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HomeMy WebLinkAbout00-06454 ~~._". M _ ~~~O_ ~ . . '~ , PINNACLE HEALTH HOSPITALS Plaintiff v. : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 00 - 1.4[;'1 dc.>iL I~ : CIVIL DIVISION - LAW CATHY L. PREMICI Defendant NOTICE YOU HAVE BEEN SUED IN COURT. IF YOU WISH TO DEFEND AGAINST THE CLAIM SET FORTH IN THE FOLLOWING PAGES, YOU MUST TAKE ACTION WITHIN TWENTY (20) DAYS AFTER THIS COMPLAINT AND NOTICE ARE SERVED, BY ENTERING A WRITTEN APPEARANCE PERSONALLY OR BY AN 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 TWO LIBERTY AVENUE CARLISLE PA 17013 (717) 249-3166 NOTICA LE HAN DEMANDADO A USTED EN LA CORTE. SI USTED QUI ERE DEFENDERSE DE ESTAS DEMANDAS EXPUESTAS EN LAS PAGINAS SIGUIENTES, USTED TIENE VEINTE (20) DIAS DE PLAZO AL PARTIR DE LA FECHA DE LA DEMANDA Y LA NOTIFICACION. USTED DEBE PRESENTAR UNAAPARIENCIA ESCRITA 0 EN PERSONA 0 POR ABOGADO Y ARCHIVAR EN LA CORTE EN FORMA ESCRITA SUS DEFENSAS 0 SUS OBJECIONES A LAS DEMANDAS EN CONTRA DE SU PERSONA. SEA AVISADO QUE SI USTED NO SE DEFIENDE, LA CORTE TOMARA MEDIDAS Y PUEDA ENTRAR UNA ORDEN CONTRA USTED SIN PREVIO AVISO 0 NOTIFICACION Y POR CUALQUIER QUEJA 0 ALlVIO QUE ES PEDIDO EN LA PETICION DE DEMANDA. USTED PUEDE PERDER DINERO 0 SUS PROPIEDADES 0 OTROS DERECHOS IMPORTANTES PARA USTED. LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATAMENTE. SI NO TIENE ABOGADO 0 SI NO TIENE EL DINEBO SUFICIENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASISTENCIA LEGAL. CUMBERLAND COUNTY BAR ASSOCIATION TWO LIBERTY AVENUE CARLISLE PA 17013 (717) 249-3166 110) -- 1- '~.f_~~,'#(r . PINNACLE HEALTH HOSPITALS Plaintiff v. : IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA : NO. 0tJ- ~ '15'1 CM-P ~ CATHY L. PREMICI Defendant CIVIL DIVISION - LAW COMPLAINT The Plaintiff, PINNACLE HEALTH HOSPITALS, by its attorneys, KNUPP, KODAK & IMBLUM, P.C., brings this action of Assumpsit against the Defendant to recover the sum of SEVENTEEN THOUSAND, THREE HUNDRED SIXTY-SIX DOLLARS AND NINETY-TWO CENTS ($17,366.92), along with interest thereon from July 13, 2000 upon a cause of action of which the following is a statement: 1. The Plaintiff, PINNACLE HEALTH HOSPITALS, is a corporation having an office and place of business at P.O. Box 2353, Harrisburg, PA 17105. 2. The Defendant, CATHY L. PREMICI, is an adult individual residing at 554 Brighton Place, Mechanicsburg, PA 17055. 3. On the dates, in the amounts, and for the prices set forth in a true and correct copy of the Plaintiffs books of original entry hereto attached, made a part hereof and marked Exhibit "N, Plaintiff provided medical care, medical assistance and medical supplies of the kind and description set forth on said Exhibit"A" to the total amount of SEVENTEEN THOUSAND, THREE HUNDRED SIXTY-SIX DOLLARS AND NINETY-TWO CENTS ($17,366.92). 