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HomeMy WebLinkAbout99-00761 - -- --.. ,,, l' r."'~:~ 1'1'" . \;-............. . .' f' ~ \ o ~; -(.1[\: lTln, :.:-~: ::0 x: C" (,'1 ' ~- ~: ~.D 0 \J) " -., .... '" rq T:o '" co 11lr- "- I "I.:JIT1 '.0 '/)0 :.~1(~ '-"0 ":r.:-r; ;"3:0 :::.,.0 S'~ 0['11 ,:.;:. :p! .~o ".1 '-< .;:JC) ~I~ FD -'~~.... ' ~ ...,:, """" ('0. ~ 'I'- ..... ~ Qt '" -S> ,.(' ........ -- ~ ~ S;)~~ \0..J ~. ~ v..., 0\ .C; (:1 ~:~ ":, -~ PROOF OF SERVICE OF NOTICE OF APPEAL AND RULE TO FILE COMPLAINT Ohio /lIoot ot .?flfvlco MUST DE FILED WITHIN TEN (10) DA YS AFTER tiling 1110 notice ot appeal. Cl1eck applicable boxes) COMMONweAL TII 0"peNNSYLVANIA COllNrYOF '" AFFIDAVIT: II",wIIY 'w"a, or affirm Iha' I '''rvcd ['I il GOPY or till! NoticeofAppeul, Gommon Pleas No. (rlM"ot".."v;",,) .19_. 0 rnr:ldpt .1tlaclwd hefnto, ilnd upon the appellee, (name) ---~--, 19_D by personal service D and hlrllwr that. I served the Rule _ to whom the Rule was ;:Iddresscd on mnil, sendw"s rC,ccipt i:lttachcd hereto. File a Complaint accompanying the above Notice of Appeal unon theappellee(sJ to. .19_. D by personal service 0 by (certified) (registered) SWORN (AFFIRMED) ANO SUBSCRIBED BEFORE ME TillS DAY OF___ .19_. --~---_._--- SigillI Will uf (Jlfif:ii" IllJlul/I whom "flichlVit was mado Tit", (~f officllll 'My conllnlss!ul1 uxpirflS 01\__ .19_. , upon ,the District Justice designated therein on by personal service 0 by (certified) (registered) mail, seqder's , on o by (certified) (registered) mail, sender's receipt att~chedhereto. Signa tun' of a.~fi<Jnt \. '1' '\' ." :\. ': ' J,' ;., -'~HI.':I.:!. :',:; '_',ir., ., ' ;,.1". ',; : ( , ! (~ ,.-,r'..,,' ,',(: '/ ':',11 :';': lIn -",,, ,., ,. ". ,.1'....",,,-,.., -.-..--..-'..----,-..___.h.._.. ...._.......--:.____--'-_ _.___._ __.___. ~.". i).,COMriJ,o,NWEALT,H OF.:PENNSYLVANIA'" , :i;;COUNTY OF,-.:Q.Auf'l-I itJ.-,,--- <'., ' \:;-()-;:- d.,. . --" PROOF OF SERVICE OF NOTICE OF APPEAL AND8ULE, TO FILE COMPLAiNT, , " ''(n;);/prob! of 'Se;vice M/JST BE' FILEDwin-IIN TEN (10) DA YS AFTER iiling I/'e notice of appeal, Check apPti;abi;~xes) ".",,, ,,", ; .. .__.,-._--~-..-. -._----.__._~----_..,-- .1;, , .. ", 'I' ',:1' ~:d;' "".i:,-.,:';.'" I'.'~ 'YI!IP, ; I I , _._1 ;ss, ~_f.fJPA_Y 1 T: ..I.I.l€:.~el?y_s~r"Cilr, 9.f~ aifir"r]l !hal../ s_erved, '",' ~i,,'J C?~Y.,oft!;~NP;iC~,';;\lq);i:J'~I:. C~',n:';';"P1"il" N(,llJ::.7_b~i.'-:"pJ,: tI'", D,,'il;' /s;,.edCSigfl~ted !hcrcin_~f1\ (daw ofserviceJ____2../LC>,/:.i7_. 19___: f.J, by PCls\,llal,;;" vice", EJ, 'ceni(ie' lregistered)mail;senclcr's" 1'''CC;pt attached hereto, illld upon lho appellee, (1/iJ!"e).t:.l.1~'!1B.r1.(CLf.B..;lsdRJS.<_,_ ,---,!:I.!)o,:,(i!tL.t ~,- ,.', o~.. .19-__0 hy pcrsoll"; service ~ hi ~~[Dren",ter:":llm"iI, sC"'dei'sriceipt"ittaciieatic'rbtoi.i, ", :;;:,:'",; :::~:o:,:j/":':'i:;(:(""CI-j'l alid' 'fliither. that:-'I'~ervp.d- the' Rufec-10 ""'.,;"c,,' ,--' whom the Rulcwas addressed on. ,~~"''!