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Home My WebLink About99-05989 i A Z CHONG 0. LEE, : IN THE COURT OF COMMON PLEAS Administratrix of THE : CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF YOUNG H. LEE, : Plaintiffs NO. 99- 5,Kf Civil V. : CIVIL ACTION - LAW MARIA G. MEDINA, Defendant JURY TRIAL DEMANDED PRAECIPE FOR WRIT OF SUMMONS TO THE PROTHONOTARY OF CUMBERLAND COUNTY: Please issue a Writ of Summons against the Defendant, Maria G. Medina at the following address: 5506 N. American St. Philadelphia, PA 19122 and have the Sheriff of Cumberland County deputize the Sheriff of Philadelphia County to serve the same. and BY: DATE: ?IZjfl?y Matthew S. CrosK, Esq. ID No. 69367 319 Market St., P.O. Box 1177 Harrisburg, PA 17108 Tel. No.: 717-238-2000 Attorneys for Plaintiff C c? k71 r. i.] V: N? C • ? M J _ d ^ ^ ? Q O rh zq C) I? Q ^ ¢cqm tl1 y X dMM O C? TNn 0 = - p X OK o „ ` ~ ? a Y LL al I " ?r Commonwealth of Pennsylvania County of Cumberland Chong O. Lee, Administratrix of the Estate of Young H. Lee VR Maria G. Medina 5506 N. American St. Philadelphia PA 19122 Court of Common Pleas No. Term -------- 19 In ___ Civil- -A-c--t-i--o-n ---- ---L-a--w ---------------- Maria G. Medina: To ----------------------- You are hereby notified that Chong O. Lee, Administratrix of the estate of Young H. Lee - ---------------------------------------------.-------------------- ---- --- Summons ----Civil- the Plaintiff ha s commenced an action in ________._ _A_ction__-__ Law against you which you are required to defend or a default judgment may be entered against you. (SEAL) Date ----- -Sep-----tember 30, -- I9__ 99 ------------- . _ CDRTIS_.R._ _LQWMG------------------------- -Pro?tary By - ----- - - Depu W i ? C i i .. ? ? f!1 v i i r 4j i i r to e F( i ,?F N ? .7 130 i ? n .? w to I a ^? QQ H o ?' may' °i 4J rz 8 awa co 0 4-1 j V) v Ln i O.k T C7 i i I I = ???? ml 04J C H C?, LLlr? N ?> r , J O N ] ;, ' [i I_I. F ib 1 65 fT `j 0*% U d`' CHONG O. LEE, : IN THE COURT OF COMMON PLEAS Administratrix of THE : CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF YOUNG H. LEE, : deceased, Petitioner NO. 99-5989 Civil V. : CIVIL ACTION - LAW MARIA G. MEDINA, Respondent JURY TRIAL DEMANDED ORDER AND NOW, this ;W 0day of (L-L& L, , 1999, upon consideration of the foregoing Petition, IT IS HEREBY ORDERED that a hearing in this matter be held on theX day of 2./,?. Zz n /?p1/, 1999, at//, 2d A.M. o'clock, in the Cumberland County Courthouse, I Courthouse Square, Carlisle, PA 17013, in Courtroom No. /-/ . BY THE COURT: ?? ... ,, ,•;DTPAY 99 OCT 25 AI! 10: LE PEV? JSYL4d.?9A CHONG O. LEE, : IN THE COURT OF COMMON PLEAS Administratrix of THE : CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF YOUNG H. LEE, : deceased, Petitioner : NO. 99-5989 Civil V. MARIA G. MEDINA, Respondent CIVIL ACTION - LAW JURY TRIAL DEMANDED ORDER AND NOW, this _ day of 1999, upon consideration of the foregoing petition, it is ordered that settlement in compromise of this action for the sum of $11,000.00 is approved. Furthermore, counsel fees and expenses are also set forth below. The distribution is directed as follows: (a) To Matthew S. Crosby Esq., HANDLER, HENNING & ROSENBERG, for counsel fees in the amount of $3,666.66; (b) To Matthew S. Crosby Esq., HANDLER, HENNING & ROSENBERG, for reasonable costs and expenses, in the amount of $332.06. (c) To the Department of Public Welfare (DPW), $2,116.39. (d) To Chong 0. Lee, as Administratrix of the Estate of Young H. Lee, Petitioner, in the amount of $4,884.89. BY THE COURT: J. 1 CHONG O. LEE, : IN THE COURT OF COMMON PLEAS Administratrix of THE : CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF YOUNG H. LEE, : deceased, Petitioner NO. 99-5989 Civil V. : CIVIL ACTION - LAW MARIA G. MEDINA, Respondent JURY TRIAL DEMANDED PETITION FOR SETTLEMENT OF SURVIVAL ACTION AND APPORTIONMENT OF SETTLEMENT WITH WRONGFUL DEATH ACTION AND NOW, comes the Petitioner, CHONG 0. LEE, Administratrix of the ESTATE OF YOUNG H. LEE, deceased, by and through her attorneys, HANDLER, HENNING & ROSENBERG, by Matthew S. Crosby, Esq., and petitions this Honorable Court to enter an Order permitting settlement and apportionment of the above action and, in support thereof, states the following: 1. On or about October 4, 1997, Decedent, Young H. Lee, was a passenger in a parked vehicle, owned by Bruce Horowitz. The Horowitz vehicle was facing northbound on North 5" Street in Philadelphia, Pennsylvania, and was legally parked on the eastern side of that roadway. Page -1- 1 .c 2. At or about that same time, the Respondent, who had been traveling south on North 5" Street, lost control of her vehicle, crossed the double yellow line, and violently impacted with the Horowitz vehicle. 3. As a result of the collision, Young H. Lee sustained head trauma, became incapacitated, and lost the use of his cognitive functions, before passing away on February 20, 1999 4. Petitioner, Chong O. Lee, the decedent's widow, was appointed Administratrix of the Estate of Young H. Lee, on August 25, 1999. Attached hereto, made a part hereof, and marked, "Exhibit A," is a Grant of Letters of Administration from the Cumberland County Register of Wills. 5. At all times material hereto, the Horowitz vehicle was insured under an automobile policy with Colonial Penn Insurance Company. Said policy did not include any Underinsured Motorist (UIM) benefits. 6. At all times material hereto, Decedent, Young H. Lee, was personally insured under an automobile policy with State Farm Insurance Company. Said policy included UIM benefits in the amount of $25,000. 7. Despite the fact that there were allegedly no UIM benefits available under the Colonial Penn policy, a settlement agreement in the amount of $30,000 was reached with that carrier. In addition, a settlement agreement was reached with State Farm , in the amount of $25,000. Page -2- 8. On June 25, 1998, by Order of this Honorable Court, those proposed settlements of $30,000 with Colonial Penn and $25,000 with State Farm were approved. Attached hereto, made a part hereof, and marked, "Exhibit B," is a copy of the said Order of Court, confirming its approval of the aforementioned distribution. 9. At all times material hereto, Respondent, Maria Medina, was insured under an automobile insurance policy with American International Insurance Co. At the time of the aforementioned collision, Respondent's policy had single-limit, bodily injury liability coverage in the amount of $30,000. 10. Petitioner has also confirmed that the Respondent has no other applicable insurance coverage in this matter. To that end, attached hereto, made a part hereof, and marked, "Exhibit C," is an Affidavit of no other insurance, executed by the Respondent, Maria Medina. 11. To date, six (6) bodily injury claims have been made under that policy, asa result of this collision. Two of these claims, including that of the decedent, are wrongful death claims. 12. Petitioner has been offered $11,000 by American International Insurance Co, in settlement of the survival and wrongful death actions, subject to this Honorable Court's approval. Attached hereto, made a part hereof, and marked, "Exhibit D," is a copy of the proposed settlement release. 