4. The balance due and owing by Defendant to Plaintiff is the sum of SEVENTEEN THOUSAND, THREE HUNDRED SIXTY-SIX DOLLARS AND NINETY-TWO CENTS ($17,366.92). 5. Plaintiff has frequently demanded payment from Defendant of said amount due and owing as aforesaid, but Defendant has refused and neglected and still refuses and neglects to pay said amount of any part thereof. F:\USER\RIK\C~P\WORK\26216,WPD:08SepOO - , .' )~'{ WHEREFORE, Plaintiff brings this suit to recover from Defendant the sum of SEVENTEEN THOUSAND, THREE HUNDRED SIXTY-SIX DOLLARS AND NINETY-1WO CENTS ($17,366.92), together with interest thereon from July 13, 2000. Respectfully submitted, F:\USER\RIK\C~P\WORK\26216.WPD:08SepOO Robert D. Kodak 407 North Front Street Post Office Box #11848 Harrisburg, PA 17108-1848 (717) 238-7151 Attorney ID No. 18041 Attorney for Plaintiff 2 SELECTED DETAIL DATA 07!~3!00 PT NO, 97025~0~5 PREMICI ,CATHY MR NO, 004567~04 ACCT SVC, HOS TOT CHRG, REG, 04/~4/97 DSCH, 07/3~/9B FC, 9 PT, R EXP IND, ACCT HAL, ------------------------------------------------------------------ PAGE ACCT HAL ~6.70 B34 V .00 SVC_ POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE 04~497 043097 7~20476 ~O GYN SMEAR PAP-REF ! (PF~4) SEL PT ! (PF~5) RETURN TO PT OVERVIEW PAQDTLO~ QTY ~ (PF3) SELECT DTL ! (PF~O) ACCT CMNTS PF~6 D/E , ~758 TYPE, B ~6,70 ~6,70 NO, ~ PT BAL ~6.70 AMOUNT ~6,70 ~': '"< SELECTED DETAIL DATA 07/13/00 PT NO: 970247621 PREMICI ,CATHY MR NO: 004567104 ACCT SVC: SOS TOT CHRG: REG: 04/25/97 DSCH: 06/19/98 FC: 9 PT: R EXP INn: ACCT BAL: ------------------------------------------------------------------ PAGE ACCT BAL B34 V 279,80 ,00 SVC 042597 042597 CD-DESCRIPTION/COMMENT-REF DATE MAMMOGRAM BIL BREAST UNIL OR BlLAT QTY 1 1 POST 042597 042597 INS 20 20 SVC CD 6701053 6701058 (PF14) SEL PT ! (PF15) RETURN TO PT OVERVIEW (PF3) SELECT DTL ! (PF10) ACCT CMNTS PF16 D/E PAQDTL01 ]1~~,' 1757 TYPE: B 279,80 279,80 NO: 1 PT BAL 279,80 AMOUNT 104.20 175,60 ;",," ~ ~" " SELECTED DETAIL DATA PT NO: 200417675 PREMICI ,CATHY L ""'''';3\ 07/13/00 MR NO: 004567104 ACCT SVC: CSP TOT CHRG: REG: 08/23/99 DSCH: 01/10/00 FC: 9 PT: U EXP IND: ACCT BAL: ------------------------------------------------------------------ PAGE SVC 081899 082399 082399 082399 082399 082399 082399 082399 082399 082399 ACCT BAL 4213.57 POST 081999 083199 083199 083199 083199 083199 083199 082499 083199 083199 SVC CD 115071 4110029 4110032 4110047 4129800 4129801 4129802 220427 6319900 6319901 INS 10 01 01 01 04 04 04 15 25 25 CD-DESCRIPTION/COMMENT-REF CBC & AUTO DIFFERENTIAL ORTH ADDL 1/2 HR 2 ORTH 1ST 1/2 HR 2 OPERATING ROOM SUPPLIES PACU 1ST 1/2 HOUR PACU ADDL 1/2 HR PACU SUPPLIES TISSUE EX GRP III SPU 1ST 1/2 HOUR SPU ADDL 1/2 HOUR QTY 1 1 1 1 1 1 1 1 1 3 DATE (PF14) SEL PT ! (PF15) RETURN TO PT OVERVIEW ! (PF7) NEXT PAQDTLOl (PF3) SELECT DTL ! (PFI0) ACCT CMNTS PF16 D/E ! (PF9) LAST 1758 TYPE: B 4213,57 4213,57 NO: 1 PT BAL 4213,57 AMOUNT 41. 