HomeMy WebLinkAbout08-6485
THIS IS AN ARBITRATION MATTER
ASSESSMENT OF DAMAGES HEARING NOT REQUIRED
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER, ESQUIRE
Attorney for Plaintiff
Attorney I.D. #60267
1601 Market Street, Suite 2300
Philadelphia, PA 19103
(215) 569-5050
MILTON S. HERSHEY MEDICAL CENTER
P.O. Box 853
Hershey, PA 17033
VS
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. bg - bg85 l91vi l Term
CIVIL ACTION
RICHARD CHOI &
YOUNG MIN CHOI, h/w
49 Creekbank Drive
Mechanicsburg, PA 17050
COMPLAINT - CIVIL ACTION
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 are served, by entering a written appearance personally or by 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.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH
INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE
OR NO FEE.
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, Pennsylvania 17013
(717)249-3166 or(800)990-9108
COMPLAINT - CIVIL ACTION
COUNT I
MILTON S. HERSHEY MEDICAL CENTER V. RICHARD CHOI
1. Plaintiff is a non-profit corporation located at the
address indicated in the caption hereof.
2. Count I defendant is an individual who resides at the
address indicated in the caption hereof.
3. As the result of a certain medical condition, Count I
defendant was treated at the plaintiff hospital on Jan. 3, 2007
thru Jan. 4, 2007.
4. The amounts, quantities and nature of the medical care
rendered, the date on which said medical care was rendered, and
the charges therefore are set forth in Exhibit "A", which is
incorporated herein as if set forth at length.
5. Said medical care was commensurate with the condition
of Count I defendant and was necessary for the health and welfare
of Count I defendant.
6. At or about the time of Count I defendant's treatment
at the plaintiff hospital, implied, constructive and oral con-
tracts arose between Count I defendant and plaintiff by the terms
of which Count I defendant became obligated to pay plaintiff the
charges incurred for the medical care rendered by plaintiff to
Count I defendant.
7. Count I defendant refuses to pay the balance due
although plaintiff has made demand that Count I defendant do so.
8. As a result of the foregoing, there is due and owing
from Count I defendant to plaintiff the sum indicated in Exhibit
"All
WHEREFORE, plaintiff demands judgment against Count I
defendant, jointly and severally, for the sum of $31,423.78 plus
six percent (6%) interest per annum from the date of discharge to
the date of judgment, record costs and non-record costs.
COUNT II
MILTON S. HERSHEY MEDICAL CENTER VS. YOUNG MIN CHOI
9. The foregoing paragraphs are incorporated herein as if
set forth at length.
10. Count II defendant is an individual who resides at the
address indicated in the caption hereof.
11. Count II defendant is the spouse of Count I defendant.
12. Count II Defendant's spouse was treated at the
plaintiff hospital on Jan. 3, 2007 thru Jan. 4, 2007.
13. Said medical care was commensurate with the condition
of Count II defendant's spouse and was necessary for the health
and welfare of Count II defendant's spouse.
14. Count II defendant is financially able to pay for the
medical care of Count I defendant.
15. By virtue of the marital relationship, the Act of 1937,
June 24, P.L. 2045, Sec. 3, as amended, 23 Pa. Cons. Stat. Ann.
Sec. 4603 and Article 1, Sec. 28 of the Pennsylvania Constitution
and all other applicable statutes, laws and ordinances, Count II
defendant has a duty to support Count I defendant.
16. Count II defendant has been unjustly enriched by plain-
tiff's discharge of Count II defendant's duty to support Count I
defendant, which duty Count II defendant failed to perform.
17. Count II defendant refuses to pay the balance due,
although plaintiff has made demand that Count II defendant do so.
18. As a result of the foregoing, there is due and owing
from Count II defendant to plaintiff the sum indicated in
Exhibit "A".
WHEREFORE, plaintiff demands judgment against Count II
defendant, jointly and severally, for the sum of $31,423.78 plus
six percent (6%) interest per annum from the date of discharge to
the date of judgment, record costs and non-record costs.
COUNT III
MILTON S. HERSHEY MEDICAL CENTER VS. YOUNG MIN CHOI
19. The foregoing paragraphs are incorporated herein as
if set forth at length.
20. Count III defendant is an individual who resides at the
address indicated the the caption hereof.
21. As the result of a certain medical condition, Count III
defendant was treated at the plaintiff hospital on Jan. 3, 2007,
thru Jan. 4, 2007.
22. The amounts, quantities and nature of the medical care
rendered, the date on which said medical care was rendered, and
the charges therefore are set forth in Exhibit "B", which is
incorporated herein as if set forth at length.
23. Said medical care was commensurate with the condition
of Count III defendant and was necessary for the health and wel-
fare of Count III defendant.
24. At or about the time of Count III defendant's treatment
at the plaintiff hospital, implied, constructive and oral con-
tracts arose between Count III defendant and plaintiff by the
terms of which Count III defendant became obligated to pay plain-
tiff the charges incurred for the medical care rendered by plain-
tiff to Count III defendant.
25. Count III defendant refuses to pay the balance due
although plaintiff has made demand that Count III defendant do
so.
26. As a result of the foregoing, there is due and owing
from Count III defendant to plaintiff the sum indicated in Ex-
hibit "B"
WHEREFORE, plaintiff demands judgment against Count III
defendant, jointly and severally, for the sum of $31,423.78 plus
six percent (6%)interest per annum from the date of discharge to
the date of judgment, record costs and non-record costs.