13. Petitioner desires that this settlement be approved and that the net settlement of $4,884.89 be allocated, as previously approved by the Department of Revenue, Page -3- in the amount of ninety-five percent (95%) to Decedent's statutory beneficiaries as "wrongful death" damages and five percent (5%) to Decendent's Estate as "survival" damages. Attached hereto, made a part hereof, and marked, "Exhibit E," is a copy of a letter from the Department of Revenue, confirming their approval of the aforementioned distribution. 14. Counsel has previously been retained by Petitioner to represent her and the Estate of Young H. Lee, with regard to claims stemming from the aforementioned collision of October 4, 1997. Attached hereto, made a part hereof, and marked, "Exhibit F," is a copy of the Contingent Fee Agreement. 15. Matthew S. Crosby, Esq., counsel for the Petitioner, and the Petitioner herself believe said settlement is fair and equitable under the circumstances of this case. 16. Matthew S. Crosby, Esq., pursuant to the Contingent Fee Agreement, requests reimbursement of expenses in the amount of $332.06. Attached hereto, made a part hereof, and marked, "Exhibit G," is a copy of the billing summary. 17. Pursuant to the Contingent Fee Agreement, Matthew S. Crosby, Esq., also requests attorney's fees, in the amount of 33-113% of the amount recovered, which calculates to $3,666.66. 18. The Department of Public Welfare (DPW) has asserted a lien in the amount of $81,679.39 (Attached hereto, made a part hereof, and marked "Exhibit H," is a letter from DPW, asserting such a lien.). This lien has been reduced to account for the cost of recovery and attorneys' fees, and DPW has agreed to accept $19,624.99, as payment in full. Page -4- 19. Petitioner proposes that $17,508.60, the balance of an escrow account previously set up by Order of this Court to honor future liens, be paid directly to the DPW. Petitioner further proposes to satisfy the remaining lien with a payment of $2,116.39 out of this settlement. WHEREFORE, Petitioner requests this Honorable Court to: (a) Approve the settlement stated above; (b) Approve payment of counsel fees and expenses stated above from the funds received; and (c) Direct distribution of the net funds recovered to Chong 0. Lee, as Administratrix of the Estate of Young H. Lee, as stated above. Respectfully submitted, & ROSENBERG Date: Matthew S. may. Esq. Supreme Court ID No. 69367 319 Market Street P.O. Box 1177 Harrisburg, PA 17101-1177 (717) 238-2000 Attorneys for Petitioner Page -5- VERIFICATION PURSUANT TO Pa. R.C.P. No. 1024fc) MATTHEW S. CROSBY, ESQ. states that he is the attorney for the party filing the foregoing document; that he makes this Affidavit as an attomey and verifies that it is correct and accurate to the best of his knowledge, information and belief and that this statement is made subject to the penalties of 18 Pa. C.S.A., Section 4904 relating to unswom falsification to authorities. MATTHEW S. CROSBY, ES DATE: 1 O 11? ® muum u?wm mw r¢or von.uarrn 4 STATE OF PENNSYLVANIA SHORT CERTIFICATE COUNTY OF CUMBERLAND I, MARY C. LEWIS Register for the Probate of Wills and Granting Letters of Administration &c. in and for said County of CUMBERLAND do hereby certify that on the 25th day of August A.D., j One Thousand Nine Hundred and Ninety-Nine. Letters of ADMINISTRATION i in common form were granted by the Register of said County, on the estate of LEE YOUNG H , late of CARLISLE BOROUGH in said county, deceased, to CHONG 0 LEE and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 25th day of August A.D., One Thousand Nine Hundred and Ninety-Nine. File No. 1997-00940 PA File No. 21-97-0940 Date of Death 2/20/1999 'Register S.S. $ 130-62-9826 EXHIBIT A NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL n • cn.. c.. ....nn o. «.•..n r.vndmam •?....i I? iNTuE MATTER OF YOUNG H. LEE An Incompetent, by and through his appointed guardians, Bruce Horowitz and Chong O. Lee aN IN THE COURT OF COMMON PLEAS CUMBERLAND, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-97-940 ORDER AND NOW, this ?7? day of JO'aiun of the foregoing Petition, it is ordered that Settlement in compromise of this action for the sum of $55,000.00 is approved. Furthermore, counsel fees and expenses are also set forth below. The distribution is directed as follows: a) The guardians, Bruce Horowitz and Chong 0. Lee, are authorized to execute the Releases from State Fans Insurance Co, and Colonial Penn Insurance Co. b) To Bruce Horowitz and Chong 0. Lee, as guardians of Young 0. Lee, an incompetent, in the amount of$34,399.1 I to deposit $17,199.56 in Escrow to satisfy any future liens with the Department of Public Welfare, the balance of $17,199.55 distributed to guardians; c) To the Department of Public Welfarei 32,152.60 d) To the Law Firm ofHandler &Wiener, fo-rcounselfees in the amount of 18,333.33; and 4 c) To Law Firm of Handler & Wiener, for repsonable costs and fees in the amount of $114.96. BY THE COURT: J. EXHIBIT B i It- 0" AFFIDAVIT OF NO INSURANCE My name is MARIA, G. MEDINA and I reside at 5506 North American St, Philadelphia, PA 19122 and/or 6420 North 5' St., Philadelphia, PA 19125 On October 4, 1997, 1 was involved in an accident. I understand that claims are being made against me by the Estate of Young Lee and other injured parties, for an amount that is in excess of the bodily injury limits of the automobile insurance policy with Material Damage Adjustment. Those limits are $30.000, for all damages caused to any one person in a vehicular accident. Being duly sworn according to law, I HEREBY CERTIFY that on the date of the collision, October 4, 1997, 1 was not covered by any other insurance policy. whether it be an excess policy or an umbrella policy or, otherwise, I would provide additional coverage for damages to the Estate of Young Lee, as a result of this collision. I FURTHER CERTIFY that, at the time of the collision, I was not acting on behalf of my employer in any manner. I UNDERSTAND that I am giving this Affidavit to induce representatives of the Estate of Young Lee to accept the policy limits of my above-named insurance policy, in full settlement of the Estate's claim against me. I further understand that the Estate representatives are relying on this information in making their decision to accept such settlement. I VERIFY that the statements in this Affidavit are true and correct. I understand that false statements herein are made subject to the penalties of swearing. Sworn to and subscribed before me th;s ,?