50 307,00 426,25 989,72 147,00 106.00 12.50 70,00 105,00 315.00 1<" . SELECTED DETAIv DATA 07/1,3/00 1,758 PT NO: 20041,7675 PREMICI ,CATHY L MR NO: 0045671,04 ACCT TYPE: B SVC: CSP TOT CHRG: 4213,57 REG: 08/23/99 DSCH: 01/10/00 FC: 9 PT: U EXP IND: ACCT BAL: 4213,57 ------------------------------------------------------------------ PAGE NO: 2 ACCT BAL PT BAL 4213,57 4213,57 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY AMOUNT 082399 083199 6319902 25 SPU SUPPLIES 1 87,00 082399 083199 6319903 25 SPU ADMISSION ASSESSMENT 1 147,00 082399 083199 41.36001 30 CRNA MEDICAL DIRECTN (QX MOD) 70 385,00 082399 083199 41.36002 30 ANESTHESIA SUPPLIES 1 85,50 082399 083199 41.36003 30 ANESTHESIA SUP/EQT 1,ST 1/2 HR 1, 287,25 082399 083199 41.36004 30 ANESTHESIA SUP/EQT ADDL 1/2 HR 2 210,00 082399 082699 7350153 40 BUPEPI 0.5% 10ML 1, 11. 85 082399 082699 7350447 40 DROPERID 5MG VL 1 7,00 082399 082599 7350510 40 FENTAN 5ML AMP 1 7,00 082399 082699 7350652 40 ART TEARS BTL 1 7,1,5 ! (PF1,4) SEL PT ! (PF15) RETURN TO PT OVERVIEW ! (PF6) PREVIOUS ! (PF7) NEXT PAQDTL01 (PF3) SELECT DTL (PF10) ACCT CMNTS ! (PF8) BEGINNING PF16 D/E ! (PF9) LAST " ~ ~' '-'1.:;;,; ~-< , .. ~~ -.. SELECTED DETAIL D~TA 07/13/00 PT NO: 200417675 PREMICI ,CATHY L MR NO: 004567104 ACCT SVC: CSP TOT CHRG: REG: 08/23/99 DSCH: 01/10/00 FC: 9 PT: U EXP IND: ACCT BAL: ------------------------------------------------------------------ PAGE ACCT BAL 4213,57 SVC 082399 082399 082399 082399 082399 082399 POST 082699 082699 082699 082699 082499 082499 sve CD 7350742 7350853 7351150 7359068 4161214 4161899 INS 40 40 40 40 92 92 CD-DESCRIPTION/COMMENT-REF DATE LIDO 1% 5ML VL METOCL 10MG VL PROPOFOL 20ML AMP SEVOFL 60ML BTL OXYGEN THERAPY OXYGEN EQUIPMENT ! (PF14) SEL PT ! (PF15) RETURN TO PT OVERVIEW ! (PF6) PREVIOUS PAQDTL01 (PF3) SELECT DTL (PF10) ACCT CMNTS ! (PF8) BEGINNING QTY 1 1 1 1 1 1 PF16 D/E 1758 TYPE: B 4213.57 4213,57 NO: 3 PT BAL 4213,57 AMOUNT 7.00 7,00 61. 60 157.50 216,50 9.25 u }( 'n!i~A'", "..."-~'~ ~. " ,- " '~;,~. . .. SELECTED DETAIL DATA PT NO: 200445982 PREMICI ,CATHY L 07/13/00 1759 MR NO: 004567104 ACCT TYPE: B SVC: APY TOT CHRG: 12856.85 REG: 09/01/99 DSCH: 09/13/99 FC: 9 PT: 0 EXP IND: ACCT BAL: 12856,85 ------------------------------------------------------------------ PAGE NO: 1 ACCT BAL PT BAL 12856,85 12856.85 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY AMOUNT 090199 090499 2313061 02 VENIPUNCTURE - VACUTAINER 1 8.25 090199 090499 2315103 02 EMER MED VISIT IV 1 167,75 090199 090199 3091235 06 NURSING UNIT SUPPLIES 1 19,50 090199 090299 115071 10 CBC & AUTO DIFFERENTIAL 1 41. 