COUNT IV
MILTON S. HERSHEY MEDICAL CENTER VS. RICHARD CHOI
27. The foreoing paragraphs are incorporated herein as if
set forth at length.
28. Count IV defendant is an individual who resides at the
address indicated in the caption hereof.
29. Count IV defendant is the spouse of Count III
defendant.
30. Count IV Defendant's spouse was treated at the plain-
tiff hospital on Jan. 3, 2007 thru Jan. 4, 2007.
31. Said medical care was commensurate with the condition
of Count IV defendant's spouse and was necessary for the health
and welfare of Count IV defendant's spouse.
32. Count IV defendant is financially able to pay for the
medical care of Count III defendant.
33. By virtue of the marital relationship, the Act of 1937,
June 24, P.L. 2045, Sec. 3, as amended, 23 Pa. Cons. Stat. Ann.
Sec. 4603 and Article 1, Sec. 28 of the Pennsylvania Constitution
and all other applicable statutes, laws and ordinances, Count IV
defendant has a duty to support Count III defendant.
34. Count IV defendant has been unjustly enriched by plain-
tiff's discharge of Count IV defendant's duty to support Count
III defendant, which duty Count IV defendant failed to perform.
35. Count IV defendant refuses to pay the balance due,
although plaintiff has made demand that Count IV defendant do so.
36. As a result of the foregoing, there is due and owing
from Count IV defendant to plaintiff the sum indicated in
Exhibit "B"
WHEREFORE, plaintiff demands judgment against Count IV
defendant, jointly and severally, for the sum of $31,423.78 plus
six percent (6%) interest per annum from the date of discharge to
the date of judgment, record costs and non-record costs.
TABAS & ROSEN, P.C.
LEWI C. T%AUFFER, ESQUIRE
Attorney for Plaintiff
MS HERSHEY MEDICAL CENTER PAGE: 1
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 03/24/08 at 02:46 PM
Guarantor: CHOI RICHARD T
49 CREEKBANK DRIVE
MECHANICSBURG, PA 17050-0000
Patient: CHOI RICHARD T
Visit #: 10500157
-----------------------------------------
--------------------------
Date Svc Code Description ( Units Debits Credits
-----------------------I ---------------------------------------------
01/03/07
01/03/07 10223
1 P PRIVATE MED/SURG RM 1 1240.00
01/03/07 6502
46 ADULT LEVEL II TRAUMA 1 2945.00
01/03/07 121
4 URINALYSIS DIPSTIX PR 1 7.00
01/03/07 6122
46 HEMOCCULT, STOOL 1 7.00
01/03/07 472
4 EMERGENCY VISIT, LEVE 1 587.00
01/03/07 6620
4 ROUTINE VENIPUNCTURE 1 17.00
01/03/07 6717
101 NONINVAS PULSE OX, MU 1 95.00
01/03/07 003
101 ABO BLOOD GROUP 1 21.00
01/03/07 004
1 ANTIBODY SCREEN 1 47.00
01/03/07 01005
104002 RH TYPE
ALCOHOL (ETOH)
BLOOD 1
1 20.00
01/03/07
104009 ,
AMYLASE, BLOOD
1 51.00
44
00
01/03/07 104042 CREATININE, BLOOD 1 .
14
00
01/03/07 104060 GLUCOSE, BLOOD 1 .
13
00
01/03/07 104131 POTASSIUM (K), BLOOD 1 .
14
00
01/03/07 104145 SODIUM (NA), BLOOD 1 .
14
00
01/03/07 104711 DRUG SCREEN, URINE 1 .
97.00
01/03/07
01/03/07 105052
105 PARTIAL THROMBOPLAS T 1 38.00
01/03/07 059
10 PROTHROMBIN TIME 1 23.00
01/03/07 5657
10 CBC W/PLT/DIFF AUTO 1 48.00
01/03/07 9436
11 LEGAL ETHANOL (BLOOD) 1 63.00
01/03107 1001
24
706 GLUCOSE BEDSIDE MONIT
-- 3 84.00
01/03/07 6
246 MORPHINE SULFATE
2 MG 1 3,00
01/03/07 764
25 DIPHTHERIA TETANUS 0. 1 61.85
01/03/07 1908
27 TYLENOL EXTRA STRENGT 2 3.00
01/03/07 2979
2 FAMOTIDINE 20MG PRE-M 1 10.35
01/03/07 74324
305621 HUMULIN R
KNEE 1-2 VIEWS RIGHT 200
1 38.20
01/03/07
307101
CHEST 1 VIEW
1 140.00
120
00
01/03/07
01/03/07 307220
3 PELVIS 1-2 VIEWS 1 .
158.00
01/03/07 10501
31 CT HEAD UNENHANCED 1 755.00
01/03/07 0516
31 CT THORAX ENHANCED 1 1565.00
01/03/07 0519
31 CT ABDOMEN ENHANCED 1 1080.00
01/03/07 0528
31 CT SINUS MAXILLOFAC U 1 963.00
01/03/07 0560
310562 CT C-SPINE UNENHANCED 1 837.00
01/03/07
310564 CT T-SPINE UNENHANCED
CT L-SPINE UNENHANCED 1
1 780.00
01/03/07
)1/03/07
310567
3
CT PELVIS ENHANCED
1 788.00
1227.00
)1/03/07 10704
6 OMNIPAQUE 300MG/ML 15 1 82.00
)1/03/07 21054
62 IV LACTATED RINGERS 1 1 6.00
)1/-03/07 2023
62 IRRIGATION SOD CHL 0. 1 6.00
7070 IV EXT SET 90" W/FLAS 1 17 00
----------------------------- ------------------------------------------------- ?.