&/ day 18 Pa. C.S.A. §4903, relating to false 5t,t,,CA-_ h. Lll,?J MAMA G. MEDINA of JK e -; 1999. ", /l 1 O, Note r-Public M Commission ExPIa. irres ` Feb. 26. p1 ANY PERSON-OVHO?CNOp?p AND WITH INTENT TO INJURE OR DEFRAUD ANY INSURER FILES AN APPLICATION OR CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION, SHALL, UPON CONVICTION, BE SUBJECT TO IMPRISONMENT FOR UP TO 7 YEARS AND PAYMENT OF A FINE UP TO $15,000.00 1 : EXHIBIT D RELEASE FOR THE SOLE CONSIDERATION OF ----Eleven thousand and 00/100 Dollars ($11.000.00) from American International Insurance Co., the receipt and sufficiency whereof is hereby acknowledged, the undersigned hereby releases and forever discharges AMERICAN INTERNATIONAL INSURANCE CO., MARIA MEDINA, ANGEL L. MEDINA, and MATERIAL DAMAGE ADJUSTMENT, INC. from any and all claims and causes of action that I now have or may have against said parties, resulting from a motor vehicle collision that occurred on the 4th day of October 1997 in Philadelphia, Pennsylvania THE UNDERSIGNED hereby declares that she has completely read, fully understood and voluntarily accepted the terms of this settlement for the purpose of making a full and final compromise adjustment and settlement of any and all claims, disputed or otherwise, on account of the death of Young H. Lee in the above-referenced incident and for the express purpose of precluding forever any further or additional claims arising out of the aforesaid accident. IN WITNESS WHEREOF, I have hereunto set my hand and seal this _day of , 1999 In presence of: WITNESS: SIGNED x (SEAL) CHONG O. LEE, Administratrix of the Estate of YOUNG H. LEE, deceased EXHIBIT D EXHIBIT E ® mn.v. ...,mv vc....o+nond.n:m OFFICE OF CHIEF COUMSEL COMMONWEALTH OF PENNSYLVANIA DEPT. 281081 DEPARTMENT OF REVENUE HARRISBURG, PA 17128-1061 October 15, 1999 PHONE: 717.787.1782 FAX 717.772.1459 Matthew S. Crosby, Esq. Handler, Henning and Rosenberg 319 Market Street P.O. Bor. 1177 Harrisburg, PA 17108 Re: Estate of Young H. Lee, deceased Court of Common Pleas of Cumtcrlanzi ^ty No. 99-5989 Dear Mr. Crosby: The Department of Revenue received the draft Petition for Settlement of Survival Action and Apportionment of Settlement with Wrongful Death Action, to be filed on behalf of the above- referenced Estate. Pursuant to the Petition, on February 20, 1999, the fifty- nine year old decedent died from injuries sustained in a motor vehicle accident which occurred on October 4, 1997. The injuries sustained incapacitated Decedent from the time of the accident, and also caused the loss of use of his cognitive functions. Decedent is survived by his spouse and son. Please be advised that, based upon these facts, and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the net proceeds of this action, $4,746.43 to the wrongful death claim and $249.81 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa.C.S.A. §8302, 72 P.S. §§9106, 9107. I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, I will not be attending any hearing regarding it. Please do not hesitate to contact me if you or the Court has any questions or requires anything additional from this Office. I can be reached by telephone at (717) 787-1382, extension 3063. Sincerely, Lora A. Kulick. Assistant Counsel cc: Clerk of Court LAK: dmm EXHIBIT E ?? ® mnoiu meeae o?ne¢me nun.vnww ti.ti......._..:.._._-_ __... 1.. __ ? i CONTINGENT FEE AGREEMENT 6110N(u 0 uc'ej VV I FL KNOW ALL MEN BY THESE PRESENTS that 1 AN9 ?'Ccd/' c,- J Fc•2 hereby retain HANDLER AND WIENER, of Harrisburg, Penftylvania, as my attorneys in this matter to represent me and to process, negotiate, arbitrate a settlement or to institute for me in my name any legal roceedings or actions that, in their judgement are necessary, against 4or against anyone else as for breach of contract and resulting damages sus ed by me as the result of an incident that occurred on or about October 1997. I agree not to settle, negotiate or adjust the above claim or any proceedings based thereon without the written consent of my said attorneys. NOW, THEREFORE, in consideration of the services so to be rendered by HANDLER AND WIENER, I hereby covenant, promise and agree to pay them for their professional services rendered, THIRTY-THREE AND ONE-THIRD (331/3) PERCENT of whatever sum is recovered as a result of settlement without suit; or FORTY (40%) PERCENT in the event of arbitration, mediation or if suit is filed. I will reimburse HANDLER AND WIENER for any necessary, expenses and costs advanced on my behalf in pursuing my claim. Counsel reserves the right to withdraw if, after complete investigation', they determine that there is no merit to the claim. I ACKNOWLEDGE that I have read, approved and understood the above Contingent Fee Agreement and Power of Attorney and I acknowledge having received a copy of the same. The terms set forth are accepted. IN WITNESS WHEREOF, I have hereunto set my hand and seal this day of 1997. -4f I (SEAL)T? CI?GN(, 0- LZL, W(FC 137vi) `url2i?i /1rJ roC ((ctuvu Lz j1 EXHIBIT F r EXHIBIT 6 ® Olly]Y 9„tl901 OiORIW MJT.lItl19Th HANDLER, KENNING a ROSENBERG October 12, 1999 Billed through 10/12/99 Bill number 202584-00000-005 MSC YOUNG LEE 1215 HILLSIDE DR CARLISLE PA 17013 Balance forward as of bill number 901 dated 08/28/98 Payments received since last hill (last payment 08/28/98; Net balance forward DISBURSEMENTS 07/01/98 Register of Hills Cumberland County 09/27/99 Sheriff of Philadelphia County 09/27/99 Proth of Philadelphia County 09/28/99 Proch of Cumberland county 09/28/99 Sheriff of Cumberland County 09/29/99 To Void Ck 8 37099 09/29/99 To Vold Ck a 37100 10/12/99 Document Reproduction 10/12/99 Mileage 10/12/99 Postage Costa 10/12/99 Postage Costs 10/12/99 Long Distance Telephone Charge. $18,440.29 $18,448.29 $ .00 • billing timekeeper Matthew S. Crosby • date of last bill 08/28/90 • data of last reminder • last bill through date x5/26/98 • bill type code S-4 ' action to be taken • 0-hold entire bill 3--u ... ry fees and exp • 1•a/r reminder 4.bill feel and exp • 2-bill exp., hold fees 5-summary fees/detail s • current .00 • 30 day. .00 60 days 00 90 days .00 120 days .00 • billing frequency A-12 • last payment 08/20/98 18440.29 • billing realization 0 1 • fees billed to data 10333 .33 • expo billed to date 114 .96 • fee. recd to date 16333 .33 • expo reed to date 114 .96 • matter 00000 21 .00 4CUM 07/01/90 21 .00 116 .00 2PHI 09/27/99 116 .00 338 .50 • 1PHI 09127/99 338 .50 45 .50 ICUM 09/20/99 45. 50 175 .00 2CUM 09/28199 175. 00 116 .00- VOID 09/29/99 116. 00- 330 .50- VOID 09/29/99 338. 50- 56. 80 ISI summary 56. 00 16. 25 MILE summary 16. 25 2. 97 POS summary 2. 97 6. 63 POST summary 6. 63 7. 91 TILE summary 7. 91 Total disbursements for this matter . 332.06 132.06 BILLING SUMMARY C , 1 ? C. EXHIBIT H WFNTN OF PRINSYLVANI? DEPART E WELFARE DEPARTMENT FINANCIAL PUBLIC LIC BUf1EAU OF OPERATIONS TPL SECTION CASUX 1486 VUNR P BOPA1 BI88 HARRISBURG, PA 17105 October 04, 1999 HANDLER & WIENER MATTHEW S CROSBY 319 MARKET STREET P O BOX 1177 HARRIBURG PA 17108 I? I Re: YOUNG LEE CIS N: 790139695 Incident Date: 10/04/1997 Dear Mr. Crosby: Enclosed please find the updated statement of claim you have requested. If you have any further questions, please contact me. Thank you for your cooperation in this matter. Sincerely, (,0/9.;0,/"w Carol Zellers TPL Investigator 717-772 -62 66 717-772-6553 FAX Enclosure EXHIBrr H r , COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION - CASUALTY UNIT PO BO%• S1B0 HARRISBURG PA 17105-8/80 October 4, 1999 STATEMENT OF CLAIM SUMMARY LEE, YOUNG 799139 695 .,..., ?@'i b? orFy?"?iY.ofiPENNSvivA?riing'Ff?a=?