~;,iJ(:;!l ;':;:'mail.,c;sender's recuipt 'attached herlno'.' , File a, Com!'!";lll acco'rq)~"villy,the above Notice' ofApfleal'lIPofithc'appelle~isJlo' '.-.--.-, 19_~'; . 0 . 11Y persona! service [J by Iccrtifi,ed) (r~gistcredl. . .'. . ',' '::,: i-' ; !',~ . ..,..; (i: ,"!J (':)i . ,XSWORN (AFFIRMED) AND SUBSCRIBED BEFORE ME ~;'Ti-ns"'I:_.Q';'" DAvbF""&kr:;.,""'=(_, 19~.t. <<,...;' , ~ '-,','>" "" '''{, ";':::"'~[,.. . :S~;'ri!/natu(~ of official before,Wh~m aflr'dilvit WiJS madt-' ,"'..IlJ..L /1 'I ;~:::\~:',' ;q'il'~Y;~, '~Vb> . "r', ", .:;;~~;T;tle of official" . !:,-~:;,~j<:,::,<" ,',' .' , -- ,'l.~~.Mycommissjonexp ,eso,n -, . ._, . I - ,,19_~,. .--'- , .. . ...... ," 1";;";I~i1:,!jy,;.;;l... . . U, :Picfll:'r;rr::}t;di'i .Nc.taiyPub!lc !." '!.i~,M;ii~;~:;:r'l.Dc'l:rlii:l Ca:miy, i ~~~,~~2~;f;~f~!;,;';;;.;,L,~;~~~~i~~f+i ~f) J-t,. J --.----,--...----~_..~i~ , Siyn,iJture of ill(hH'1t4 ";:;", .,~~,'r".i'~' ! ...., h;' (j .,,, , .- ,;. ,'/ " " '0 .",'. ,,1, ( (:~) '-0 ~ C 1.0 -- 'Iv ';"<':UB"J ....,'. " ~ . i: fTI mrn 1::0 ~~ 2:0 2~' -. I'; ~.,;: O~ 23 '-- ;..--C) '"U ~I.'r. :i~ O:i:J 20 ::r.: --::.C' .,-(~ )':.C: Of ~ -, ':n 55 CO -< ',,- ..., ..-'_..... I'. .-......' t -.\', I 'i" "..' ".,,"'" '. 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ORONSTEIN JEffRIES, r.A. 4830 LONDONDERRY ROAD HARRISoUR~ PA 11109-5240 (117) 651-2599 T~x 10 I: 23-1814153 Account: 3119 llRUCE SR E llAITSELL 0'2109/99 7 POPLAR DRIVE MECHANICSBURG PA 17055 PAGE NO . 1 DATE PATIENT DOCTOR DESCRIPTION/PROe A DIAG CODES CHARGES ADJUSTS RECEIPTS [lAlANCE ~~_____________w__________________________________~_________________________________________________________________ 05129191 ~CE SR DARNES DO LEV 5 CONSULT OffICE 115.00 .00 .00 115.(10 99245 195.0 06/17197 IcRUIE SR DARNES DO LEn OV EST PT 50.00 .0(1 .(10 50.00 99213 195.0 06/30/97 IcRllCE SR ml1llH DO SUDSOT HOSP-OA EAH HINR COHPL 25 75.00 .00 .00 ' 75.0(1 99232 142.9 07101/97 ORUlE SR DELHAN DO SUDSOT HoSP-DA EAN HIHR lOHPL 25 150.00 .00 .00 150.00 99232 1<12.9 06129/97 11RUlE SR OARNES DO INIT HOSP-OA EIH HI SEVERITY 70 ' 150.(1(1 .(10 .00 150.00 99223 ' 142.9 .197.7 07/03/97 ItRUCE SR OARHES DO HOSP O/C OA HeHY; HORE THAN 30 H 125.(1(1 .00 .00 125.(10 99239 142.9 197.7 (17115/97 IcRllCE SR OARNES DO LEV 3 OV EST PT 50.(~1 .00 .00 50.00 99213 195.0 07123197 ItRUIE SR lHERNIlOfF OSUOSOT ~OSP-OA EAH HIHR COHPL 25 75.00 .(10 .00 75.00 99232 ' 195.0 07124197 IcRllCE SR OARNES DO SUOSOT HOSP-OA EAH HIHR COHPL 25 75.00 .(10 .00 75.00 99232 195.(1 197.7 07120197 IcRlllE SR DELHAN DO INIT HOSP-OA EIH HI SEVERITY 70 150.00 .00 .00 150.00 99223 195.0 197.7 Exhi bit A ?? co (:: ":,,1' -"' ",' i~':: n~t ljJ~:; C).... .'- d:~,} ...::t; ....,;..:.j 'I -.' , .. . .~.. 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