Continue -
MS HERSHEY MEDICAL CENTER PAGE: 2
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 03/24/08 at 02:46 PM
Guarantor: CHOI RICHARD T
49 CREEKBANK DRIVE
MECHANICSBURG, PA 17050-0000
Patient: CHOI RICHARD T
Visit #: 10500157
--------------------------
----------------------- -------
Date- Svc Code Description---
escription- - - - Units Debits---
ebits Credits
01/03/07 670334 IV INFUSION SET, UNIV 1 8
00
03/23/07
07/31/07 902040
9800 AUTO/WORK COMP PAYMEN -1 . 4037.11-
07/31/07 90
98 HOSPITAL BAD DEBT W/O -1 10100.29-
08/02/07 0091
980 HOSPITAL BAD DEBT PLA 1 10100.29
08/02/07 092
980 RETURN HOSPITAL, BAD D -1 10100.29-
09/30/07 093
980 RETURN FROM B/D HOSP 1 10100.29
09/30/07 090
98 HOSPITAL BAD DEBT W/O -1 10100.29-
0091 HOSPITAL BAD DEBT PLA 1 10100.29
* - Not posted Balance: 10100.29
------------------------
¦
#-I
PENNS
0100 TATE Milton S 1st Statement
Hershe
Medical Center Y
MSHMC PHYSICIANS GROUP
BILLING SERVICES
PO Box 843313, Pittsburgh, PA 15284-3313
RICHARD T CHOI POW16
49 CREEK BANK DR
MECHANICSBURG PA 17050-1814
IN III IN III III IN It n11111n11111if 11u111n111r11n11NJ r
Patient Name RICHARD T CHOI
Statement Date 10/23/07
Account Number 7500157
Total Charges $ 7,022.00
Insurance Payments/Adjustments $ -2,095.62
Patient Payments $ 0.00
Pending with Insurance $ 0.00
Amount You Owe $ 4,926.38
This new statement has been specially designed with
you in mind. Let us know what other improvements
we should make.
Please e-mail your ideas to:
Statementideas ftmc osu edu
or write to us at:
Penn State A4itten S Hershey Medical Center
Statement Ideas, PO Box 854, MC A410
Hershey, PA 17033
Page 1 of 4
Thank you for allowing Penn State University Physicians Group to
provide you with services. Please send your payment for the full
amount. If you have any questions concerning how your insurance
company processed your claim, please call them. If no insurance is
listed on the back of this statement and one is available please
contact our office with your information.
Please note: To keep your account current, our policy is to apply
your payment to the oldest outstanding balance.
To make payments, billing questions.or.insurance changes:
Para preguntas acerca de su factura o cambios de seguro contamos con
representantes disponibles pare asistir a la comunidad hispana.
Phone: (717) 531-5069 or (800) 254-2619
In Person: Financial counselors are available in the Academic Support
Building (on campus just east of the main hospital and University
Physicians Center).
Available hours: Monday, Tuesday & Wednesday 8:00 am to 5:30 pm
Thursday & Friday 8:00 am to 4:30 pm
Written Correspondence:
Penn State Milton S. Hershey Medical Center
Patient Financial Services Department
PO Box 854, Mail Code A410
Hershey, PA 17033-0854
. Department of Public Welfare 1-800-692-7462
. Children's Health' Insurance"Program (CHIP) 1-800-543-7101
(Uninsured children and adolescents under age 19)
. AdultBasic Program 1-800-543-7101
(Uninsured adults between the ages of 19 and 64)
RNM3
a?
i?
Tllic .statement is fur yotir pltysicirnl sel•Pices only. The hospittil ilitiy GlASepartitely for tllair' sen iceS'.
HERSHPHYSTI-01
PENNSTATE Statement Date: 10/23/07
® Milton S. Hershey
Medical Center
MSHMC PHYSICIANS GROUP
BILLING SERVICES
PO Box 843313
Pittsburgh, PA 15284-3313
CHECKS SHOULD BE MADE PAYABLE AND
SENT TO:
MSHMC PHYSICIANS CROUP
PO BOX 643313
PITTSBURGH, PA 15264-3313
III III III lilt III IIInIIII 11111111 1111111111111111 11111111 1111 1
.......................................................................................
Patient Name Account. Number , Date Due
RICHARD T CHOI ' 7500157 Upon Receipt
Amount You OW'e Amount Paid'
$ 4,926.38
l-4 Check here if your address or insurance information has changed.
Please indicate changes on the back of this page.
To pay by credit card: For your convenience, you may pay by Visa,
MasterCard or Discover Card. Please indicate your credit card
preference, provide the account information, and sign below.
?z ?
Account No.