^a;, { aG 1? mi UPDATE TO PREVIOUS SOC DATED Ofi1031§S 81,879.39 October 4, 1999 STATEMENT OF CLAIM LEE, YOUNG C 790139 695 BELVEDERE MEDICAL CORP BMC RADIOLOGICAL ASSOC 850 WALNUT BOTTOM RD CARLISLE PA 17013 11110/98 11/1098 02/08199 9011857753/01 0000000000100 40.00 19.00 DIAGNOSIS 1 : 9983 POSTOP_WOUND DISRUPTION DIAGNOSIS 2: E8199 MV TR_ACQUNSP_NAT•UNSP_PER PROCEDURE : 99212 OV/OP VST FOR EVAL & MGMT OF ESTAB PAT PROS-SELF LTD OR MINOR 10-MIN FACE-FACE BELVEDERE MEDICAL CORP gO,Op 19,00 01 0656161 October 4, 1999 STATEMENT OF CLAIM ID LEE, YOUNG 780139 695 HARM KENNETH R 1030 GOOD HOPE RD ENOLA PA 17025 01/15/99 - 01115199 05/31199 9124865269/01 0000000000100 45.00 1150 DIAGNOSIS 1: 85400 BRAIN INJURY_NEC DIAGNOSIS 2 : PROCEDURE: 99312 SUBSO NSG FAC CARE/DAY, EVAL 6 MGMT RESPOND INADO-MINOR COMP 25 MIN BEDSIDE 02105/99 - 02/05/99 05!31/99 9124995289/01 0000000000/00 35.00 1150 DIAGNOSIS 1 : 5950 ACUTE CYSTITIS DIAGNOSIS 2: 6829 CELLULITIS NOS PROCEDURE : 99311 SUBSO NSG FAC CARE, MAY, FOR EVAL 6 MGMOF NEW OR ESTAB PT 15 MIN BEDSIDE 02119199 - 02M9199 05/31/99 9124865269/02 0000000000/00 35.00 1150 DIAGNOSIS 1 : 5950 ACUTE CYSTITIS DIAGNOSIS 2: 6929 CELLULTRS NOS PROCEDURE : 99311 SUBSO NSG FAC CARE, /DAY, FOR EVAL d MGMOF NEW OR ESTAB PT 15 MIN BEDSIDE HARM KENNETH R 115.00 34.50 01 0672020 October 4, 1999 STATEMENT OF CLAIM LEE, YOUNG 1 790139 995 MASLAND ASSOCS, INC MEDICAL ARTS BLDG 220 WILSON ST CARLISLE PA 17013 12M4/98 - 12104198 02115199 9015010907101 0000000000100 140.00 31.20 DIAGNOSIS 1 : 4349 CEREBR ARTERY OCCLUS NOS DIAGNOSIS 2: 2765 HYPOVOLEMIA PROCEDURE : 94657 VENT ASSIST & MGMIJNT PRESS/VOL PRESET VENT ASSIST CONTROL BREATH;SUBO DAYS 12105/98 - 12/05198 02/15/99 9015610607102 0000000000100 140.00 31.20 DIAGNOSIS 1 : 4349 CEREBR ARTERY OCCLUS NOS DIAGNOSIS 2: 2765 HYPOVOLEMIA PROCEDURE : 94657 VENT ASSIST & MGM,INT PRESSIVOL PRESET VENT ASSIST CONTROL BREATH;SUBO DAYS 12/06198 - 12/"g 02/15189 9015610808/01 0000000000100 77.00 16.00 DIAGNOSIS 1 : 4349 CEREBR ARTERY OCCLUS NOS DIAGNOSIS 2: 2765 HYPOVOLEMIA PROCEDURE : 99233 SUB HOSP CAREIDAY FOR EVAL & MGMT OF PATPT UNSTABLE OR SIGN COMPL 35-MIN BEDSIDE MASLANDASSOCS,INC 357.00 '711-0 01 0712494 __ F October 4, 1999 STATEMENT OF CLAIM LEE,YOUNG ID 790139 695 BERKTHEODORE 40 BROOKWOOD AVE CARLISLE PA 17013 11127/98 11127198 02/08199 8348830946/01 0000000000/00 493.80 176.50 DIAGNOSIS 1 : 5370 ACO PYLORIC STENOSIS DIAGNOSIS 2: 2639 PROTEIN-CAL MALNUTR NOS PROCEDURE : 43235 UGI ENDO INC ESO,STO,DUOD OR JEJ AS APP;DX,WM/O COLLECT SPECIMEN(S) BRUSHIWASH 12MWS - 12/05196 03/22/99 9057640112/01 0000000000/00 403.00 186.00 DIAGNOSIS 1: 2639 PROTEIN-CAL MALNUTR NOS DIAGNOSIS 2: 63642 PROCEDURE: 43760 PERCUTANEOUS PLACEMENT GASTROTOMY TUBE ONE BERK THEODORE 896.00 362.50 1 01 0855405 October 4,1999 STATEMENT OF CLAIM 0 DLEE, YOUNG 790 139 695 MACMORAN JAY W CENTER ONE RADIOLOGY ASSOC 9880 BUSTLETON AVE STE 101 PHILADELPHIA PA 19115 11/28187 - 11128A)7 O5125A8 8128110024/01 0000000000/00 29.00 7.50 DIAGNOSIS I: 75609 RESPIRATORY ABNORM NEC DIAGNOSIS 2: PROCEDURE: 71010 RADIOLOGIC ERAM,CHEST;SINGLE VIEW,FRONTL MACMORAN JAY W 29.00 7.50 01 0925896 October 4, 1999 STATEMENT OF CLAIM LEE, YOUNG ID 790 139 695 SWEER LEON W 220 WILSON ST STE 210 CARLISLE PA 17013 11,111151 O ICIICC IS G 11/23188 - 11/23!98 03/22/99 9057820083/01 0000000000/00 DIAGNOSIS 1 : 51881 RESPIRATORY_FAILURE 150.00 47'00 DIAGNOSIS 2: PROCEDURE: 99254 INIT INP CONSULT FOR NEW OR ESTAB PT. PROS-MOD TO HIGH SEVERE-80 MIN-BEDSIDE SWEEP! LEON W 01 1007875 150.001 47.00 October 4,1999 STATEMENT OF CLAIM LEE, YOUNG D 790139 695 SILVESTRI STEERMAN SURG ASSC 7600 CENTRAL AVENUE PHILADELPHIA PA 19111 01/08198 01108/98 0=1198 8141160646/01 0000000000/00 1,100.00 292.00 DIAGNOSIS 11: 8703 OPN_WND-ANT- ABDOMEN-COMP DIAGNOSIS 2 : 5609 INTESTINAL OBSTRUCT NOS PROCEDURE : 15100 SPL GFT 100 SO CM OR <;TRUNK,SCALP, ETC.EA 1% BODY AREA INFANTS & CHILDREN S11100,00 292.00 01 1033641 , October 4, 1999 STATEMENT OF CLAIM LEE, YOUNG 790139 695 GOLDBERG GARY MOSS PRACTICE PLAN, INC 1200 W TABOR ROAD PHILADELPHIA PA 19141 024)6198 - 02108/98 06101198 8141100377/01 0000000000/00 110.00 15.00 DIAGNOSIS 1: 85400 BRAIN_INJURY_NEC DIAGNOSIS 2: PROCEDURE: 99232 SUB HOSP CARE0IAY FOR EVAL & MGMT OF PATRESPD INADEG OR MINOR COMP 25-MIN BEDSID GOLDBERG GARY 110.00 15.00 01 1065535 October 4,1999 STATEMENT OF CLAIM 0 0.1 LEE, YOUNG 790139 695 CAMPBELL JOSEPHJ 850 WALNUT BOTTOM RD SUITE A-1 CARLISLE PA 17013 11/21198 11/21MB 04105/99 9061600919/01 0(XXXXX XXI/DO 1,000.00 330.00 DIAGNOSIS 1: 9983 POSTOP_WOUND_DISRUPTION DIAGNOSIS 2 : PROCEDURE : 49000 EXPLORATORY LAPAROTOMY EXPLOR CEILOTOMY W,W/O BIOPSY(SXSEPARATE PROC) 11/21/98 - 11/21M 04/12199 9070620417/03 0000000000/00 800.00 47.38 DIAGNOSIS 1: 9983 POSTOP_WOUND DISRUPTION DIAGNOSIS 2: PROCEDURE: 49900 SUTURE,SEC,ABD WALL EVICERATIONIDEHIS Otn4/99 - 01/14199 03/22/99 W55600128/02 0000000000100 250.00 31.00 DIAGNOSIS 1: 7098 SKIN DISORDERS NEC DIAGNOSIS 2: PROCEDURE: 11042 DEBRIDEMENT;SKIN,AND SUBCUTANEOUS TISSUE CAMPBELL•JOSEPHJ 2,050.00 408.38 01 1141836 Oclo6v 4, 1000 STATEMENT OF CLAIM LEE, YOUNG 700 130 595 ZUCKERMAN JERRY 101 EAST OLNEY AVENUE SUITE 400 PHILADELPHIA PA 10120 01/05196 - 01/08198 12107/98 5313101410/01 0000000000/00 490.00 DIAGNOSIS 1: 00545 INTEST INFECT DUE TO CLOSTRIDIUM DIFFICL DIAGNOSIS2: 7505 PYREXIA UNKNOWN ORIGIN PROCEDURE : 98231 SUB HOSP CARE/DAY FOR EVAL 8 MGMT OF PATPT STABLEAECOVAMPROV 16•MIN AT BEDSIDE 75.00 01/12M - 01/12198 12177195 5313101418/02 0000000000/00 90.00 DIAGNOSIS 1 : 00545 INTEST INFECT DUE TO CLOSTRIDIUM DIFFICL DIAGNOSIS 2: 7505 PYREXIA UNKNOWN ORIGIN PROCEDURE : 99231 SUB HOSP CAREIDAY FOR EVAL 6 MGMT OF PATPT STABLE,RECOVAMPROV 15-MIN AT BEDSIDE 15.00 01114M - 01114195 12107196 5313101419/03 0000000000/00 90.00 DIAGNOSIS 1 : 00546 INTEST INFECT DUE TO CLOSTRIDIUM DIFFICL DIAGNOSIS 2: 7805 PYREXIA UNKNOWN ORIGIN 15 00 PROCEDURE: 99231 SUB HOSP CAREIDAY FOR EVAL 8 MGMT OF PATPT STABLE,RECOVAMPROV 15-MIN AT BEDSIDE 01/15/95 - 01/15/85 12/07/95 6313101410/04 0000000000/00 90.00 DIAGNOSIS 1 : D0645 INTEST INFECT DUE TO CLOSTRIDIUM DIFFICL DIAGNOSIS 2: 7BOS PYREXIA UNKNOWN ORIGIN 15 00 PROCEDURE: 99231 SUB HOSP CARE/DAY FOR EVAL & MGMT OF PATPT STABLEAECOVAMPROV 15-MIN AT BEDSIDE 01119188 - 01/19196 12/07195 5313101420/01 0000000000100 90,00 DIAGNOSIS 1 : 00645 INTEST INFECT DUE TO CLOSTRIDIUM DIFFICL DIAGNOSIS 2 : 7506 PYREXIA UNKNOWN ORIGIN 1500 PROCEDURE : 99231 SUB HOSP CARE/DAY FOR EVAL & MGMT OF PATPT STABLE,RECOVAMPROV 15-MIN AT BEDSIDE +5'OTAC? ZUCKERMAN JERRY 510.00 135.00 01 1202593 October 4,1999 STATEMENT OF CLAIM LEE, YOUNG IQ R790139695 I CARLISLE PATHOLOGY ASSOC PC PO BOX 188 LANDISVILLE PA 17638 1121198 - 1121199 02108199 9014949014/01 0000000000/00 05,00 DIAGNOSIS 1 : 7092 SCAR FIBROSIS OF SKIN 18.50 DIAGNOSIS 2: PROCEDURE: 80304 LEVEL III-SURG PATH,GROSS 6 MICRO EXAM CARLISLE PATHOLOGY ASSOC PC 85 00 1050 01 1225079 October 4, 1999 STATEMENT OF CLAIM 39696 1 790LEE,139 995 CARLISLE IMAGING ASSOCIATES PO BOX 100 CARLISLE PA 17013 10/17/98 - 10/17198 01125199 8352140114101 0000000000/00 DIAGNOSIS 1: 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: PROCEDURE: 71010 RADIOLOGIC EXAM,CHEST;SINOLE VIEW,FRONTL 11/15/98 - 11/15/98 0112889 8352140118/01 OOOODOO000/00 DIAGNOSIS 1: 5789 GASTROINTEST HEMORR NOS DIAGNOSIS 2: PROCEDURE: 71010 RADIOLOGIC EXAM,CHEBT;SINGLE VIEW,FRONTL 171/98 - 11121/98 01125199 8382140112/01 0000000000/00 DIAGNOSIS 1: 56320 VENTRAL HERNIA NOS DIAGNOSIS 2: PROCEDURE: 71010 RADIOLOGIC EXAM,CHEST;81NGLE VIEW,FRONTL 11/23/98 - 11/23/98 01/25199 5352140112102 9000000000/00 DIAGNOSIS 1: 56320 VENTRAL HERNIA NOB DIAGNOSIS 2: PROCEDURE: 71010 RADIOLOGIC EXAM,CHEBT;SINGLE VIEW,FRONTL 11/25/98 - 11/2588 0112880 8352140113/01 0000000000/00 DIAGNOSIS 1: 65320 VENTRAL HERNIA NOS DIAGNOSIS 2: PROCEDURE: 71010 RADIOLOGIC EXAM,CHEST;SINOLE VIEW,FRONTL 1112888 - 11/20/88 01/25/09 8352140113102 0000000000/00 DIAGNOSIS 1: 55320 VENTRAL HERNIA NOS DIAGNOSIS 2: PROCEDURE: 71010 RADIOLOGIC EXAM,CHEST;SINGLE VIEW,FRONTL 11127/98 - 11/27/08 01/2580 3352140113/03 