50 090199 090299 115139 10 VALPROIC ACID(DEPAKOTE) 1 92,00 090199 090299 117038 10 BASIC METABOLIC PANEL 1 52,00 090199 090299 7357219 40 DIVALPRO 250MG TB 2 10.00 090199 090299 7357219 40 DIVALPRO 250MG TB 4 20,00 090199 090299 7357219 40 DIVALPRO 250MG TB 2 10,00 090199 090199 3090101 0 ROOM M420 0 1 734,00 ! (PF14) SEL PT ! (PF15) RETURN TO PT OVERVIEW ! (PF7) NEXT (PF3) SELECT DTL ! (PF10) ACCT CMNTS PF16 D/E ! (PF9) LAST PAQDTL01 ,"'.. ~ -h - _'.J ',.' .'.~~' _ ,. -t'~'t SELECTED DETAIL DATA PT NO: 200445982 PREMICI ,CATHY L 07/13/00 1759 MR NO: 004567104 ACCT TYPE: B SVC: APY TOT CHRG: 12856,85 REG: 09/01/99 PSCH: 09/13/99 FC: 9 PT: 0 EXP IND: ACCT BAL: 12856.85 ------------------------------------------------------------------ PAGE NO: 2 ACCT BAL PT BAL 12856,85 12856,85 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY AMOUNT 090299 090299 3091235 06 NURSING UNIT SUPPLIES 1 19,50 090299 090799 3097035 06 INITIAL IP LEVEL 3 P/F 1 194,75 090299 090399 7350005 40 APAP 325MG TAB 2 6,00 090299 090399 7350774 40 LORAZEP 1MG TB 2 6.00 090299 090399 7350774 40 LORAZEP 1MG TB 1 3,00 090299 090399 7351430 40 ZOLPID 5MG TB 2 18.20 090299 090399 7359204 40 QUETIAP 25MG TB 2 14,00 090299 090299 3090101 0 ROOM M415 0 1 734.00 090399 090399 3091235 06 NURSING UNIT SUPPLIES 1 19,50 090399 090799 3097032 06 SUBSEQ IP LEVEL 2 P/F 1 52.00 ! (PF14) SEL PT ! (PF15) RETURN TO PT OVERVIEW ! (PF6) PREVIOUS ! (PF7) NEXT PAQDTL01 (PF3) SELECT DTL (PF10) ACCT CMNTS ! (PF8) BEGINNING PF16 D/E ! (PF9) LAST c.,p~ -".~ ~_ '0 SELECTED DETAIL DATA PT NO: 200445982 PREMICI ,CATHY L 07/U/00 1759 MR NO: 004567104 ACCT TYPE: B SVC: APY TOT CHRG: 12856,85 REG: 09/01/99 DSCH: 09/13/99 FC: 9 PT: 0 EXP IND: ACCT BAL: 12856,85 ------------------------------------------------------------------ PAGE NO: 3 ACCT BAL PT BAL 12856,85 12856.85 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY AMOUNT 090399 090499 J.17042 10 HEPATIC FUNCTION PANEL 1 62,25 090399 090499 151500 10 VENIPUNCTURE CHARGE 1 5.25 090399 090499 7350126 40 BENZTROP 1MG TB 8 24.00 090399 090499 7350594 40 HALOPER 5MG TB 8 24.00 090399 090499 7350774 40 LORAZEP 1MG TB 1 3,00 090399 090499 7351430 40 ZOLPID 5MG TB 2 18,20 090399 090499 7357219 40 DIVALPRO 250MG TB 3 15,00 090399 090499 7357219 40 DIVALPRO 250MG TB 6 30,00 090399 090499 7357219 40 DIVALPRO 250MG TB 1 5,00 090399 090499 7359204 40 QUETIAP 25MG TB 2 14,00 ! (PF14) SEL PT ! (PF15) RETURN TO PT OVERVIEW ! (PF6) PREVIOUS ! (PF7) NEXT PAQDTL01 (PF3) SELECT DTL (PF10) ACCT CMNTS ! (PF8) BEGINNING PF16 D/E ! (PF9) LAST '", ~""-k.~, ~",,(,'J1=b,="'~",,_ - d'iIjf,'i SELECTED DETAIL DATA PT NO: 200445982 PREMICI ,CATHY L 07/13/00 1759 MR NO: 004567104 ACCT TYPE: B SVC: APY TOT CHRG: 12856,85 REG: 09/01/99 OSCH: 09/13/99 FC: 9 PT: 0 EXP IND: ACCT BAL: 12856,85 ------------------------------------------------------------------ PAGE NO: 4 ACCT BAL PT BAL 12856,85 12856.85 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY AMOUNT 090399 090499 7359205 40 QUETIAP 100MG TB 4 50.20 090399 090499 7359205 40 QUETIAP 100MG TB 