Expiration Date CW Code
Signature X
00007500157 UP 0000000000492638102307
Page 2 of 4
CPT
Date Code Diagnosis Description
01/03/07 99245 959.8 TRAUMA TEAM DIAG EVAL INT
03/23/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
Payments/
Charges Adiustments
$ 3,283.00
$ -196.12
Pending Patient
Insurance Balance
$ 3,086.88
TOTAL:
CPT
Date Code Diagnosis Description
01/03/07 73560 959.7 KNEE LIMITED
03/20/07 WKC OR AUTO PAYMEN
03/20/07 ACT 6 AUTO ALLOWANCE
TOTAL:
CPT
Date Code Diagnosis Description
01103/07 72170 959.6 PELVIS ANTERPOSTER
03/23/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
01/03/07 71010 959.19 CHEST 1 VIEW
03/23/07 WKC.OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
TOTAL:
$ 3,283.00 $ -196.12 $ 0.00 $ 3,086.88
Payments/ Pending Patient
Charges Adiustments Insurance Balance
$ 60.00
$ -8.84
$ -51.16
$ 60.00 $ -60.00 $ 0.00 $ 0.00
Payments/ Pending Patient
Charges Adiustments Insurance Balance
$ 57.00
$ -8.84
$60.00 $ 48.16
$ -9.26
$ 50.74
$ 117.00 $ -18.10 $ 0.00 $ 98.90
" (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL
......................................... ..- HERSHPHYSTt-04
PLEASE COMPLETE IF YOUR ADDRESS QR INSURANCE HAS CHANGED
NAME RELATIONSHIP TO PATIENT HOME TELEPHONE WORK TELEPHONE
ADDRESS CITY STATE ZIP
INSURANCE COMPANY NAME GROUP POLICYIPLAN NUMBER
POLICYHOLDER'S IDENTIFICATION NUMBER CLAIM MAILING ADDRESS
POLICYHOLDER'S DATE OF BIRTH RELATIONSHIP TO PATIENT CITY STATE ZIP
POLICYHOLDER'S EMPLOYER NAME INSURANCE COMPANY TELEPHONE
(Workers Compensation &Auto Insurance Claims Only) DATES OF COVERAGE
Adjusters Name: Claim #: EFFECTIVE FROM: EFFECTIVE TO:
Page 3 of 4
rh cry NAMM KIGNARD T CHOF VISIT:NUMBER: 10500157
DOGT.OR(S):,SANGAM G "KANEKAR MD DIV OF DIAL RADIOLOGY LOCATION INPATIENT
CPT
Date Code Diagnosis Description
01/03/07 72125 959.8 CT CERVICAL SPINE UNENHAN
03/20/07 WKC OR AUTO PAYMEN
03/20/07 ACT 6 AUTO ALLOWANCE
01/03/07 72131 959.8 CT LUMBAR SPINE UNENHANCE
03/20/07 WKC OR AUTO PAYMEN
03/20107 ACT 6 AUTO ALLOWANCE
01/03/07 70486 959.09 CT MAXILLOFACIAL UNENH
03/20/07 WKC OR AUTO PAYMEN
03/20/07 ACT 6 AUTO ALLOWANCE
01/03/07 70450 959.01 CT HEAD UNENHANCED
03/23/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
01/03/07 72128 959.8 CT THORACIC SPINE UNENHAN
03123/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
Payments/
Charges Adjustments
$ 377.00
$ -58.95
$ -318.05
$ 377.00
$ -58.95
$ -318.05
$ 371.00
$ -58.16
$ -312.84
$ 278.00
$ -43.18
$ 377.00
$ -58.95
Pending Patient
Insurance Balance
TOTAL:
DOCTOR SAITHOMAS M DYKES MID DIV OF DIAG RADIOLOGY LOVISIT CNUMBINPATlENT
ATION: INPATIENT
$ 234.82
$ 318.05
$1,780.00 $ -1,227.13 $ 0.00 $ 552.87
CPT
Date Code Diagnosis Description
Charges Payments/ Pending
Adiustments Insurance Patient
Balance
01/03/07 72193 959.12 CT PELVIS ENHANCED $ 377
00
03/23/07 WKC OR AUTO PAYMENT . $ -58
95
04/24/07 MAXIMUM BENEFITS PAID . $ 318
05
01/03/07 71260 959.19
03/23
7 CT THORAX W/CONTRAST ENH $ 401.00 .
/0 WKC OR AUTO PAYMENT $ -63
42
04/24/07 MAXIMUM BENEFITS PAID .
01/03/07 74160 959.12
C T ABDOMEN ENHANCED
$ 413
00 $ 337.58
03/23/07 WKC OR AUTO PAYMENT . $ -64
96
04/24/07 MAXIMUM BENEFITS PAID . $ 348.04
TOTAL
: $1,191.00 $ -187.33 $ 0.00 $1,003.67
PATIENT NAME: RICHARD T CHOI _
VISIT NUMBER:
10500157
DOCTOR(S):. DANIEL K FRENCH MD DIV OF EMERG ROOM ,
LOCATION: EMERGENCY ROOM
CPT
Date Code Diagnosis Description
01103/07 99285 959.8 EMERGENCY VISIT
03/23/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
Payments/
Charges Adiustments
$ 361.00
Pending Patient
Insurance Balance
TOTAL:
$ -176.94
$ 184.06
$ 361.00 $ -176.94 $ 0.00 $184.06
PATIENT NAME: RICHARD T CHOI
VISIT NUMBER: 10500157
DOCTOR(S): JOSEPH A BARBER MD DIV PSYCH CONSULTS ADULT. LOCATION- INPATIENT
CPT Payments/ Pending Patient
Date Code Diagnosis escri tion Charges Adiustments Insurance B lance
01/03/07 99233 305.02 DAILY HOSPITAL CARE $ 230.00
03/20/07 WKC OR AUTO PAYMEN $ -97.37
03/20/07 ACT 6 AUTO ALLOWANCE $ -132.63
TOTAL: $ 230.00 $ -230.00 $ 0.00 $ 0.00
* (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL
HERSHPHYSTI.03
Page 4 of 4
GRAND TOTAL: $ 7,022.00 $ -2,095.62
$ 0.00 $ 4,926,38
" (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL
/9-
HERSHPHYSTI.03
MS HERSHEY MEDICAL CENTER PAGE: 1
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/23/07 at 02:41 PM
Guarantor: CHOI YOUNG MIN
49 CREEKBANK ROAD
MECHANICSBURG, PA 17050-0000
Patient: CHOI YOUNG MIN _
Visit #: 10500156
----------------------------------------
----------------------------
Date Svc Code Descrition --- - Units --Debits Credits --
-----------------------I ------------------------------------------------
01/03/07 10211
01/03/07 P PRIV MED/SURG RM 1 1240.00
16502
01/03/07 4 ADULT LEVEL II TRAUMA 1 2945.00
6472
01/03/07 46 EMERGENCY VISIT, LEVE 1 587.00
620
01/03/07 46 ROUTINE VENIPUNCTURE 1 17.00
699
01/03/07 4 THERA/DIAG INJECTION 1 56.00
6717
01/03/07 46 NONINVAS PULSE OX, MU 1 95.00
937
01/03/07 101003 THER IV PUSH,EA ADDL
ABO BLOOD GROUP 1 56.00
01/03/07 101004
ANTIBODY SCREEN 1
1 21.00
47
00
01/03/07 101005 RH TYPE 1 .
