-"'l'AYl'IEI\'T Ii n.T. -l1E-CDNSIDERED DEL1NgFEl;'T
McSSI-GE IF NOT RECEIVED BY THE lOTI!. I'AH1ENTS
RECEIVED AFTER THE 10TIl MAY 1\01' Dr:
REF I.ECTED ON TIll S STATEMENT,
tor Bi,ilng irH;/Ulllt"1lo ..,:cot.f- ,...:1
ACCOUNT NUMBER
285 97167
~
I'; 1 I
o 'hb\~ . ~
\~ if V \
STATEMENT DATE
03{01{98
OTY I DAYS
AMOUNT
6
20
1
1
19
93
18
1
Z
1
1
23
1
11
1
3
1
1
1
1
3
2
6
1
1
11
31
30
30
1
7
,
3320:00
163:10
59:00
12!00
1:00
2128
93:00
18:00
0:84
20i!t0
~OO
0:84
95:91
100
20~6
22[39
32:50
6:50
mo
3'30
oi50
68137
19:92
6:00
100
1170
-3007
203500
490500
314500
3145:00
7000
146':50
I
,
,
,
:
\
i
,
:
!
· . .. · 17388.44
\ Payment due by the 10t';~'-~;ch -;;'onth I
I .....,. \
.
:ffiIEVIE'I1t':
FACILITY NO. L7.J (I'5'
cc '.ECTION PROGRESS RECC )
, .w"'_.
ADMIT DATE I DISCH, /;i j /5'e I A'SIOCNT~ N>ME frx./\el'\ (lo.I/' , ~:t.'^-
1/,}w /:;7 DATE
~ BIWNG NAME tie (' ^'" I P~E 00. , I RESIDENT NO, 9 7/67
Cr.-ss,..,c, "'- ) 77'1- ;)7'::
- Cln- STATE
BILLING ADDm:SS liP
RESIDENT ;- ~'VA.TI; o M/CARE A 0 WCAID o 'ill o M/CARE B o QI!-illl DESCRIPTION
TYPE
ACCOUNTS RECEIVABLE AGING PROGRESS ANALYSIS SOUIC4I .-.ccoUNTS RECEIVABLE AGING (1..R.t.f.211j
MONTHIYR, TOTAL NR i PRE-BILL 1 .30 30.60 60 - 90 90 - 120 120 +
I
I I I
I
I
DATE ACTION TAKEN BY WHOM
(A1WlfI'l "lCord I'IlIme ("11 Pftf~, cont""tox1)
(J/cJ{ al(c.i /./ a....:Ji,t.<Y "!- I J. 'CJ v
--r I
--
I
-
,
.
I
BE 31' te.'t,)
.
.
u.(:J.f/
SHERIFF'S OFFICE
50 NORTH DUKE STREET, P,O, BOX 83480, LANCASTER, PENNSYLVANIA 17608.3480 . (717) 299.8200
--- .------- SHERIFF SERVICE '---I'
PROCESS RECEIPT, and AFFIDAVIT OF RETURN __
lPlAINTIFFI"SI------.--
Beverly Health and Rehabilitation Services, Inc.
3 DEFENDANT/SI
Verna Griss inger '
SERVE {!; NAME or INDIVIDUAL. COMPANY, COAPOIMTlON, [le. 10 HE SEIWLD
~ Verna Grissinqer
...,.. 6 ADDRESS IStreet or Rro, Apar1menl No ,City, Boro. Twp , Slale and lIP Code)
AT :113 Lewisberry Road, New Cumbg,rland, P^ 17070 -
7, INDICATE UNUSUAL SERVICE )0 OEPUTlZE rJ OHiER, ("1 lmhp r 1 ~ nn
Now. ? I J I Q 9 _ '9 _ , I, SHERIFF OF ~)(l!:ltR COUNTY, PA, do ll")4j>y#putize the~
Yor!!' , County to execule this Wri ~tle!4r~y'!~of ~
to law, This deputation being made at the request and risk of the plainWl, . . ",," t
S"l'Rlnor -.OIJ ,
8, SPECIA~ INSTRUCTIONS OR OTHER INFORMATION THAT WI~~ ASSIST IN EXPEDITING SERVICE,
PLEASE TYPE OR PRINT LEGIBLY.
DO NOT DETACH ANY COPIES.
l;? COURT NuMBER W
98-7011 Civil
11 TYPE or WHIT OR COMPLAINT
cins.
Notice & Complaint
......
Cumberla~
ADVANCE FEE PAID BY CUMBERLAND COUNTY SHERIFF
'J\
--
c"J
co'
......,~.
\..01-..