1 12.55 090399 090399 3090101 0 ROOM M419 0 1 734,00 090499 090499 240002 02 EMER MED VISIT II P/F 1 85,00 090499 090499 240233 02 EMERMED VISIT II* 1 .00 090499 090499 3091235 06 NURSING UNIT SUPPLIES 1 19,50 090499 090599 115098 10 DRUG SCREEN URINE-* 1 ,00 090499 090599 115099 10 DRUG SCREEN URINE-A 1 16.00 090499 090599 115100 10 DRUG SCREEN URINE-B 1 16,00 090499 090599 115101 10 DRUG SCREEN URINE-C 1 15.50 (PF14) SEL :E'T ! (PF15) RETURN TO PT OVERVIEW ! (PF6) PREVIOUS ! (PF7) NEXT PAQDTL01 (PF3) SELECT DTL (PF10) ACCT CMNTS ! (PF8) BEGINNING PF16 D/E ! (PF9) LAST o"'~.~"~ "~ "" ., 1 H .tm."", SELECTED DETAIL DATA 07/13/00 1759 PT NO: 200445982 PREMICI ,CATHY L MR NO: 004567104 ACCT TYPE: B SVC: APY TOT CHRG: 12856.85 REG: 09/01/99 DSCH: 09/13/99 FC: 9 PT: 0 EXP IND: ACCT BAL: 12856,85 ------------------------------------------------------------------ PAGE NO: 5 ACCT BAL PT BAL 12856,85 12856,85 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY AMOUNT 090499 090599 115102 10 DRUG SCREEN URINE-D 1 16,00 090499 090599 115103 10 DRUG SCREEN URINE-E 1 16,00 090499 090599 115104 10 DRUG SCREEN URINE-F 1 16,00 090499 090599 115105 10 DRUG SCREEN URINE-G 1 16,00 090499 090599 115106 10 DRUG SCREEN URINE-H 1 16.00 090499 090599 115107 10 DRUG SCREEN URINE-I 1 16,00 090499 090599 115108 10 DRUG SCREEN URINE-J 1 16,00 090499 090599 115189 10 URINE MICROSCOPIC 1 13,00 090499 090599 115189 10 URINE MICROSCOPIC 1 13.00 090499 090599 115222 10 URINE DIPSTICK ONLY 1 16.00 ! (PF14) SElL PT ! (PF15) RElTURN TO ! (PF6) PRElVIOUS PAQDTL01 PT OVERVIEW ! (PF7) NEXT (PF3) SELECT DTL (PF10) ACCT CMNTS ! (PF8) BEGINNING PF16 D/E ! (PF9) LAST .-' ^ ~~~ , " - uu ,..y, SELECTED DETAIL DATA 07/13/00 1759 PT NO: 200445982 PREMICI ,CATHY L MR NO: 004567104 ACCT TYPE: B SVC: APY TOT CHRG: 12856.85 REG: 09/01/99 DSCH: 09/13/99 FC: 9 PT: 0 EXP IND: ACCT BAL: 12856.85 ------------------------------------------------------------------ PAGE NO: 6 ACCT BAL PT BAL 12856.85 12856.85 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY AMOUNT 090499 090599 115222 10 URINE DIPSTICK ONLY 1 16.00 090499 090899 11 7 04 7 10 DRUG OF ABUSE CONFIRMATION 1 47.50 090499 090599 140755 10 HEPATITIS PANEL 1 171. 75 090499 090599 151500 10 VENIPUNCTURE CHARGE 1 5.25 090499 090599 7351430 40 ZOLPID 5MG TB 2 18.20 090499 090599 7351430 40 ZOLPID 5MG TB 2 18.20 090499 090599 7351430 40 ZOLPID 5MG TB 1 9.10 090499 090499 3090101 0 ROOM M419 0 1 734.00 090599 090599 3091235 06 NURSING UNIT SUPPLIES 1 19.50 090599 090699 7350126 40 BENZTROP 1MG TB 2 6.00 ! (PF14) SEL PT ! (PF15) RETURN TO PT OVERVIEW ! (PF6) PREVIOUS ! (PF7) NEXT PAQDTL01 (PF3) SELECT DTL (PF10) ACCT CMNTS ! (PF8) BEGINNING PF16 D/E ! (PF9) LAST - ~, "J ,_ """;"';'-"'"'.' SELECTED DETAIL DATA 07/13/00 1759 PT NO: 200445982 PREMICI ,CATHY L MR NO: 004567104 ACCT TYPE: B SVC: APY TOT CHRG: 12856.85 REG: 