01/03/07 104002
ALCOHOL (ETOH), BLOOD
1 20.00
51
00
01/03/07 104009
01/03/07 10 AMYLASE, BLOOD 1 .
44.00
4042
01/03/07 10 CREATININE, BLOOD 2 28.00
4060
01/03/07 104131 GLUCOSE, BLOOD
POTASSIUM (K)
BLOOD 1
1 13.00
01/03/07 104145 ,
SODIUM (NA), BLOOD
1 14.00
14
00
01/03/07 105052
01/03/07 105 PARTIAL THROMBOPLAS T 1 .
38.00
059
01/03/07 10 PROTHROMBIN TIME 1 23.00
5656
01/03/07 2 CBC W/PLT AUTO 1 30.00
45206
01/03/07 2 LIDOCAINE 10MG/ML 1 3.00
46021
01/03/07 2 BACITRACIN 15 GM 1 4.60
46706
01/03/07 MORPHINE SULFATE 2 MG 5 15.00
247831
01/03/07 2 ACETAMINOPHEN 325 MG 4 6.00
48225
01/03/07 272199 SENNA SYRUP 1ML
ONDANSETRON 2MG/ML 2M 1
8 5.95
01/03/07 272979
01/03/07 3
FAMOTIDINE 20MG PRE-M
2 34.60
20.70
05611
01/03/07 307101 WRIST 1-2 VIEWS RIGHT
CHEST 1 V 1 113.00
01/03/07 307220 IEW
PELVIS 1-2 VIEWS 1
1 120.00
01/03/07 307290
01/03/07 3
HAND 3 OR MORE VIEWS
1 158.00
111.00
10501
01/03/07 310516 CT HEAD UNENHANCED 1 755.00
01/03/07 310519 CT THORAX ENHANCED
CT ABDOMEN ENHANCED 1
1 1565.00
01/03/07 310528
)1/03/07 31
CT SINUS MAXILLOFAC U
1 1080.00
963.00
0560
)1/03/07 3 CT C-SPINE UNENHANCED 1 837.00
10562
31/03/07 31 CT T-SPINE UNENHANCED 1 780.00
0564
)1/03/07 310567 CT L-SPINE UNENHANCED 1 788.00
)1/03/07 310704 CT PELVIS ENHANCED
OMNIPAQUE 300MG/ML 15 1
1 1227.00
)1/03/07 621044
I V SODIUM CHLORIDE 0
1 82.00
6
00
)1/03/07 621054
)1/03/07
2 IV LACTATED RINGERS 1 2 .
12.00
6
2023 IRRIGATION SOD CHL 0. 1 6 00
--------------------------------------------- - ---------------------------
Continue -
MS HERSHEY MEDICAL CENTER PAGE: 2
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 10/23/07 at 02:41 PM
Guarantor: CHOI YOUNG MIN
49 CREEKBANK ROAD
MECHANICSBURG, PA 17050-0000
Patient: CHOI YOUNG MIN
Visit #: 10500156
---------------------------------
Date I Svc Code I Description Unitsl Debits Credits
-------------------------------------------
01/03/07 627070 IV EXT SET 90" W/FLAS 2
01/03/07 670334 IV INFUSION SET, UNIV 1
01/04/07 245847 CEPHALEXIN 500 MG 4
01/04/07 246021 BACITRACIN 15 GM 1
01/04/07 246226 INFLUENZA VAC (ADULT) 1
01/04/07 246706 MORPHINE SULFATE 2 MG 1
01/04/07 247831 ACETAMINOPHEN 325 MG 6
01/04/07 249441 FAMOTIDINE 20MG UD 2
01/04/07 621054 IV LACTATED RINGERS 1 1
04/02/07 902040 AUTO/WORK COMP PAYMEN -1
09/06/07 900011 PATIENT PAY CHECK -1
09/30/07 980090 HOSPITAL BAD DEBT W/O -1
09/30/07 980091 HOSPITAL BAD DEBT PLA 1
34.00
8.00
12.00
4.60
53.70
3.00
9.00
6.00
6.00
3693.47-
50.00-
10424.68-
---10424.68
----------------------
----------------------
* - Not posted I Balance: I 10424.68
PENNST
REIM ATE Milton S Hems 1 St Statement
h
ey
Medical Center
MSHMC PHYSICIANS GROUP
BILLING SERVICES
PO Box 643313, Pittsburgh, PA 152643313
YOUNG MIN CHOI P00015
49 CREEK BANK DR
MECHANICSBURG PA 17050-1814
11111111111111U111111nr111111II111poll III IIIII IIII III I I I I I
Patient Name YOUNG MIN CHOI
Statement Date 10/23/07
Account Number 7500156
Total Charges $ 6,846.00
Insurance Payments/Adjustments $ -873.57
Patient Payments $ 0.00
Pending with Insurance $ 0,00
Amount You Owe $ 5,972.43
This new statement has been specially designed with
you in mind. Let us know what other improvements
we should make.