0000000000/00 DIAGNOSIS 1: 55320 VENTRAL HERNIA NOS DIAGNOSIS 2 : PROCEDURE: 71010 RADIOLOGIC EXAM,CHEST;SINGLE VIEW,FRONTL 12/0488 - 12/04198 0112589 8352140115101 0000000000100 DIAGNOSIS 1: 65320 VENTRAL HERNIA NOS DIAGNOSIS 2 : PROCEDURE: 74000 RADIOLOG EXAM,ABDOMEN;SINGLE AP VIEW 19.00 19.00 38.00 19.00 19.00 19.00 19.00 22.00 7.50 7.50 15.00 7.50 7.50 7.50 7.50 7.50 Oelober 4, 1999 STATEMENT OF CLAIM LEE,YOUNG I790139695 CARLISLE IMAGING ASSOCIATES PO BOX 100 CARLISLE PA 17013 12105198 - 12105198 01/25/99 8352140119101 0000000000100 22.00 7.50 DIAGNOSISI: 55320 VENTRAL HERNIA NOS DIAGNOSIS 2: _ PROCEDURE: 74000 RADIOLOG EXAM,ABDOMEN;SINGLE AP VIEW CARLISLE IMAGING ASSOCIATES 198.00 75.00 01 1225040 October 4, 1999 STATEMENT OF CLAIM LEE, YOUNG 1 790139 695 CAVANAUGH BARBARA CENTER ONE RADIOLOGY ASSOC 9880 BUSTLETON AVE STE 101 PHILADELPHIA PA 19115 11/08/97 - 11108197 07106198 8170091511/01 0000000000/00 29.00 7.50 DIAGNOSIS 1: 6180 PULMONARY COLLAPSE DIAGNOSIS 2: PROCEDURE : 71010 RADIOLOGIC E .AM,CHEST;SINGLE VIEW,FRONTL CAVANAUGH BARBARA 29.00 7.50 01 1227968 October 4,1999 gg STATEMENT OF CLAIM LEE, YOUNG ID 790139895 FISCHER ROBERT A 101 EOLNEY AVE SUITE 400 PH1LA PA 19120 02/09198 - 02/10/98 072058 8170090887/02 0000000000100 180.00 30.00 DIAGNOSIS I: 0381 STAPHYLOCOCC SEPTICEMIA DIAGNOSIS 2: PROCEDURE : 99231 SUB HOSP CAREIDAY FOR EVAL & MGMT OF PATPT STABLE,RECOV/IMPROV 15-MIN AT BEDSIDE 02/1158 - 02/1358 072058 8170090887/03 0000000000100 270.00 45.00 DIAGNOSIS 1 : 0381 STAPHYLOCOCC SEPTICEMIA DIAGNOSIS 2: PROCEDURE : 99231 SUB HOSP CAREA7AY FOR EVAL & MGMT OF PATPT STABLE,RECOVAMPROV 15-MIN AT BEDSIDE 02218198 - 0211698 072058 8170090887/04 0000000000/00 90.00 15.00 DIAGNOSIS 1 : 0381 STAPHYLOCOCC SEPTICEMIA DIAGNOSIS 2: PROCEDURE : 99231 SUB HOSP CAREIDAY FOR EVAL & MGMT OF PATPT STABLE,RECOVAMPROV 15-MIN AT BEDSIDE 0211758 - 02/1758 075858 8170090888101 0000000000/00 110.00 15.00 DIAGNOSIS 1: 0381 STAPHYLOCOCC SEPTICEMIA DIAGNOSIS 2: PROCEDURE: 99232 SUB HOSP CARE/DAY FOR EVAL & MGMT OF PATRESPD INADEO OR MINOR COMP 2S-MIN BEDSID 0211858 - 02/108 075858 8170090888/02 0000000000/00 90.00 15.00 DIAGNOSIS 1 : 0381 STAPHYLOCOCC SEPTICEMIA DIAGNOSIS 2 : PROCEDURE : 99231 SUB HOSP CARE/DAY FOR EVAL & MGMT OF PATPT STABLE,RECOVIIMPROV 1S-MIN AT BEDSIDE 022058 - 022058 07/0858 8170090888/03 0000000000100 110.00 15.00 DIAGNOSIS 1 : 0381 STAPHYLOCOCC SEPTICEMIA DIAGNOSIS 2 : PROCEDURE : 99232 SUB HOSP CAREIDAY FOR EVAL & MGMT OF PATRESPD INADEO OR MINOR COMP 25-MIN BEDSID 02/23198 - 022758 075858 8170090888/04 0000000000/00 450.00 75.00 DIAGNOSIS 1 : 0381 STAPHYLOCOCC SEPTICEMIA DIAGNOSIS 2 : PROCEDURE : 99231 SUB HOSP CARE/DAY FOR EVAL & MGMT OF PATPT STABLE,RECOVAMPROV 16-MIN AT BEDSIDE ![,'j1O ?ER,?$UB?TOT(}Ci FISCHER ROBERT/ 1,300.00 210.00 October 4, 1999 STATEMENT OF CLAIM 1311 LEE, YOUNG 790139 695 BLUE MOUNTAIN ANES ASSOC PC PO BOX 249 GREENCASTLE PA 17225 11121198 11121/98 04/12/99 9082601363/02 0000000000/00 325.00 88.00 DIAGNOSIS 1: 9983 POSTOP_WOUND DISRUPTION DIAGNOSIS 2: PROCEDURE : 38489 PLACE CV CATH;PERCUTANEOUS OVERAGE 2 (SUBCLAVIAN,JUGULAR, OR OTHER VEIN) 1121198 - 11/21198 02/07/09 8344011728/01 0000000000/00 1,235.00 183.00 DIAGNOSIS 1: 9983 POSTOP_WOUND_DISRUPTION DIAGNOSIS 2: PROCEDURE: 49900 SUTURE,SEC,ABD WALL EVICERATION/DEHIS BLUE MOUNTAIN ANES ASSOC PC 11560.00 251.00 01 1390303 -mi October 4, 1999 STATEMENT OF CLAIM LEE, YOUNG 790139 695 PINKER MARK E 47 BROOKWOOD AVENUE CARLISLE PA 17013 03117/98 - 03/17/98 06122/98 8147600514/01 0000000000100 50.00 11.50 DIAGNOSIS 1 : 1101 DERMATOPHYTOSIS OF NAIL DIAGNOSIS 2: 7030 INGROWING NAIL PROCEDURE : 99312 SUBSO NSG FAC CARE/DAY, EVAL & MGMT RESPOND INADQ-MINOR COMP 25 MIN BEDSIDE 07107198 - 07107/90 01/25/99 8341620559/01 0000000000/00 35.00 11.50 DIAGNOSIS 1 : 1101 DERMATOPHYTOSIS OF NAIL DIAGNOSIS 2: ' PROCEDURE : 99311 SUBSO NSO FAC CARE, /DAY, FOR EVAL & MGMOF NEW OR ESTAB PT 15 MIN BEDSIDE 10108/88 - 10/061198 01125199 8341620568101 0000000000/00 47.00 20.00 DIAGNOSIS 11: 1101 DERMATOPHYTOSIS OF NAIL DIAGNOSIS 2: PROCEDURE: 11721 DEBRID NAIL(S) ANY METHOD;6 OR MORE Imi PINKER MARK E 13200 43.00 04 0916500 October 4, 1999 STATEMENT OF CLAIM LEE, YOUNG i D 790139 695 ALBERT EINSTEIN MED CTR IMMUNO-DEFICIENCY CLINIC 1335 TABOR RD SUITE 309 PHILADELPHIA PA 19141 10/04!97 - 03W,198 01130199 9017058472/01 8317670146/01 860,147.45 35,608.37 DIAGNOSIS 1 : 80184 OP_SKL BASE_FR-PROL_COMA DIAGNOSIS 2 : 00845 INTEST INFECT DUE TO CLOSTRIDIUM DIFFICL PROCEDURE: - ALBERT EINSTEIN MED CTR 860,147.45 35,008.37 11 0529454 , P October 4,1999 STATEMENT OF CLAIM LEE, YOUNG `Nrx; 790139695 CARLISLE HOSPITAL COMM & HOME HLTH SVCS CHC 117 NORTH HANOVER STREET CARLISLE PA 17013 03116M - 03116/98 03108199 9042060001 / 01 0000000000/00 30.00 6.00 DIAGNOSIS 1: 2959 ANEMIA NOS OIAGNOSIS2: V6861 LONGTERM(CURRENT) USE ANTICOAGULANTS PROCEDURE: 85025 BLOOD COUNT;HEMOGRAM & PLATELET COUNT, AUTOMATED,& AUTOMATED COMP DIFF W8C(CBC) 03/18/98 - 03MMS 03/08199 9042060015103 0000000000/00 72.00 8.00 DIAGNOSIS 1: 6990 URIN TRACT INFECTION NOS DIAGNOSIS2: 7808 PYREXIA UNKNOWN ORIGIN PROCEDURE: 87184 SENSITIVITY STUDIES,ANTISIOTIC;DISC METHPER PLATE (120R LESS DISC) 03/1698 - 03116/98 03!011199 9042060015/01 0000000000/00 51.00 8.00 DIAGNOSIS 1: 5990 URIN TRACT INFECTION NOS DIAGNOSIS2: 7806 PYREXIA UNKNOWN ORIGIN PROCEDURE: 07086 CULTURE,BACTERIAL,URINE;OUANTITATIVE, COLONY COUNT 03/18198 - 03110/98 03/08/99 9042060015/02 0000000000100 50.00 3.00 DIAGNOSIS/: 5990 URIN TRACT INFECTION NOS DIAGNOSIS 2: 7806 PYREXIA UNKNOWN ORIGIN PROCEDURE: 87161 CULTURE,TYPING;SEROLOGIC METHOD SPECIATN 03/23/98 - 032319 8 03108199 9042060002/01 0000000000/00 30.00 6.00 DIAGNOSIS 1: 2859 ANEMIA NOS DIAGNOSIS2: V5861 LONGTERM (CURRENT) USE ANTICOAGULANTS PROCEDURE: 85025 BLOOD COUNT;HEMOGRAM 6 PLATELET COUNT, AUTOMATED,& AUTOMATED COMP DIFF WBC(CBC) 03/30198 - 03130198 03/08/99 9042060003/01 0000000000/00 40.00 10.00 DIAGNOSIS 1 : 2859 ANEMIA NOS DIAGNOSIS 2 : V5861 LONGTERM (CURRENT) USE ANTICOAGULANTS PROCEDURE: 85023 BLOOD COUNT;HEMOGRAM & PLATELET COUNT, AUTOMATED,& MANUAL DIFF WSC COUNT(CBC) 0320/98 - 03/30/98 03/08199 9042060017/04 0000000000/00 72.00 8.00 DIAGNOSIS 1: 7862 COUGH DIAGNOSIS 2 : PROCEDURE : 87184 SENSITIVITY STUDIES,ANTIBIOTIC;DISC METHPER PLATE (12 OR LESS DISC) 03/30198 - 03130/98 03108/99 9042060017103 0000000000/00 22.00 4.50 DIAGNOSIS 1: 7862 COUGH DIAGNOSIS 2 : PROCEDURE: 87205 SMEAR,PRIMARY SOURCE,WANTERPRETATION; ROUTINE STAIN BACTERIA,FUNGICELL TYPE October 4, 1999 STATEMENT OF CLAIM 191 LEE, YOUNG 790139695 CARLISLE HOSPITAL COMM 6 HOME HLTH SVCS CHC 117 NORTH HANOVER STREET CARLISLE PA 17013 03/30188 - 03130198 03/08/99 9042080017/01 0000000000/00 41.00 8.90 DIAGNOSIS 1: 7862 COUGH DIAGNOSIS 2: PROCEDURE: 87070 CULTURE, BACTERIAL, DEFINITIVE;ANYOTHERSOURCE 03x30/08 - 0300/88 03108199 9042060017/02 0000000000/00 50.00 3.00 DIAGNOSIS 1 : 7962 COUGH DIAGNOSIS 2: PROCEDURE: 87151 CULTURE,TYPING;SEROLOGIC METHOD SPECIATN 04AMS - 04/08198 03108/99 9042060014101 0000000000/00 17.00 4.37 DIAGNOSIS/: 5990 URIN TRACT INFECTION NOS DIAGNOSIS 2: PROCEDURE: 81000 URINALYSIS BY DIP STICKITAB REAGENT FOR ETC. CONSTITUENTS; WITH MICROSCOPY 04106198 - 04!08198 03100199 9042080009101 0000000000/00 30.00 8.00 DIAGNOSIS 1: 2859 ANEMIA NOS DIAGNOSIS 2: PROCEDURE: 85025 BLOOD COUNT;HEMOGRAM & PLATELET COUNT, AUTOMATED,& AUTOMATED