09/01/99 DSCH: 09/13/99 FC: 9 PT: 0 EXP IND: ACCT BAL: 12856.85 ------------------------------------------------------------------ PAGE NO: 7 ACCT BAL PT BAL 12856.85 12856.85 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY AMOUNT 090599 090699 7350594 40 HALOPER 5MG TB 1 3.00 090599 090699 7357219 40 DIVALPRO 250MG TB 4 20.00 090599 090699 7357219 40 DIVALPRO 250MG TB 2 10.00 090599 090699 7357219 40 DIVALPRO 250MG TB 3 15.00 090599 090599 3090101 0 ROOM M419 0 1 734.00 090699 090699 3091235 06 NURSING UNIT SUPPLIES 1 19.50 090699 090799 3097033 06 SUBSEQ IP LEVEL 3 P/F 1 78.00 090699 090899 7350005 40 APAP 325MG TAB 2 6.00 090699 090899 7351430 40 ZOLPID 5MG TB 2 18.20 090699 090799 7357219 40 DIVALPRO 250MG TB 4 20.00 ! (PF14) SEL PT ! (PF15) RETURN TO PT OVERVIEW ! (PF6) PREVIOUS ! (PF7) NEXT PAQDTLO~ (PF3) SELECT DTL (PF10) ACCT CMNTS ! (PF8) BEGINNING PF16 D/E ! (PF9) LAST \"'''''''''''''~ i-.l SELECTED DETAIL DATA 07/13/00 1759 PT NO: 200445982 PREMICI ,CATHY L MR NO: 004567104 ACCT TYPE: B SVC: APY TOT CHRG: 12856.85 REG: 09/01/99 DSCH: 09/13/99 FC: 9 PT: 0 EXP IND: ACCT BAL: 12856.85 ------------------------------------------------------------------ PAGE NO: 8 ACCT BAL PT BAL 12856.85 12856.85 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY AMOUNT 090699 090799 7357219 40 DIVALPRO 250MG TB 6 30.00 090699 090799 7359205 40 QUETIAP 100MG TB 2 25.10 090699 090799 7359205 40 QUETIAP 100MG TB 4 50.20 090699 090699 3090101 0 ROOM M419 0 1 734.00 090799 090799 3091235 06 NURSING UNIT SUPPLIES 1 19.50 090799 090899 3097033 06 SUBSEQ IP LEVEL 3 P/F 1 78.00 090799 090899 115139 ~O VALPROIC ACID(DEPAKOTE) ~ 92.00 090799 090899 ~5~500 10 VENIPUNCTURE CHARGE ~ 5.25 090799 090899 73572~9 40 DIVALPRO 250MG TB 4 20.00 090799 090799 3090~0~ 0 ROOM M419 0 ~ 734.00 ! (PF14) SEL PT ! (PF~5) RETURN TO PT OVERVIEW ! (PF6) PREVIOUS ! (PF7) NEXT PAQDTLO~ (PF3) SELECT DTL (PF~O) ACCT CMNTS ! (PF8) BEGINNING PF~6 D/E ! (PF9) LAST -J " -" ,~~~, "'''''''';' . ~ ~ .,- SELECTED DETAIL DATA 07/~3/00 PT NO: 20041~425 SHOMPER ,SANDRA D MR NO: 182509952 ACCT SVC: AMD TOT CHRG: REG: 07/3~/99 DSCH: 08/02/99 FC: 9 PT: S EXP IND: ACCT BAL: ---------------------'-------------------------------------------- PAGE ACCT BAL 50~ V 45.00 .00 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY 080299 080399 7358503 40 NEFAZOD 100MG TB 6 080299 080399 7358603 40 RISPERID ~MG TB 2 080299 080399 7359042 40 CLONAZ 1MG TB 2 080299 080299 311043 47 ADULT ECHO 2D/M-MODE 1 080299 080299 311045 47 ECHO DOPPLER ~ 080299 080299 31~055 47 COLOR FLOW MAP ~ 080399 080499 7350500 40 FAMOTID 20MG PMB 2 080399 080499 7357~ n 40 RTU SLN 50- (NC) 2 080399 080499 7357219 40 DIVALPRO 250MG TB 1 080399 080499 7357219 40 DIVALPRO 250MG TB 3 ! (PF14) SEL PT ! (PF15) RETURN TO PT OVERVIEW ! (PF6) PREVIOUS ! (PF7) NEXT PAQDTLO~ (PF3) SELECT DTL (PF~O) ACCT CMNTS ! (PF8) BEGINNING PF16 D/E ! (PF9) LAST ..