Please e-mail your ideas to:
Statementidea?9L@-hmc.psu.edu
or write to us at:
Penn State Milton S. Hershey Medical Center
Statement Ideas, PO Box 854, MC A410
Hershey, PA 17033
Page 1 of 4
Thank you for allowing Penn State University Physicians Group to
provide you with services. Please send your payment for the full
amount. If you have any questions concerning how your insurance
company processed your claim, please call them. If no insurance is
listed on the back of this statement and one is available please
contact our office with your information.
Please note: To keep your account current, our policy is to apply
your payment to the oldest outstanding balance.
To make payments. billing questions or insurance changes:
Para preguntas acerca de su factura o cambios de seguro contamos con
representantes disponibles para asistir a Is comunidad hispana.
Phone: (717) 531-5069 or (800) 254-2619
In Person: Financial counselors are available in the Academic Support
Building (on campus just east of the main hospital and University
Physicians Center).
Available hours: Monday, Tuesday & Wednesday 8:00 am to 5:30 pm
Thursday & Friday 8:00 am to 4:30 pm
Written Correspondence:
Penn State Milton S. Hershey Medical Center
Patient Financial Services Department
PO Box 854, Mail Code A410
Hershey, PA 17033-0854
?Jljrm
Department of Public Welfare 1-800-692-7462
. Children's Health Insurance Program (CHIP) 1-800-543-7101
(Uninsured children and adolescents under age 19)
. AdultBasic Program 1-800-543-7101
(Uninsured adults between the ages of 19 and 64)
RNM3
This strttetuettt fs fttr your pl{ysiciati services oirly. The hospital may bill separalely,for their services.
• • • .......... - HERSHPHYSTI-01
PENNSTATE Statement Date: 10/23/07
Milton S. Hershey
Medical Center
MSHMC PHYSICIANS GROUP
BILLING SERVICES
PO Box 643313
Pittsburgh, PA 15264.3313
Statement of'PhysicittnServices
CHECKS SHOULD BE MADE PAYABLEAND
SENT TO:
MSHMC PHYSICIANS GROUP
PO BOX 643313
PITTSBURGH,.PA 15264-3313
1111111111111 111111111111111111Is11111111111111111111111111111
.......................................................................................
Patient `Name, Account Number Date Due
YOUNG MIN CHOI 7500156 Upon Receipt
Amount You Owe Amaunt Paid
$ 5,972.43 $
F.JI Check here if your address or insurance information has changed.
Please indicate changes on the back of this page.
To pay by credit card: For your convenience, you may pay by Visa,
MasterCard or Discover Card, Please Indicate your credit card
preference, provide the account information, and sign below.
rJ ? ?0
Account No. _
Expiration Date
Signature X
CW Code
00007500156 UP 0000000000597243102307
Page 2 of 4
CPT
Date Code Diagnosis Description
* 01/12/07 99024 V67.09 POST-OP FOL-UP VISIT
TOTAL:
CPT
Date Code Diagnosis Description
* 01/19/07 99024 V67.9 POST-OP FOL-UP VISIT
TOTAL:
Payments/ Pending Patient
Charge s Adiustments Insurance Balance
$0.00 $0.00 $0.00 $0.00
Payments/ Pending Patient
Charges Adiustments Insurance Balance
$ 0.00 $ 0.00 $ 0.00 $ 0.00
PATIENT NAME YOUNG MIN `CHOI L ' VISIT NUMBER 10500156
'DOCT.QR(S);1?AN q GALVAI,:MD TRAUMA $URGE?tY DIV- LOCATION EiVIERGENCY ROOM
CPT Payments/ Pending Patient
Date Code Diagnosis Description Charges Adiustments Insurance Balance
01103/07 99245 959.8 TRAUMA TEAM DIAG EVAL INT $ 3,283.00
03/19/07 WKC OR AUTO PAYMENT $ -196.12
04/24/07 MAXIMUM BENEFITS PAID $ 3,086.88
TOTAL:
$ 3,283.00 $ -196.12 $ 0.00 $ 3,086.88
+.._
* (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL HERSHPHYSTI-02
PLEASE COMPLETE IF YOUR ADDRESS OR INSURANCE HAS CHANGED
NAME RELATIONSHIP TO PATIENT HOME TELEPHONE WORK TELEPHONE
ADDRESS CITY STATE ZIP
POLICYHOLDER'S NAME INSURANCE COMPANY NAME GROUP POLICY/PLAN NUMBER
POLICYHOLDER'S IDENTIFICATION NUMBER CLAIM MAILING ADDRESS
POLICYHOLDER'S DATE OF BIRTH RELATIONSHIP TO PATIENT CITY STATE ZIP
