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IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
MEMORIAL HOSPITAL.
Plaintiff
NO. 00 - PAlO?
C'D.~tr~
vs.
CIVIL ACTION - IN LAW
THEREASA L. BROWN,
Defendant
NOTICE
You have been sued in Court. If you wish to defend against the claims set forth in the
following pages, you must take action within twenty (20) days after this Complaint and Notice
is served, by entering a written appearance, personally of by attorney, and filing in waiting 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
document, or for any other claim or relief requested by he Plaintiff. You may lose money or
property or other right 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 TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
NOTICIA
Le han demandado a used en la corte. 51 used quaere defensas de esas demandas expuestas en
las paginas, siguientes, used tiene viente (20) dias de plazo al partir de la fecha de lademanda y la
notifiation. Used debe presentar una apariencia escrita 0 en persona 0 por abogado y archivar en la
corte en forma escrita sus defensas 0 sus objeciones a last demandas en contra de su persona. Sea
avisado que si used no se defienda, la corte tomara medidas y psedido entrar una orden contra used sin
previo aviso 0 notificacion y por cualquier queja 0 alivio que es pedido en la peticion de demanda. Used
puede perder dinero 0 sus propiedades 0 otros derechos importantes para used.
LLEVE EST A DEMANDA A UN ABODOAGO IMMEDIA T AMENTE. 51 NO TIENE ABOGADO 0
51 NO TIENE EL DINERO sUFFICIENTE DE PAGAR TAL sERVICIO VAYA EN PERSONA 0
LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION sE ENCUENTRA EsCRlTA ABAJO
PARA A VERIGUAR DONDE sE PUEDE CONsEGUIR AsslT ANCIA LEGAL.
Court Administrator
Cumberland County Court House
1 Court House Square, 4th Floor
Cartisle, Pennsylvania 1 7013
(717) 240-6200
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IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
MEMORIAL HOSPITAL.
Plaintiff
NO. 00- J7'/o7 ~ ~
vs.
CIVIL ACTION - IN LAW
THEREASA L. BROWN,
Defendant
COMPLAINT
AND NOW, this ~ay of _~8vfJJ)t(, 2000, comes the Plaintiff,
Memorial Hospital, by and through its attorneys, Daniel F. Wolfson, Esquire and the
law firm of Wolfson & Associates, P.C, and files the within Complaint and in support
avers as follows:
1. Plaintiff, Memorial Hospital, (hereinafter referred to as "Plaintiff") is a
health care provider qualified to conduct business in the Commonwealth of
Pennsylvania with offices and/or a place of business situate at 325 S. Belmont Street,
York, York County, Pennsylvania.
2. Defendant, Thereasa L. Brown, (hereinafter referred to as "Defendant"),
is an adult individual with a last known address of 202 D Ramsey Place, New
Cumberland, Cumberland County, Pennsylvania 1 7070.
3. That on or about March 15, 2000, through March 18, 2000,
Defendant was a patient of Memorial Hospital, where she did receive various necessary
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medical services and medical treatment by Plaintiff. An itemization of said services is
attached hereto, incorporated herein and collectively marked as Exhibit "A".
4. That a Treatment Consent and Billing Authorization statement was
provided to Defendant outlining the terms and conditions of repayment to the Plaintiff
for medical services provided by the Plaintiff. A true and correct copy of the
Treatment Consent and Billing Authorization statement of said terms and conditions is
attached hereto, incorporated herein and collectively marked as Exhibit "B".
S. That the amounts charged for the medical services to Defendant were fair
and reasonable and the amounts the Defendant agreed to pay.
6. That Plaintiff has submitted to Defendant a copy of the Statement of
Account accurately showing all debits and credits for transactions with Plaintiff. Said
Statement of Account is identified as Exhibit "A" and incorporated herein by
reference.
7. Defendant has not objected to the above mentioned Statement of
Account submitted by Plaintiff to Defendant,
8. As of November 10, 2000, the balance due, owing and unpaid on
Defendant's account as a result of said charges is Six Thousand Three Hundred Forty-
Four and 30/100 Dollars ($6,344.30). See Exhibit "A".
9. Defendant has made no attempts to make payment toward the balance
due and owing, all to the damage and detriment of Plaintiff.
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1 O. Despite Plaintiff's reasonable and repeated demands for timely payments,
Defendant has failed, refused, and continues to refuse to pay all sums due and owing on
Defendant's account balance, all to the damage and detriment of the Plaintiff.
11. Pursuant to the terms and conditions of the Treatment Consent and
Billing Authorization statement, Plaintiff is entitled to receive, and Defendant agreed to
pay reasonable attorney's fees in an amount not to exceed twenty percent (20%) of
the outstanding balance, in addition to all court and collection costs in the event the
account was placed for collection with an attorney. See Exhibit "B".
12. Plaintiff has retained the services of the law firm of Wolfson & Associates,
P.c., in the collection of the amounts due from Defendant.