- ''''''1#_ ~802 TYPE: B 8886.45 45.00 NO: 9 PT BAL 45.00 AMOUNT 37.80 28.50 6.00 744.25 364.00 31. 75 80.90 20.00 4.65 13.95 I"d=.... ," -"--" ~ " 'I~\l'''':' "~lli:o''- SELECTED DETAIL DATA 07/13/00 ~759 PT NO: 200445982 PREMICI ,CATHY L MR NO: 004567104 ACCT TYPE: B SVC: APY TOT CHRG: ~2856.85 REG: 09/0~/99 DSCH: 09/~3/99 FC: 9 PT: 0 EXP IND: ACCT BAL: ~2856.85 ------------------------------------------------------------------ PAGE NO: 10 ACCT BAL PT BAL ~2856.85 ~2856.85 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY AMOUNT 090999 090999 3091235 06 NURSING UNIT SUPPLIES 1 19.50 090999 09~599 3097032 06 SUBSEQ IP LEVEL 2 P/F 1 52.00 090999 091099 7359205 40 QUETIAP ~OOMG TB 2 25.10 090999 091099 7359205 40 QUETIAP ~OOMG TB 1 12.55 090999 090999 309010~ 0 ROOM M414 0 1 734.00 09~099 09~099 309~235 06 NURSING UNIT SUPPLIES ~ ~9.50 09~099 091599 3097033 06 SUBSEQ IP LEVEL 3 P/F ~ 78.00 09~099 09~~99 ~~5139 10 VALPROIC ACID(DEPAKOTE) ~ 92.00 091099 09~~99 ~~7042 10 HEPATIC FUNCTION PANEL ~ 62.25 091099 091199 ~51500 10 VENIPUNCTURE CHARGE ~ 5.25 ! (PF~4) SEL PT ! (PF15) RETURN TO PT OVERVIEW ! (PF6) PREVIOUS ! (PF7) NEXT PAQDTL01 (PF3) SELECT DTL (PF~O) ACCT CMNTS ! (PF8) BEGINNING PF~6 D/E ! (PF9) LAST ~ -111'iJ1iI_~ SELECTED DETAIL DATA PT NO: 200445982 PREMICI ,CATHY L 07 /13/00 ~ 759 MR NO: 004567104 ACCT TYPE: B SVC: APY TOT CHRG: ~2856.85 REG: 09/0~/99 DSCH: 09/13/99 FC: 9 PT: 0 EXP IND: ACCT BAL: ~2856.85 ------------------------------------------------------------------ PAGE NO: 1~ ACCT BAL PT BAL 12856.85 ~2856.85 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY AMOUNT 09~099 091199 735~430 40 ZOLPID 5MG TB 2 ~8 .20 09~099 09~299 735~430 40 ZOLPID 5MG TB 2 ~8.20 09~099 091199 73572~9 40 DIVALPRO 250MG TB 12 60.00 09~099 091199 73572~9 40 DIVALPRO 250MG TB -4 -20.00 09~099 091199 7359205 40 QUETIAP ~OOMG TB 6 75.30 09~099 091199 7359205 40 QUETIAP ~OOMG TB 6 75.30 091099 091199 7359205 40 QUBTIAP ~OOMG TB -~ -12.55 09~099 091099 3090~0~ 0 ROOM M4~4 0 1 734.00 091~99 09~~99 3091235 06 NURSING UNIT SUPPLIES 1 19.50 091~99 091299 735~430 40 ZOLPID 5MG TB 2 ~8.20 (PF~4) SEL PT ! (PF15) RETURN TO PT OVERVIEW ! (PF6) PREVIOUS ! (PF7) NEXT PAQDTLO~ (PF3) SELECT DTL (PF~O) ACCT CMNTS ! (PF8) BEGINNING PF16 D/E ! (PF9) LAST """""""....- .~ ,<' tilf- SELECTED DETAIL DATA 07/13/00 1759 PT NO: 200445982 PREMICI ,CATHY L MR NO: 004567~04 ACCT TYPE: B SVC: APY TOT CHRG: ~2856.85 REG: 09/01/99 DSCH: 09/~3/99 FC: 9 PT: 0 EXP IND: ACCT BAL: 12856.85 ------------------------------------------------------------------ PAGE NO: ~2 ACCT BAL PT BAL 12856.85 12856.85 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY AMOUNT 091199 091299 7357219 40 DIVALPRO 250MG TB 5 25.00 091~99 091299 7359205 40 QUETIAP ~OOMG TB ~O ~25.50 091199 091199 3090~0~ 0 ROOM M4~4 0 1 734.00 09~299 