POLICYHOLDER'S EMPLOYER NAME INSURANCE COMPANY TELEPHONE
(Workers Compensation & Auto Insurance Claims Only) DATES OF COVERAGE
Adjusters Name: Claim #: EFFECTIVE FROM: EFFECTIVE TO:
Page 3 of 4
PATIENT NAME YOUNG MIN CHOC VISIT NUMBER: 10$00156
DOCTOR(S)y%PAUL KALAPOS MD DIV OF DIAG RADIOLOGY LOCATION: INPATIENT ,
CPT
Date Code Diagnosis Description
01/03/07 72128 959.8 CT THORACIC SPINE UNENHAN
03/19/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
01/03/07 70450 959.01 CT HEAD UNENHANCED
03/19/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
01/03/07 70486 959.09 CT MAXILLOFACIAL UNENH
03/19/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
01/03/07 72125 959.8 CT CERVICAL SPINE UNENHAN
03/19/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
01/03107 72131 959.8 CT LUMBAR SPINE UNENHANCE
03/19/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
TOTAL:
Payments/ Pending Patient
Charges Adiustments Insurance Balance
$ 377.00
$ -58.95
$ 318.05
$ 278.00
$ -43.18
$ 234.82
$ 371.00
$ -58.16
$ 312.84
$ 377.00
$ -58.95
$ 318.05
$ 377.00
$ -58.95
$ 318.05
$1,780.00 $ -278.19 '$0.00 $1,501.81
FA I IEN I. NAME: YOUNG' MIN CHOI VISIT NUMBER: 10900156,
DOCTOR(S):.MARK:E LOBELL MD DIV OF DIAG RADIOLOGY,: LOCATION: INPATIENT
CPT
Date Code Diagnosis Description
01/03/07 73100 959.3 WRIST ANTEROPOSTE LATERAL
03/19/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
01/03107 73130 959.4 HAND >3 VIEWS
03/19/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
TOTAL:
.PA
Charge s
$ 57.00
$ 57.00 Payments/ Pending
Adiustments Insurance
$ -8.05
$ -8.84 Patient
Balance
?
$ 48.95
$ 48.16
$ 114.00 $ -16.89 $ 0.00 $ 97.11
NAME: YOUNG MIN CHOI VISIT NUMBER: 10500186
(Sj: RICKHESVAR MAHRAJ MD, DIV OF DIAG RADIOLOGY. LOCATION: INPATIENT i
CPT
Date Code Diagnosis Description
01/03/07 71010 959.19 CHEST 1 VIEW
03/19/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
01/03/07 72170 959.6 PELVIS ANTERPOSTER
03/19/07 WKC OR AUTO PAYMENT
04/24/07 MAXIMUM BENEFITS PAID
TOTAL:
Payments/ Pending Patient
Charges Adiustments Insurance Balance
$ 60.00
$ -9.26
$ 50.74
$ 57.00
$ -8.84
$ 48.16
$117.00 $ -18.10 $ 0.00 $ 98.90
" (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL
13
HERSHPHYSTI-03
Page 4 of 4
CPT Payments/ Pending Patient
Date Code Diagnosis Description Charges Adjustments Insurance Balance
01/03/07 71260 959.19 CT THORAX W/CONTRAST ENH $ 401.00
03/23/07 WKC OR AUTO PAYMENT $ -63.42
04/24/07 MAXIMUM BENEFITS PAID $ 337.58
01/03/07 74160 959.12 C T ABDOMEN ENHANCED $ 413.00
03/23/07 WKC OR AUTO PAYMENT $ -64.96
04/24/07 MAXIMUM BENEFITS PAID $ 348.04
01/03/07 72193 959.12 CT PELVIS ENHANCED $ 377.00
03/23/07 WKC OR AUTO PAYMENT $ -58.95
04/24/07 MAXIMUM BENEFITS PAID $ 318.05
TOTAL: $1,191.00 $ -187.33 $ 0.00 $ 1,003.67
;,',PATIENT,-'N'AME'- YOUNG MIN CHOI VISIT NUMBER b5001`56
DOC:TOR(S)..DANIEI :K FRENCH MD DIV OF EMERG; ROOM LOCATION„EMERGENCY ROOM , . .
CPT Payments/ Pending Patient
Date Code Dia
qn psis Description
Charges
Adjustments
Insurance
Balance
01/03/07 99285 959.8 EMERGENCY VISIT $ Op
03/19/07 WKC OR AUTO PAYMENT $ -176.94
04/24/07 MAXIMUM BENEFITS PAID $ 184.06
TOTAL: $ 361.00 $ -176.94 $ 0.00 $ 184.06
GRAND TOTAL: $ 6,846.00 $ -873.57 $ 0.00 $ 5,972.43
" (preceding the date) INDICATES NEW FINANCIAL ACTIVITY SINCE THE LAST BILL
HERSHPHYSTI-03
CHOI, RICHARD #7500157 $10,100.29 (Hosp)
4,926.38 (Phys)
CHOI, YOUNG MIN #7500156 $10,424.68 (Hosp)
5,972.43 (Phys)
VERIFICATION
LINDA SCHLADER hereby states that she is the
Team Manager, Customer Service of the Milton S. Hershey
Medical Center and verifies that the statements made in the
foregoing pleading are true and correct to the best of her
knowledge, information and belief. The undersigned understands
that the statements therein are made subject to the penalties of
18 Pa. C.S. §4904 relating to unsworn falsification to
authorities.