1 3. As of the filing of this Complaint, Plaintiff has incurred reasonable
attorneys fees from the law office of Wolfson & Associates, P .c., in the collection of
the amounts due and owing by Defendant incident to the within action, and Plaintiff
shall continue to incur such attorney's fees throughout the conclusion of the
proceedings.
14. Plaintiff has incurred reasonable attorney fees in the amount of One
Thousand Two Hundred Sixty-Eight and 86/100 Dollars ($1,268.86).
15. Any and all conditions precedent to the bringing of this action have been
performed by Plaintiff.
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16. The amount in controversy is within the jurisdictional amount requiring
compulsory arbitration.
WHEREFORE, Plaintiff, Memorial Hospital, respectfully requests this Honorable
Court enter judgment in favor of Plaintiff and against Defendant, Thereasa L. Brown, in
the amount of Six Thousand Three Hundred Forty Four and 30/100 Dollars
($6,344.30), plus reasonable attorney fees in the amount of One Thousand Two
Hundred Sixty-Eight and 86/100 Dollars ($1,268.86), plus interest, the costs of this
action and such other relief as the Court deems proper and just.
Respectfully Submitted,
Daniel F. Wolfson, Esquire
WOLFSON & ASSOCIATES, P.c.
267 East Market Street
York, PA 17403
(717) 846-1252
I.D. No. 20617
Attorney for Plaintiff
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VERIFlCA liON
I, Barb Forry, Collection Specialist for Memorial Hospital, verify that the statements
made in the foregoing Complaint are true and correct to the best of my information
and belief. I understand that false statements herein are made subject to the penalties of
18 Pa. C.S. Section 4904, relating to unsworn falsification to authorities.
DATE:
II/;;':Z ) 00
~Ak Jj
Barb Forry Ii
"'Memorial Hosp-ital
325 S. Belmont St.. York, >,t.I740H118' (717)84H623
(TYPE Of: BILL
D
I PAGE" I BILL DATE )
. " :LO/12/00
SERVICE FROM THROUGH
03/15/00 03/18/00
FEDERAL TAX I.D. NO. 23~1265004
BRDI,IN
THEREASA
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RESPONSIBLE PARTY
PATIENT
BROWN THEREASA
202 D RAMSEY PLACE
NEW CUMBERLAND. PA 17070
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':?S'?62D- [I 1
DISCHARGE DA'rE/TIME
03./18.'00
STAY
ACCOUNT NUMBER
ADMISSION DATEiTlME
0:5/15/00
"
GUARANTOR NO,
2 :j8487898
1:16098
PLAN NUMBER ONE
PLAN NUMBER TVVO
PLAN NUMBER THREE
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SELF PAY APPLY FOR M
INSURED, i3RObIN THEREASA L
EMP.:
ROADWAY PACKAGING SERVICE
FOR PROPER CREDIT. PLEASE ENCLOSE THIS TOP PORTION WITH PAYMENT.
N SUR A N C E
CATEGOP'i
S'JM.'1ARY
120
2'5:'
252
379
ROOM- BOARD/Sal I
DRUGS/GENERIC
DRUGS/NONGENER!C
I I) SDLUT IONS
I l) THERAPY
I1ED- SUR SUPPL r ES
STER II_E SUPPLY
SUPPL'y'/DTHER
LAB/CHEMISTRY
LAB/HEMDTOLOGY
LAB/BACT - i1 I CRO
PATHOLOGY LAB/PROF 1-
PATHOLOGY LAB/TECH C
0>< ><- RA'y'
OR SERUICES
ANESTHESIA/CRNA
SELF-ADl1IN DRUGS
RECOUERY l'iOml
1;14'?"DO
1'53,00
241.]0
36::" . f5 ~J
93. :10
739, t;:]
1;411080
1",3.:) 0
77. :)0
:'4,00
185,50
94. S:U
23.::?O
.00
1,3'50.00
. [10
60.'00
228.00
2l:5l3
2~IO
'270
272
279
301
30S
..,.06
:no
319
320
3!::.0
,~\37
710
TOTAL CHARGES
':';344,30
TOTAL PA'ii1ENTS
.00
TOTAL ADJUSTMENTS
6;344.3D-
*.~* TOTAL
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(PATIENT
, BRmJN
THEREASA
L ) ACCOUNT N~M~E; 6:2 0 _ 0 1 SE~~3~:;~O~\.,. J 0 TH~JO~~,~ 18./ 0 0 (PAGEl)
ANY SERVICE RENDERED BUT NOT INCLUDeD ABOVE WILL BE BILLED AT A LATER DATE.
THESe CHARGES ARE FOR HOSPITAL SERVICES ONLY. PHYSICIANS BILL SEPARATELY.
MEMORIAL HOSPITAL . YORK PA
KEEP THIS DOCUMENT FOR INCOME TAX AND OTHER RECORDS
~i~;~~::."~~~,
325 S. Belmont Street
P.O. Box 15118
York, PA 17405-7118
(717) 843-8623
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, TREATME~~ CON~~:;:;';'''''''';'~f'~~-~r~;g''~JJ _"
BILLING AUTHORIZATION'" -." ,;. 'u.,;, ,';-
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(please indicate those applicable authorizations, releases and agreements 'by p/afi.1Jg- ;;'(l~~X ~;~shoJn.:~ [n7irrlappropnate boxes.)