09~299 309~235 06 NURSING UNIT SUPPLIES 1 ~9.50 091299 091499 735~430 40 ZOLPID 5MG TB 2 ~8 .20 09~299 09~299 3090~0~ 0 ROOM M4~4 0 1 734.00 091399 091599 309703~ 06 DISCHARGE MGMT P/F 1 90.00 09~399 09~499 7350538 40 FLUOXET 20MG CP 3 46.20 09~399 09~499 73572~9 40 DIVALPRO 250MG TB 4 20.00 091399 09~499 7359205 40 QUE'l'IAP 100MG TB 4 50.20 (PF14) SEL l'T ! (PF15) RETURN TO PT OVERVIEW ! (PF6) PREVIOUS ! (PF7) NEXT PAQDTL01 (PF3) SELECT DTL (PF10) ACCT CMNTS ! (PF8) BEGINNING PF16 D/E ! (PF9) LAST ~-. SELECTED DE'l'AIL DATA PT NO: 200445982 PREMICI ,CATHY L 07/13/00 1759 MR NO: 004567104 ACCT TYPE: B SVC: APY TOT CHRG: 12856.85 REG: 09/0~/99 DSCH: 09/13/99 FC: 9 PT: 0 EXP IND: ACCT BAL: 12856.85 ------------------------------------------------------------------ PAGE NO: 13 ACCT BAL PT BAL 12856.85 12856.85 SVC POST SVC CD INS CD-DESCRIPTION/COMMENT-REF DATE QTY AMOUNT 091399 091499 7359205 40 QUETIAP 100MG TB 2 25.10 091499 091599 7350126 40 BENZTROP 1MG TB -8 -24.00 091499 091599 7350538 40 FLUOXET 20MG CP -2 -30.80 091499 091599 7350594 40 HALOPER 5MG TB -8 -24.00 091499 091599 7357219 40 DIVALPRO 250MG TB -3 -15.00 091499 091599 7359205 40 QUETIAP 100MG TB -1 -12.55 091499 091599 7359205 40 QUETIAP 100MG TB -4 -50.20 091499 091599 7359205 40 QUETIAP 100MG TB -2 -25.10 ! (PF14) SEJ:. PT ! (PF15) RE'l'URN TO PT OVERVIEW ! (PF6) PREVIOUS PAQDTL01 (PF3) SELECT DTL (PF10) ACCT CMNTS ! (PF8) BEGINNING PF16 D/E -~" il!j. 'I_'~jlj~,:: . _" I" ~ ~~e '" ::;: SEP-20-00 10: 18 From: 6103785340 T-259 P.03/03 Job-931 T-177 P 03/06 Job-.45., , SEP-II-OO II :52 From: 6103785340 ';11' 11 '''''' k1"/:,','(IM KNlH'I' X. KlJ[1(lI< t-'I ~ '.1 . VI!!.I'IC~T'~N I. :t=?....,~ ~ - ~~ gf PlnnlCllt HIlIIh HOlillllalli. ve~ Ih.llhe itllell1llnll macle in the elClRlllCling document ere trill Bnel correct. I unlleratan4 that faille Ilatemill1tl1 herein are made &utljeot to the pln.la. gf 18 PR. C. S. f4ICI4, reIatInl to IIll1WOm fallltlc:llian lD aLltllarltlel. PINNACLE HEAL.TH HOIPITALI By: ?i~~ ~-^.J Title: Oa.~ ~YIP F,\U.~"IKICCHIPIWORK\.lIt"WPD:a,"'plJll I ,"~~~~- ~ . ~"'~ ~~~~ . ~ ~ " ~ I , .~ .-.....u~.~',""'"~<~.t- SHERIFF'S RETURN - REGULAR CASE NO: 2000-06454 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND PINNACLE HEALTH HOSP!TALS VS PREMICI CATHY L KATHY CLARKE , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon PREMICI CATHY L the DEFENDANT , at 0015:13 HOURS, on the 5th day of October ,2000 at 554 BRIGHTON PLACE MECHANICSBURG, PA 17055 by handing to RAYMOND PERMICI (HUSBAND) a true and attested copy of COMPLAINT & NOTICE together with IN EJECTMENT and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge 18.00 6.82 .00 10,00 .00 34.82 so;;~~ R. Thomas Kline me this /0 ~ day of 10/06/2000 KNUPP, KODAK & IMBLUM, P,C. By: /./~ ~ ;; ~ h . ff D ty Sen. Sworn and Subscribed to before (JJ~ J-o-v-o A.D. ~. O~ nvpp,,~~ rothonotary