COMP DIFF WSC(CSC) 04/10198 - 04/10198 03MM 9042060016/03 0000000000/00 22.00 4.50 DIAGNOSIS 1 : 7808 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 7864 ABNORMAL SPUTUM PROCEDURE: 87205 SMEAR,PRIMARYSOURCE,WANTERPRETATION; ROUTINE STAIN BACTERIA,FUNG/CELL TYPE 04!10188 - 04/10/88 03/OM 9042060016/01 0000000000100 41.00 6.90 DIAGNOSIS I: 7808 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 7864 ABNORMALSPUTUM PROCEDURE : 87070 CULTURE, BACTERIAL, DEFINITIVE;ANY OTHERSOURCE 04/10198 - 04/10198 03mm 9042060016104 0000000000100 108.00 8.00 DIAGNOSIS 1 : 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 7884 ABNORMALSPUTUM PROCEDURE: 67184 SENSITIVITY STUDIES,ANTISIOTIC;DISC METHPER PLATE (120R LESS DISC) 04110198 - 04110198 03100199 9042060016/02 0000000000/00 75.00 3.00 DIAGNOSIS 1 : 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2 : 7864 ABNORMALSPUTUM PROCEDURE : 87151 CULTURE,TYPING;SEROLOGIC METHOD SPECIATN October 4, 1999 STATEMENT OF CLAIM IM LEE, YOUNG a780139 895 CARLISLE HOSPITAL COMM & HOME HLTH SVCS CHC 117 NORTH HANOVER STREET CARLISLE PA 17013 05/11198 - 05/11/98 03108/99 9042060008/01 0000000000100 30.00 6.00 DIAGNOSIS 1: 2859 ANEMIA NOS DIAGNOSIS 2: PROCEDURE : 95025 BLOOD COUNT;HEMOGRAM 6 PLATELET COUNT, AUTOMATEDA AUTOMATED COMP DIFF WBC(CBC) 0520/98 - 0520198 03108/89 9042060007/04 0000000000/00 72.00 8.00 DIAGNOSIS 1: 1369 INFECT/PARASTTE DIS NOS DIAGNOSIS 2: V090 INFECT W/MICROORGAN RESISTANT PENICILLIN PROCEDURE: 87184 SENSITIVITY STUDIES,ANTIBIOTIC;DISC METHPER PLATE (12 OR LESS DISC) 0520198 - 0520/98 03109199 9042060007/03 0000000000/00 22.00 4.50 DIAGNOSIS 1 : 1369 INFECTIPARASITE DIS NOS DIAGNOSIS 2 : V090 INFECT W/MICROORGAN RESISTANT PENICILLIN PROCEDURE: 87205 SMEAR,PRIMARY SOURCE,WANTERPRETATION; ROUTINE STAIN BACTERIA,FUNGICELL TYPE 0520198 - 052028 0amW99 9042060007/01 0000000000/00 41.00 6.90 DIAGNOSIS i : 1369 INFECT/PARASITE DIS NOS DIAGNOSIS 2: V090 INFECT W/MICROORGAN RESISTANT PENICILLIN PROCEDURE: 87070 CULTURE, BACTERUIL, DERNTTIVE;ANY OTHERSOURCE 0520/38 - 0520198 03108/89 9042080007/02 0100000000/00 50.00 3.00 DIAGNOSIS 1 : 1369 INFECT/PARASITE DIS NOS DIAGNOSIS 2: VD90 INFECT W/MICROORGAN RESISTANT PENICILLIN PROCEDURE: 87151 CULTURE,TYPING;SEROLOGIC METHOD SPECIATN 05129/98 - 0529198 03/08/99 9042060006/03 0000000000/00 22.00 4.60 DIAGNOSIS 1 t 8793 OPN WND ANT ABDOMEN-COMP DIAGNOSIS 2: PROCEDURE: 87205 SMEAR,PRIMARY SOURCE,WANTERPRETATION; ROUTINE STAIN BACTERIA,FUNGICELL TYPE 0529/98 - 0529/98 03/18/99 9042060008/02 0000000000100 25.00 3.00 DIAGNOSIS 1 : 8793 OPN WND_ANT_ABDOMEWCOMP_ DIAGNOSIS 2: PROCEDURE: 87151 CULTURE,TYPING;SEROLOGIC METHOD SPECIATN 0529/30 - 0529198 03108/99 9042060006/01 0000000000100 43.00 6.90 DIAGNOSIS 1 : 8793 OPN_WND_ANT_ABDOMEN•COMP DIAGNOSIS 2: PROCEDURE: 87070 CULTURE, BACTERIAL, DEFINITIVE;ANY OTHERSOURCE October 4, 1999 STATEMENT OF CLAIM LEE, YOUNG 790139 695 CARLISLE HOSPITAL COMM 6 HOME HLTH SVCS CHC 117 NORTH HANOVER STREET CARLISLE PA 17013 08/07/98 - 08/07/98 01/18/99 8357905731/01 0000000000100 30.00 DIAGNOSIS 1: 2859 ANEMIA NOS DIAGNOSIS 2 : PROCEDURE : 85025 BLOOD COUNT;HEMOGRAM 6 PLATELET COUNT, AUTOMATED,& AUTOMATED COMP DIFF WBC(CBC) 10/99/98 - 10109/98 01/18/99 83579OS732/01 0000000000/00 50.00 DIAGNOSIS 1 : V5889 OTH SPEC AFTERCARE DIAGNOSIS 2: PROCEDURE: W9045 ER SUPPSERV,SPEC NON-EMERGENCY(ENR APRXENROLLMEMT APPROVAL REQUIRE) tom/98 - 10/11/98 01/18/99 83579057331 01 0000D00000/00 18.00 DIAGNOSIS 1 : 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 78703 VOMITINGALONE PROCEDURE : 81000 URINALYSIS BY DIP STICK/TAB REAGENT FOR ETC. CONSTITUENTS; WITH MICROSCOPY 10/14/98 - 10/14198 01/18/99 8357905734/02 OOOOOOOM/00 44,00 DIAGNOSIS 1: 7808 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 9974 SURE COMPLIC-GI_TRACT PROCEDURE: 87070 CULTURE, BACTERIAL, DEFINITIVE;ANY OTHERSOURCE 10/14188 - 10/14/98 01/18199 8357905734/01 0000000000/ DO 23.00 DIAGNOSIS 1 : 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 9974 SURG_COMPLICGI_TRACT PROCEDURE: 87205 SMEAR,PRIMARY SOURCE,WANTERPRETATION; ROUTINE STAIN BACTERIA,FUNG/CELL TYPE 10/15/98 - 10/15/98 01/18/99 8357905735/03 0000000000/00 52,00 DIAGNOSIS 1 : 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 78703 VOMITINGALONE PROCEDURE: 87151 CULTURE,TYPING;SEROLOGIC METHOD SPECIATN 10/15/98 - 10/15/98 01/18199 8357905735/01 0000000000/00 232,00 DIAGNOSIS 1: 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 78703 VOMITINGALONE PROCEDURE: 87040 CULTURE, BACTERIAL, DEFINITIVE; BLOOD (INCLUDES ANAEROBIC SCREEN) 8.00 23.00 4.37 6.90 4.50 3.00 14.00 10/17/98 - 10/17/98 01/18/99 8357905739/01 0000000000/00 73.00 10.50 DIAGNOSIS 1 : 486 PNEUMONIA, ORGANISM NOS DIAGNOSIS 2: 9070 LT_EFF_INTRACRANIAL_INJ PROCEDURE: 71010 RADIOLOGIC EXAM,CHEST;SINGLE VIEW,FRONTL October 4, 1999 STATEMENT OF CLAIM LEE, YOUNG 790139 695 CARLISLE HOSPITAL COMM & HOME HLTH SVCS CHC 117 NORTH HANOVER STREET CARLISLE PA 17013 10117198 10/17/98 01/18/99 8357905738/04 0000000000100 42.00 8.90 DIAGNOSIS 1: 486 PNEUMONIA, ORGANISM NOS DIAGNOSIS 2: 9070 LT_EFF_INTRACRANIAL_INJ PROCEDURE: 87070 CULTURE, BACTERIAL, DEFINITIVE;ANY OTHERSOURCE 10117/98 - 10/17198 01/18199 8357905738/03 0000000000/00 53.00 8.00 DIAGNOSIS 1: 498 PNEUMONIA, ORGANISM NOS DIAGNOSIS 2: 9070 LT_EFF-INTRACRANIAL INJ PROCEDURE: 87088 CULTURE,BACTERIAL,URINE;GUANTRATIVE, COLONYCOUNT 10/17198 - 10117/98 01/18199 9357905738102 0000000000/00 23.00 4.50 DIAGNOSIS 1: 486 PNEUMONIA, ORGANISM NOS DIAGNOSIS 2: 9070 LT EFF_INTRACRANIAL_INJ PROCEDURE: 67205 SMEAR,PRIMARY SOURCE,W/INTERPRETATION; ROUTINE STAIN BACTERIA,FUNG/CELL TYPE 10/17198 - 10/17/98 01/18199 8357905738/01 0000000000100 232.00 14.00 DIAGNOSIS 1 : 489 PNEUMONIA, ORGANISM NOS DIAGNOSIS2: 9070 LT_EFF_INTRACRANIAL INJ PROCEDURE : 87040 CULTURE, BACTERIAL, DEFINITIVE; BLOOD (INCLUDES ANAEROBIC SCREEN) 10117/98 - 10117/88 01/18199 8357905737102 0000000000/DO 18.00 4.37 DIAGNOSIS 1 : 486 PNEUMONIA, ORGANISM NOS DIAGNOSIS 2: 9070 LT_EFF_INTRACRANIAL INJ PROCEDURE : 81000 URINALYSIS BY DIP STICK/TAB REAGENT FOR ETC. CONSTITUENTS; WITH MICROSCOPY 10117/98 - 10/17198 01/18/99 8357905737101 0000000000100 31.00 6.00 DIAGNOSIS 1: 488 PNEUMONIA. ORGANISM NOS DIAGNOSIS 2: 9070 LT_EFF_INTRACRANIAL INJ PROCEDURE: 85025 BLOOD COUNT;HEMOGRAM 8. PLATELET COUNT, AUTOMATED,& AUTOMATED COMP DIFF WBO(CBC) 10/17198 - 1WI7198 01/18/99 8357905736/02 0000000000100 228.00 70.00 DIAGNOSIS 1: 486 PNEUMONIA, ORGANISM NOS DIAGNOSIS 2: 9070 LT EFF_INTRACRANIAL_INJ PROCEDURE: W9047 ER SUPP SERV,SPECIAL EMERGENCY SERVE-AXENROLLMENT APPROVAL REQUIRED) 10/17/98 - 10117198 01/18199 8357905736/01 0000000000100 BS.00 8.00 DIAGNOSIS 1 : 486 PNEUMONIA, ORGANISM NOS DIAGNOSIS 2: 9070 LT EFF_INTRACRANIAL_INJ __.-_- PROCEDURE: 80049 BASIC METABOLIC PANEL COA OOH''?q?IE?*A,?LpTE,?y"O?FY?PE(?NS' V ?lA D-ge aCLE?SUr_.PArUBL?Ctr'1-.E October 4, 1999 STATEMENT OF CLAIM LEE YOUNG 790139 695 CARLISLEHOSPITAL COMM & HOME HLTH SVCS CHC 117 NORTH HANOVER STREET CARLISLE PA 17013 10/17/_8 - 10117/98 01/18JS9 8357905735/02 0000000000/00 37.00 DIAGNOSIS 1: 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS2: 78703 VOMITINGALONE PROCEDURE: 67184 SENSITIVITY STUDIES,ANTIBIOTIC;DISC METHPER PLATE (12 OR LESS DISC) 11/1658 - 11/16198 02!08/99 9011879753102 0000000000100 27.00 DIAGNOSIS 1! 