NOTE ONLY APPLICABLE ON WRIT OF EXECUTION: N .8. WAIVER OF WATCHMAN - Any deputy shenlllevying upon or allachmg 8f'Y proper1y Linder
wIthin INnl mayle8ve !l>arne without a watchman, Ul custody 01 whomever IS found in pos!:>ess1on. aller notifYing person 01 levvor allachmenl, wl1houlllabllityon
the par1 01 such deputy or the shenff 10 any plalnllll herein lor any loss, destruchon or removal 01 any such property belore sheriff's sale thcreol
t. SIGNATURE 01 ATTORNEY Of olher ORIGINATOR 10 TELEPHONE NUMBER 11 DATE
Samuel B. Fineman
3109 N. Front st., Harrisburg, PA 17110 717-901-5795 01/29/99
12. SEND NOTICE OF SERVICE COPY TO NAME AUD ADDRESS BELOW: (Th'S .r~. mUlt b. completed If notice " to be mined)
Cumberland County Sheriff, 1 Courthouse Sq., Carllsle, PA 17013
SPACE BELOW ~OR USE OF SHERIFF ONLY DO NOT WRITE BELOW THIS LINE
NLAMUEdow, AiU'ghOtlZOd leso Depl;ty or Clmk 214/D5./,e9R9cceived 2'5/ E2xQ.i'/.'9,on9'Heanng dale
13.13CknOWledOtlrCCelPtolthewril,1 tl
or complaint 8" mdlcated above J .
16 I helebv CERTIFY and RETURN 1hs' I fl hav~ personally sef'llccl,rJ have 11'>\)"'1 eVlden(.E' 01 SCl'\'lce as llhown '" "Remarks", U have ("eculed as shown In
"Rem8rks~, the vml Of complaint dCSC1lbf'd on the indiVidual, company. corporallon, etc. althc addre~5 shown above or on the mdwldual. company. cor.
porallon, etc. allhe l'IddlC\S In~(>rted ht;'>low tJy hancling It TRUE .nd ATTESTED COPY Ih(>r~ol
17 [J I hereby c~r1lly and rr.lum 8 NOT fOUND becl!.u!.e I am unable 10 locale the indiVidual, company, corporaHon, efc . named above ($E"C remark~ belOW)
1,8 Name ilf\d !11It\' 01lndlVldV" A't'I' ('to (It not shown above) (Rolallonshlp ~o Oelf"ndanll =r9 Ap~lhon{)t"u'l.bleag.llndd,,:c,.,'I(Hl
~ /~( ~ L .. ':1_ InNl .el>.dH'I'iI'l'l HI. de't'ndalll" lJhulll
.~ ~~ ;o.JJ.t'J/..:J.-:r2..~" ?(':, _ ___ place 01 abode I.!
20 "ddu~6S 01 whNC 'Served (comp~f"e on, !y II dlllpl ,__ Uan~wn above) (Strcet or Rr 0, AnartmE'nl No ,City, Boro, 1 wn ~ 01 Service 1'22 lIme
Stale and ZIP Codel . .;/" " ! -. -
/- ;;/ /~19 '1 ' .2.ce
~
lOST
23. ATTEMPTS
~
G 24
\11
Mil.1I
::1 D.. Inl, -
29 COST DUE OR R[FUNO
~(>
, 100.00
"30 ~~'R'SCOU-NTY COSTS:
+5.00
I()L~ ()(.,
STA
18.00
26.00
(44.00)
2.00
46.00
29.00-
_"-'1, G'O
'__ro~~~.li~~ ~~~"I',,~-I___-=1-------
U ..' , . '..,. ~,CvUl"~ '1 so ANSWER.
3,,.,rfIRI.J(t an(3 ~.-tr-fl~;~''''''\~:.~;f.t(~~, ".~~;1.-~~-l,]~2..~}:!..._--- -~, ~'\------:r7~~" -- -
,,' ":"";;~'fy' ""'--',9'99 'i,~,':f;~.',;"'I~c..v-..-.,l'-\ ' "},)i/fi--
:: :_::7!Q~~1~';:;{ ~{fl;;~~/ ::V:~1,';;~J;~~~L~.~~~,~q'Sh.;:;~~-
~ r: g_~~~~':l.:..:~:..!.~!:"~~~~~ ~" _.I.:......'!-1: _ /;;/ / j. _ "lor .~___._ __ ___
38 l.t1( H~(h'..l ([),,;r F[ CJ };'1 () "1"1 s.....{ ~[', 'S P[1 UR~ StGI.AllJ~r I
or p<J1!~(.\n:n (1 !','::':l~_~ ,.1,'''..:'14,1 ~ I-'~; 'I~i I
--~ -.'-' ,-- .~. .
.'~ "~' " ....., .. .,....','
, \,.,.;j11 1':"''''',,/,.11 ,,',
I",. I.",
P',!.;:;" ''''1.'(' e,':,., ~
!:",.,