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Authorization for Treatment and Dia~ostic .Procedures: I understand that the medical care and diagnostic procedur~s I rece~ve, ..
will be that ordered by my physician, his assistants or designees. I consent to any hospital services rendered at the instruction of my .
physician and I understand that no guarantee or assurance was made to me as to the results that may be obtained. I further
understand and have no objection to doctors in training or other hospital approved persons assisting in or observing my treatment
when the purpose of this is to advance medical education.
Consent for Treatment: I understand that if there are invasive procedures or surgery to be performed, I will be required to sign a
separate consent, and the procedure will be fully explained to me by my physician. I further understand that Memorial Hospital is
not liable for any act or omission in following the instructions of my physicians. I consent to any X-ray examination, laboratory
procedures, anesthesia, medical or surgical treatment or to any other hospital services rendered under the instruction of my physician.
1 understand that all physicians furnishing services to the patient are independent contractors and are not employees or agents of
Memorial Hospital. Should my treatment require an implantable devicellife sustaining device, I give consent to release my Social
Security number to the manufacturerfFDA in accordance with the Safe Medical Device Act.
Medicare Authorization: "Patients Certification Authorization to Release lnfonnation and Payment Request"; I certify that the
information given by me in applying for payment under Title A'Vill of the Social Security Act is correct. I authorize any holder of
medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any
information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf.
Medigap Authorization: I request.tbat payment of authorized Medigap beuefits be made either to me or on my behalf to Memorial
Hospital for any services furnished me by Memorial Hospital and/or associated physicians.
"An Important Message from-Medicare/Champus'.': I acknowledge that I have received, at the time of my admission to
. Memorial Hospital or shortly thereafter, _a copY' of "" Ari Important Message from MedicarefChampus. .. My signature does not waive
any of my rights to request a review 9r ma}::e me liable for payment.
Medical Assistance Recipient Statement: I certify that the information is true, correct and accurate. I understand that payment
and satisfaction of this claim will be frorp Federal and state funds and that any false claims, statements or documents or concealment
of material facts may be prosecuted under appIicabl~ Federal and State laws.
Financial Ae:reement: The undersigned, in consideration of "the services to be rendered to the patient, is obligated to pay the
hospital in accordance with its regular rafes and terms and, if the account is referred to an attorney or agency for collection, to pay
reasonable attorney's fees and collection expens,es. The undersigned agrees to be responsible for charges not covered by insurance. It
is understood that the obligation to pay the Hospital may not be deferred for any reason, including pending legal actions against other
parties to recover medical costs.
Private Room Aereement: I hereby request that the patient be placed in a private room. r understand and agree that the difference
between the daily basic rate for a private room and a semi-private room is to be paid at discharge; that said difference may be in
addition to other charges due and payable by myself, the patient or financially responsible person.
Assignment of Benefits: I hereby assign to Memorial Hospital of York and/or any physician providing medical services while I am
a patient at Memorial Hospital of York all hospital and medical benefits payable to me or for my benefit for my hospitalization
and/or treatment. I understand that I am financially responsible for the charges not covered by this assignment.
Authorization for Release of information: To obtain payment for services or to provide for continuity of care should I be
transferred to another institution or referred to a home bealth provider, I hereby authorize Memorial Hospital, to disclose to my
insurance carrier, admitting institution or home health provider, portions of my medical record including, but not limited to:
discharge summary, medical history and physical, laboratory and X-ray results, and diagnosis as they relate to my care and treatment.
I recognize that the records disclosed may contain information that is proteci~d by Federal and State law, and I specifically consent to
the disclosure of such information. I understand that this authorization may be revoked at any time, except to the extent that action
has been taken in reliance upon it, and will expire without express revocation in 120 days after the date below or at time of discharge,
whichever is longer.
Personal Valuables: I understand and agree that the Hospital maintains a safe for the safekeeping of money and other valuables and
that the Hospital shall not be liable for the loss of such valuables. I understand that I am responsible for all my personal effects.
fully read and fully understand this patient consent and financial agreement, have received a copy thereof and accept its
Relationship to Patient
Signature of Person Authorized to Consent for Patient
Signature of Patient
If Patient is Unable to. Sign State Reason and Initial
50 (VjO{)
Signature of Insure,9-.if Different
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Signamre of Registrar
Date
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THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
MEMORIAL HOSPITAL,
NO. 2000 8407
Plaintiff
vs.
THEREASA BROWN,
CIVIL ACTION - LAW
Defendant
PRAECIPE TO WITHDRAW COMPLAINT
Please withdraw without prejudice the above referenced matter. The Defendant
resides in another county.
Respectfully submitted,
WOLFSON & ASSOCIATES, P.c.
Dated:
I~v /60
~~~
Daniel f. Wolfson, Esquire'
267 East Market Street
York, Pennsylvania 17403
717/846-1252
I.D. #20617
Attorney for Plaintiff
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