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 78003 PERSISTENT VEGETATIVE STATE PROCEDURE: 85730 THROMBOPLASTINTIME,PARTIAL(PTT);PLASMAOR WHOLE BLOOD 11115198 - 11/15/98 02108199 9011879753/01 0000000000/00 20.00 DIAGNOSIS 1: 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2 : 78003 PERSISTENT VEGETATIVE STATE PROCEDURE: 85610 PROTHROMBINTIME 8.00 7.50 4.00 1111558 - 11/15198 02108199 9011879752/04 0000000000/00 31.00 6.00 DIAGNOSIS 1 : 7808 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 78003 PERSISTENT VEGETATIVE STATE PROCEDURE : 85025 BLOOD COUNT;HEMOGRAM & PLATELET COUNT, AUTOMATED,& AUTOMATED COMP DIFF WBC(CBC) 11/1558 - 11/1558 0210M 9011879752103 0000000000/00 23.00 7.06 DIAGNOSIS 1: 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 78003 PERSISTENT VEGETATIVE STATE PROCEDURE: 82565 CREATININE;BLOOD 11/1558 - 11/1558 0208/99 9011879752102 0000000000/00 122.00 23.00 DIAGNOSIS 1 : 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 78003 PERSISTENT VEGETATIVE STATE PROCEDURE: W9045 ER SUPP SERV,SPEC NON-EMERGENCY(ENR APRXENROLLMEMT APPROVAL REQUIRE) 11/1558 - 11/1558 0258199 9011879752101 0000000000/00 17.00 5.44 DIAGNOSIS 1: 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 78003 PERSISTENT VEGETATIVE STATE PROCEDURE: 84520 UREA NITROGEN;OUANTITATIVE 11/1558 - 11/1558 02/0859 9011879754/01 0000000000/00 161.00 10.50 DIAGNOSIS 1: 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS2: 78003 PERSISTENT VEGETATIVE STATE PROCEDURE: 71010 RADIOLOGIC EXAM,CHEST;SINGLE VIEW,FRONTL October 4, 1999 STATEMENT OF CLAIM LEE, YOUNG ION 790139 895 CARLISLE HOSPITAL COMM & HOME HLTH SVCS CHC 117 NORTH HANOVER STREET CARLISLE PA 17013 11/15/98 - 11/15/98 02118199 9011879753/03 0000000000/00 29,00 7.00 DIAGNOSIS I: 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: 78003 PERSISTENT VEGETATIVE STATE PROCEDURE: 80051 ELECTROLYTE PANEL 11119/98 - 11/19/98 01/1859 8357905740/01 0000000000/00 31.00 810 DIAGNOSIS 1 : 2859 ANEMIA NOS DIAGNOSIS 2: PROCEDURE : 85025 BLOOD COUNT;HEMOGRAM & PLATELET COUNT, AUTOMATED,& AUTOMATED COMP DIFF WBC(CBC) 11/19/98 - 11/19/98 02/1S59 9021890712/01 0000000000100 12200 70.00 DIAGNOSIS I: 99811 HEMORRHAGE COMPLICATA PROC DIAGNOSIS 2 : PROCEDURE: W9047 ER SUPP SERV,SPECIAL EMERGENCY SERV(E-AXENROLLMENT APPROVAL REQUIRED) 11/20/98 - 11/20/98 01/1859 8357905741/01 0000000000/00 18.00 4.37 DIAGNOSIS 1 : 5990 URIN TRACT INFECTION NOS DIAGNOSIS 2: PROCEDURE : 61000 URINALYSIS BY DIP STICKITAB REAGENT FOR ETC. CONSTITUENTS; WITH MICROSCOPY 11/21498 - 12!08/98 03101/99 9032972479/01 0000000000/00 54,789.00 5,757.88 DIAGNOSIS 1 : 9983 POSTOP_WOUND_DISRUPTION DIAGNOSIS 2: 486 PNEUMONIA, ORGANISM NOS PROCEDURE: 12/18/98 - 12/1658 02/22/99 9028869480/02 0000000000/00 42.00 6.90 DIAGNOSIS 1 : 04111 BACTER INFECT DUE TO STAPHYLOCOCCUS AURE DIAGNOSIS 2: V090 INFECT W/MICROORGAN RESISTANT PENICILLIN PROCEDURE: 87070 CULTURE, BACTERIAL, DEFINMVE;ANY OTHERSOURCE 12116/98 - 12118/98 02/22/99 9028869480/01 0000000000/00 23.00 4.50 DIAGNOSIS 1 : 04111 BACTER INFECT DUE TO STAPHYLOCOCCUS AURE DIAGNOSIS 2: V090 INFECT W/MICROORGAN RESISTANT PENICILLIN PROCEDURE: 87205 SMEAR,PRIMARYSOURCE,WANTERPRETATION; ROUTINE STAIN BACTERIA,FUNG/CELL TYPE 12/2158 - 12/2158 03101/99 9032884502/04 0000000000/00 26.00 3.00 DIAGNOSIS 1 : 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: PROCEDURE: 87151 CULTURE,TYPING;SEROLOGIC METHOD SPECIATN October 4, 1999 STATEMENT OF CLAIM LEE,YOUNG 1911 79900139895 CARLISLE HOSPITAL COMM 6 HOME HLTH SVCS CHC 117 NORTH HANOVER STREET CARLISLE PA 17013 12/21198 - 12121/98 03101199 9032884502103 0000000000/00 DIAGNOSIS 1 : 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: PROCEDURE : 87106 CULTURE,FUNGI,DEFINTTIVE IDENTIFICATION OF EACH FUNGUS 62.00 9.70 12/1158 - 12121198 03101199 9032884602/02 0000000000/00 DIAGNOSIS 1: 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: PROCEDURE: 87070 CULTURE, BACTERIAL, DERNITIVE;ANYOTHERSOURCE 88.00 &90 12/11198 - 12121/08 0310159 9032884602101 0000000000/00 46.00 DIAGNOSIS 1: 7806 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: PROCEDURE : 87205 SMEAR,PRIMARY SOURCE,WANTERPRETATION; ROUTINE STAIN BACTERIA,FUNGICELL TYPE 12131196 - 12/31198 03108199 9039091770102 0000000000100 DIAGNOSIS 1 : 5609 INTESTINAL OBSTRUCT NOS DIAGNOSIS 2: PROCEDURE: 87070 CULTURE, BACTERIAL, DEFINITIVE;ANYOTHERSOURCE 4.50 44.00 8.90 12131198 - 12/31/98 03108/99 9039091770101 0000000000/00 23.00 DIAGNOSIS 1 : 5609 INTESTINAL OBSTRUCT NOS DIAGNOSIS 2: PROCEDURE: 87205 SMEAR,PRIMARY SOURCE,WANTERPRETATION; ROUTINE STAIN BACTERIA,FUNG/CELL TYPE 01104199 - 01/04199 03/18199 9041868174/02 0000000000/00 44.00 DIAGNOSIS 1 : 5609 INTESTINAL OBSTRUCT NOS DIAGNOSIS 2: PROCEDURE: 87070 CULTURE, BACTERIAL, DEFINITIVE;ANY OTHERSOURCE 0110459 - 01/14199 03108199 9041868174101 0000000000100 23.00 DIAGNOSIS 1: 5609 INTESTINAL OBSTRUCT NOS DIAGNOSIS 2: PROCEDURE: 87205 SMEAR,PRIMARY SOURCE,W/INTERPRETATION; ROUTINE STAIN BACTERIA,FUNGICELL TYPE 01/30199 - 0113059 0329199 9062883404102 0000900000100 53.00 DIAGNOSIS/: 7880 RENALCOLIC DIAGNOSIS 2: PROCEDURE: 87086 CULTURE,BACTERIAL,URINE;OUANTITATIVE, COLONY COUNT 4.50 6.90 4.50 8.00 October 4, 1999 STATEMENT OF CLAIM LEE,YOUNG 790 139 995 CARLISLE HOSPITAL COMM 8 HOME HLTH SVCS CHC 117 NORTH HANOVER STREET CARLISLE PA 17013 02/19/99 - 02119/99 04/19/99 9082900087/01 0000000000/00 37.00 8.00 DIAGNOSIS 1: 7808 PYRE%IA UNKNOWN ORIGIN DIAGNOSIS 2: PROCEDURE: 87184 SENSITIVITY STUDIES,ANRBIOTIC;OISC METHPER PLATE (12 OR LESS DISC) CARLISLE HOSPITAL 58,515.00 8,371.94 11 0720020 Oetober4,1999 STATEMENT OF CLAIM LEE,YOUNG 10, 790139 695 WEST SHORE ADV LIFE SUP SVC 503 N 21ST STREET CAMP HILL PA 17011 11/15198 - 11/15/98 02/08/99 9014916643/01 0000000000/00 327.41 40.00 DIAGNOSIS 1 : 4590 HEMORRHAGE NOS DIAGNOSIS 2: PROCEDURE: W0017 ADVANCED LIFE SUPPORT(ALS) SERVICE WITHOUT TRANSPORT (PRE- HOSPITAL) 11/18/98 - 11/19/98 02/08/99 9014916644/01 0000000000100 327.41 40.00 DIAGNOSIS 1: 4590 HEMORRHAGE NOS DIAGNOSIS 2: PROCEDURE: W0017 ADVANCED LIFE SUPPORT(ALS) SERVICE WITHOUT TRANSPORT (PRE-HOSPITAL) 11121/98 - 1121198 02/08199 9014918845/01 0000000000/00 327.41 40.00 DIAGNOSIS 1: 9599 INJURYSITE_NOS DIAGNOSIS2: 4590 HEMORRHAGE NOS PROCEDURE: W0017 ADVANCED LIFE SUPPORT(ALS) SERVICE WITHOUT TRANSPORT (PRE-HOSPITAL) D WEST SHORE ADV LIFE SUP SVC 982.23 120.00 19 1173277 u; October 4, 1M STATEMENT OF CLAIM LEE, YOUNG E` r 790139 695 MOBILE X-RAY IMAGING INC 6120 LANCASTER STREET HARRISBURG PA 17111 10/14!98 - 10114198 01A4/99 8341121626/02 000000000000 110.00 44.00 DIAGNOS:S 1 : 7808 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: PROCEDURE : 80070 TRANSP PORT X-RAY EOUIP AND PERSONNEL TOHOME OR NRSG HOME PER TRIP TO EA ONE PAT 10/14/88 - 10/14198 OtA4l99 8341121628/01 0000000000/00 55.00 11.50 DIAGNOSIS 1: 7808 PYREXIA UNKNOWN ORIGIN DIAGNOSIS 2: PROCEDURE: 71010 RADIOLOGICEXAM,CHEST-,SINGLEVIEW,FRONTL 02/18/99 - 02118M 007199 9112090890/01 0000000000/00 64.00 11.50 DIAGNOSIS 1 : V7281 PRE-OPERATIVE CARDIOVASCULAR EXAM DIAGNOSIS 2 : - PROCEDURE: 93005 ELECTROCARDIOGRAM,ROUTINE W/12 LEADS TRACING ONLY W/O INTERP AND REPORT MOBILE X-RAY IMAGING INC 229.00 67.00 1 20 1523132 October 4, 1999 STATEMENT OF CLAIM [{AME,. LEE, YOUNG ID 790139695 CUMBERLAND CO COMMRS I CLAREMONT NRC OF CUMB CNTY 376 CLAREMONT DR CARLISLE PA 17013 k.l W7'YdF.L'•"7 t.C7 r -. ?. •r rs",{ .i u?, 'Sw?YS+k¢t Y R IC ,i • +?: ,?,rY?.tE{JT?;b TE.y OR[a ADORN ,ADJUSTED,Cjpl &„ (?Yp?fSSR' t Y US A G' RGE3 03104198 - 03131198 04/12199 9096560005/01 0000000000100 3,526.60 3,526.60 DIAGNOSIS 1 : DIAGNOSIS 2: PROCEDURE: - 04101198 - 04/30/98 04/12199 9096560007/01 0000000000/00 3,778.50 3,778.50 DIAGNOSIS 1 : DIAGNOSIS 2: PROCEDURE: 05/01/98 - 05131198 04112199 9096560006/01 0000000000/00 3,350.45 3,350.45 DIAGNOSIS 1 : DIAGNOSIS 2: PROCEDURE: 09/01/98 - 06130198 O1/18199 8345540572/01 0000000000/00 3,224.50 3,224.50 DIAGNOSIS 1 : DIAGNOSIS 2: PROCEDURE: 07/01198 - 07191198 01/18/99 8345540573101 0000000000/00 3,350.45 3,350.45 DIAGNOSIS 1 DIAGNOSIS 2: PROCEDURE: 08101198 - 08131198 01/18199 8345540574/01 0000000000100 3,350.45 3,350.45 i DIAGNOSIS 1 : , ?1 DIAGNOSIS 2: PROCEDURE: 09101/98 - 09130198 01118/99 8345540575/01 0000000000/00 3,224.50 3,22450 f DIAGNOSIS 1 : DIAGNOSIS 2: f PROCEDURE: I 10101196 - 10/31198 01/18/99 8345540576/01 OOOOOOOOOO/G0 3,350.45 3,350.45 DIAGNOSIS 1 DIAGNOSIS 2: PROCEDURE: i October 4,1999 :?gipy STATEMENT OF CLAIM r7A1+1Ex: LEE, YOUNG lei f+? 