LINDA SCHLADER
DATE: llaL??
f? -bll.
C4 C?
01
C-)
M
CA) ?j t
LO C
4.1
i
D ?7 s
SHERIFF'S RETURN - NOT FOUND
CASE NO: 2008-06485 P
COMMONTWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
MILTON S HERSHEY MEDICAL CTRE
VS
CHOI RICHARD ET AL
R. Thomas Kline Sheriff or Deputy Sheriff, who being
duly sworn according to law, says, that he made a diligent search and
inquiry for the within named DEFENDANT
CHOI RICHARD but was
unable to locate Him in his bailiwick. He therefore returns the
COMPLAINT & NOTICE
NOT FOUND , as to
the within named DEFENDANT CHOI RICHARD
49 CREEK BANK DRIVE
MECHANICSBURG, PA 17050
PER NEIGHBOR, DEFENDANT MOVED TO HARRISBURG.
NO FORWARDING ON FILE AT POST OFFICE.
Sheriff's Costs:
Docketing
18.00 So answers:
?--
esl`
/
Service 10.00
Not Found 5.00 R. Thomas Kline
Surcharge 10.00 Sheriff of Cumb erland County
"I N1O q 00
43.-00
TABAS & ROSEN
11/07/2008
Sworn and Subscribed to befo re
me this day of ,
A. D.
SHERIFF'S RETURN - NOT FOUND
CASE NO: 2008-06485 P
COMMONTWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
MILTON S HERSHEY MEDICAL CTRE
VS
CHOI RICHARD ET AL
R. Thomas Kline Sheriff or Deputy Sheriff, who being
duly sworn according to law, says, that he made a diligent search and
inquiry for the within named DEFENDANT
CHOI YOUNG MIN but was
unable to locate Her in his bailiwick. He therefore returns the
COMPLAINT & NOTICE
NOT FOUND , as to
the within named DEFENDANT
CHOI YOUNG MIN
49 CREEK BANK DRIVE
MECHANICSBURG, PA 17050
PER NEIGHBOR DEFENDANT MOVED TO HARRISBURG.
NO FORWARDING ADDRESS ON FILE AT POST OFFICE.
Sheriff's Costs:
Docketing 6.00
Service .00
Not Found 5.00
Surcharge 10.00
00
21.00
So answer
R. Thomas Kline
Sheriff of Cumberland County
TABAS & ROSEN
11/07/2008
Sworn and Subscribed to before
me this day of ,
A.D.
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER, ESQUIRE
I.D. #60267
1601 Market Street, Suite 2300
Philadelphia, PA 19103
(215) 569-5050
Attorney for Plaintiff
MILTON S. HERSHEY MEDICAL CENTER : COURT OF COMMON PLEAS
VS
: CUMBERLAND COUNTY
RICHARD CHOI & : NO. 08-6485
YOUNG MIN CHOI, h/w
P R A E C I P E
TO THE PROTHONOTARY:
Please reinstate the attached Complaint to be served
at 3521 Louisa Lane, Mechanicsburg, PA 17050.
LEWIS C. TRAUFFER, ESQUIRE
Attorney for Plaintiff
9A 73
UN
N
SHERIFF'S RETURN - REGULAR
CASE NO: 2008-06485 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
MILTON S HERSHEY MEDICAL CTRE
VS
CHOI RICHARD ET AL
NOAH CLINE
Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE was served upon
(`P4nT PT(WLPn the
DEFENDANT , at 1123:00 HOURS, on the 17th day of January , 2009
at 3521 LOUISA LANE
MECHANICSBURG, PA 17050
YOUNG MIN CHOI, WIFE
by handing to
a true and attested copy of COMPLAINT & NOTICE together with
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
So Answers:
18.0 0 '
10.80
00
10.00 R. Thomas Kline
.00
38.80 01/20/2009
TABAS & ROSEN
Sworn and Subscibed to
before me this
By: day Deputy Sheriff
of A. D.
crj ..?-
C N
SHERIFF'S RETURN - REGULAR
CASE NO: 2008-06485 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
MILTON S HERSHEY MEDICAL CTRE
VS
CHOI RICHARD ET AL
NOAH CLINE , Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE was served upon
CHOI YOUNG MIN the
DEFENDANT at 1123:00 HOURS, on the 17th day of January. , 2009
at 3521 LOUISA LANE
MECHANICSBURG, PA 17050 by handing to
a true and attested copy of COMPLAINT & NOTICE together with
and at the same time directing Her attention to the contents thereof.
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
Sworn and Subscibed to
before me this
of
So Answers:
6.00
.00
.00
10.00 R. Thomas Kline
.00
16.00 01/20/2009
TABAS & ROSEN
By: ;7/
day Deputy Sheriff
A. D.
T
?
?t
v
C7, }
? N C.?
t?
't?
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER
I.D. No. 60267
1601 Market Street, Suite 2300
Philadelphia, PA 19103
(215)569-5050
Attorney for Plaintiff
MILTON S. HERSHEY MEDICAL CENTER
VS
RICHARD CHOI &
YOUNG MIN CHOI, h/w
TO THE PROTHONOTARY:
10lD F?? ?' -3 PI-11 12: 4- 9
: COURT OF COMMON PLEAS
: CUMBERLAND COUNTY
: No. 08-6485
P R A E C I P E
Please discontinue the above matter as to RICHARD CHOI &
YOUNG MIN CHOI, h/w without prejudice.
LEWIS C. TRAU FER, ESQUIRE
Attorney for Plaintiff