790139995 CUMBERLAND CO COMMRS CLAREMONT NRC OF CUMS CNTY 375 CLAREMONT OR CARLISLE PA 17013 11/01198 - 11/30198 05/17/99 9120550263/01 0000000000/00 2,394.80 2,384.60 DIAGNOSIS 1 DIAGNOSIS 2 : PROCEDURE: ' 12101196 - 12105198 02/15/99 9022550122101 0000000000/00 209.90 209.90 DIAGNOSIS 1 : DIAGNOSIS 2: PROCEDURE: 12108198 - 12/31/98 02115/99 9022550121101 0000000000/00 2,468.80 2,468.80 DIAGNOSIS 1 DIAGNOSIS 2 : PROCEDURE: 01/01/99 - 01131/99 00/07/99 9144550230/01 0000000000/00 3,413.07 3,413.07 DIAGNOSIS 1 DIAGNOSIS 2: PROCEDURE: 02101/99 - 02/19199 06107/99 9144550391101 0000000000/00 1,877.43 1,677.43 DIAGNOSIS I: DIAGNOSIS 2: PROCEDURE: PROVIDER SUB 6TAL CUMBERLAND CO COMMRS 37,509.90 37,509.90 35 0749064 r r, i' i. Q LL N u 00 wt?0 w u•Op ?/ ? O O N^ p Q O N W Q ? Vf ?1wQ? W ?6^ ? w ? O OOH r Y • Q ` ? w y 2 m n u ri U Q pC sP p O^ C s m: n Z c i o s^ o ® T Q EMI 2 CHONG O. LEE, : IN THE COURT OF COMMON PLEAS Administratrix of THE : CUMBERLAND COUNTY, PENNSYLVANIA ESTATE OF YOUNG H. LEE, : deceased, Petitioner V. MARIA G. MEDINA, Respondent NO. 99-5989 Civil CIVIL ACTION - LAW JURY TRIAL DEMANDED PRAECIPE TO REPLACE VERIFICATION TO THE PROTHONOTARY: Please replace the Verification, executed by Matthew S. Crosby, Esq., on behalf of the Petitioner, currently attached to the Petition for Settlement of Survival Action and Apportionment of Settlement with Wrongful Death Action, with the attached Verification that was executed by the Petitioner, Chong 0. Lee. & ROSENBERG Date:-1111-1-(2 / g By: Matthew S. Crokye q Supreme Court ID No. 69367 319 Market Street P.O. Box 1177 Harrisburg, PA 17101-1177 (717) 238-2000 Attorneys for Petitioner VERIFICATION I, CHONG O. LEE, Administratrix of THE ESTATE OF YOUNG H. LEE, deceased, hereby verify that the statements made in the foregoing pleading are true and correct to the best of my knowledge, information, and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S.A., Section 4904 relating to unsworn falsification to authorities. xL A .D. --? LOCH VG 0. LEE, Administratrix of THE ESTATE OF YOUNG H. LEE, deceased DATE: it /8I Q ? CHONG O. LEE, Administratrix of THE ESTATE OF YOUNG H. LEE, deceased, Petitioner V. MARIA G. MEDINA, Respondent : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA NO. 99-5989 Civil : CIVIL ACTION -LAW : JURY TRIAL DEMANDED ORDER AND NOW, this z z day ofAvc . 4 n, 1999, upon consideration of the foregoing petition, it is ordered that settlement in compromise of this action for the sum of $11,000.00 is approved. Furthermore, counsel fees and expenses are also set forth below. The distribution is directed as follows: (a) To Matthew S. Crosby Esq., HANDLER, HENNING & ROSENBERG, for counsel fees in the amount of $3,666.66; (b) To Matthew S. Crosby Esq., HANDLER, HENNING & ROSENBERG, for reasonable costs and expenses, in the amount of $332.06. (c) To the Department of Public Welfare (DPW), $2,116.39. (d) To Chong O. Lee, as Administratrix of the Estate of Young H. Lee, Petitioner, in the amount of five percent (5%) or $244.25, to the Decedent's Estate, as "survival" damages. (e) To Chong O. Lee, as the surviving spouse of the Decedent, Young H. Lee, as her intestate share, pursuant to 42 Pa. C.S.A. §8301 (b), the remaining ninety-five percent (95%) or $4,640.64, in "wrongful death" damages. BY THECOURTj? y9 NO'd 22 P1712?'?5 CU IFENNSYU NIA SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 1999-05989 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND LEE CHONG O VS. MEDINA MARIA G R. Thomas Kline , Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named defendant, to wit: MEDINA MARIA G but was unable to locate Her in his bailiwick. He therefore deputized the sheriff of PHILADELPHIA County, Pennsylvania. to serve the within WRIT OF SUMMONS On November 30th, 1999 this office was in receipt of the attached return from PHILADELPHIA County, Pennsylvania. Sheriff's Costs: So answ s: - Docketing 18.00 Out of County 9.00 ?rsrr?? Surcharge 8.00 Dep. Phila Co 116.00 omas ine, eri Sr5Z?0 HA. DOLER§9HHENNING & ROSENBERG 11/3 Sworn and subscribed to before me this - CI ` day of n e.aua ?ev 19 n A. D. l w, - l -i t PL fir- qL tono ary' Commonwealth of Pennsylvania County of Cumberland Chong O. Lee, Adminietratrix of the Estate of Young H. Lee Court of Common Pleas K Maria G. Medina 5506 N. American St. Philadelphia PA 19122 No. 99_5989_Civil_Term___-__-_ 19____ ------------------- In ---Civil- Action____ Law --------------------------------- Maria G. Medina: To --------------------------------------------- You are hereby notified that Chong O--------------------------------------- Lee, Administratrix of-the estate-of Young H._Lee________________ the Plaintiff ha s commenced an action in summons - Civil Action - Law ------------------------------------------------- against you which you arc required to defend or a default judgment may be entered against you. m Te:,?- 'rl'f^?,>:,', ! n4f'i +J 4!@ S9l Rt}" ha"fYU ?-cam (SEAL) Ti1jS PrWHionolM Date ----- - S-- ep--tember 30:-- -- I9___29 ---- .-CURTLS-E._ Lowata------------------------- ?,?I nePtothotary By ----- -!? ---- - --- ,- -- Depu M6 es Q'D OFFICE OF THE SHERIFF 01M ..;'+'y OCT I 3 4e PH 'M PENNSYLVANIA t? 44 1 , .?., 0 1 1 I WW i C W ' ? F 'I N i oef? ' 1 ? ? Q vi v"°; b B ° ?3yy a O1 awa s ; o h N a o i 0 I 9 4j Ni i , ?x G 41 I C. t QI N i '•I i . !` c: D o FI 0 to ; M a .. x UN>4 x ul t In The Court of Common Pleas of Cumberland County, Pennsylvania Chong 0. Lee VS. Mariq„G. Medina No. 99-5989 Civ Now, 10/4/99 , 19_, I, SHERIFF OF CUMBERLAND COUNTY, PA, do hereby deputize the Sheriff of Philadelphia County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. Sheriff of Cumberland County, PA Affidavit of Service Now, within upon at by handing to _ a and made known to 19_, at o'clock M. served the copy of the original So answers, the contents thereof. Sheriff of Sworn and subscribed before me this _ day of , 19 COSTS SERVICE _ MILEAGE AFFIDAVIT County, PA 3 SHERIFF'S RETURN-NOT FOUND GEE VERSUS 01014 G. mea4in,<1 COMMON PLEAS NO. COUNTY COURT • / 9T/E/RM, 19 NO. Slz Z° '/% l NOT FOUND as to M41f;e l J' /' fed o")Jj defenndaa?1nt, within the County of Philadelphia, State of Pennsylvania, as of 19 L . So answers, 12.225 (Rev. 12/87) ,the above named JOHN D. GREEENN SHERIFF' Deputy Sheriff k-M , 1 I i ( . 1t