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HomeMy WebLinkAbout04-28-09NOTICE OF CLAIM (Filed Pursuant to 20 Pa.C.S. § 3532) COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF JAMES M HARTY No. 21-08-0878 To the Clerk of the Orphans' Court Division: Enter the claim of CONTINUING CARE Rx DECEASED in the (Claimant) amount of $ 1,083.48 ,against the above entitled Estate. The Decedent, who resided at Bethany Village, 325 Wesley Drive, Mechanicsburg, Pa 17055 (Street Address) died on 07-28-2008 Written notice of (Date of Death) said claim was given to Thomas E. Flower, Esg (Personal Representative or his/her counsel) at 2109 Market St., Camp Hill PA 17011 on Apri123, 2009 (Address) (Date) Continuing Care Rx (Claimant) 5775 Allentown Blvd. Suite 101 Stan Bonner (Claimant's Counrel) (Supreme Court LD. No.) 5775 Allentown Blvd Suite 101 (Address) Harrisburg PA 17112 Toll Free 877-372-2279 Ext 328 (Telephone) (Street Address) Harrisburg Pa 17112 c~ a - , ; (City, State, Zip) ~ -.~ y, ' - - `j c-~ ~ ~, t_, ~ ; -~ !~ , ~ - N T - -,'; --:-t ~ -~ i ~ N ~ '_,~ © ... Form OC-07 rev. 10.13.06 ' CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 ** S T A T E M E N T Statement Date: 3/31/09 Page: 1 Account #: 100044974 BVA JAMES HARTY CAROL HARTY 429 GRUBB STREET MIDDLETOWN, PA 17057 Date Description Qty Amount -------- 7/02/08 ------------ DOC#99173819 ---------------------------- PAYMENT - THANK YOU ---- ---------- 300.00- 11/05/08 DOC#99199252 PAYMENT CAREMARK CK 1,633.37- 2/29/08 DOC#5358104 REBILLED TO OI 1 175.03- 2/29/08 DOC#5371273 REBILLED TO OI 1 935.19- 2/29/08 DOC#5374740 REBILLED TO OI 1 51.37- 3/13/08 RX# 146135 WASHCLOTH TENA ULTRA 48/T 1 9.07 2/29/08 RF 5326756 FLORASTOR 250MG CAP 60 44.00 3/29/08 RF 5326756 FLORASTOR 250MG CAP 60 44.00 3/28/08 DOC#5358104 RX REPLACEMENT 1 175.03 2/29/08 RX# 5358105 FERROUS sulf 325MG/5GR TA 30 1.95 2/29/08 RX# 5358106 DAILY VITE TABLET 30 1.95 3/28/08 DOC#5371273 RX REPLACEMENT 1 935.19 ** continued on next page ** CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 Name: JAMES HARTY CAROL HARTY 429 GRUBB STREET MIDDLETOWN, PA 17057 Statement date: 3/31/09 Account #: 100044974 BVA CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 ** S T A T E M E N T Statement Date: 3/31/09 Page: 2 Account #: 100044974 BVA JAMES HARTY CAROL HARTY 429 GRUBB STREET MIDDLETOWN, PA 17057 Date Description Qty Amount -------- 3/28/08 ------------ DOC#5374740 --------------- RX REPLACEMENT ------------- 1 ---- - --------- 51.37 3/10/08 RX# 5399146 BALMEX CREAM 1602 JAR 1 10.78 3/13/08 RX# 5410657 VANCOCIN 125MG CAP UD 42 702.33 3/28/08 DOC#5432184 RX REPLACEMENT 1 175.03 3/29/08 RX# 5432185 FERROUS sulf 325MG/5GR TA 30 1.95 3/29/08 RX# 5432186 DAILY VITE TABLET 30 1.95 3/28/08 DOC#5456610 RX REPLACEMENT 1 469.47 3/28/08 DOC#5456611 RX REPLACEMENT 1 236.61 3/31/08 RX# 5464746 CHOLESTYRAMINE REG PKTS 30 8.26 COPAY 3/30/08 DOC#5432184 REBILLED TO OI 1 175.03- 3/30/08 DOC#5456611 REBILLED TO OI 1 236.61- 3/30/08 DOC#5464746 REBILLED TO OI 1 51.37- ** continued on next page ** CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 Name: JAMES HARTY CAROL HARTY 429 GRUBB STREET MIDDLETOWN, PA 17057 Statement date: 3/31/09 Account #: 100044974 BVA CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 ** S T A T E M E N T Statement Date: 3/31/09 Page: 3 Account #: 100044974 BVA JAMES HARTY CAROL HARTY 429 GRUBB STREET MIDDLETOWN, PA 17057 Date Description Qty Amount -------- 3/31/08 ------------ DOC#5464746 ---------------------------- RX REPLACEMENT 1 ---- - --------- 51.37 4/08/08 RX# 146583 UNDERWEAR(150001)PULLON S 40 22.52 4/08/08 RX# 146584 WASHCLOTH TENA ULTRA 48/T 2 14.40 4/10/08 RX# 5492826 HYOSCYAMINE SULF DROPS 1 2.30 COPAY 4/17/08 RX# 5515240 HYOSCYAMINE SULF DROPS 1 2.30 COPAY 4/21/08 RX# 5522548 HYOSCYAMINE SULF DROPS 1 2.30 COPAY 4/28/08 RX# 5521390 ARICEPT lOMG TAB 30 50.64 COPAY 4/28/08 RX# 5521391 FERROUS sulf 325MG/5GR TA 30 1.95 4/28/08 RX# 5521392 DAILY VITE TABLET 30 1.95 4/29/08 RX# 146916 UNDERWEAR(150001)PULLON S 60 31.91 4/30/08 RX# 5551206 metroNIDAZOLE 500MG TAB 30 3.00 COPAY 4/30/08 RX# 5551207 RIFAMPIN 300MG CAP 20 5.13 COPAY ** continued on next page ** CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 Name: JAMES HARTY CAROL HARTY 429 GRUBB STREET MIDDLETOWN, PA 17057 Statement date: 3/31/09 Account #: 100044974 BVA CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 ** S T A T E M E N T Statement Date: 3/31/09 Page: 4 Account #: 100044974 BVA JAMES HARTY CAROL HARTY 429 GRUBB STREET MIDDLETOWN, PA 17057 Date Description Qty Amount -------- 4/30/08 ---- RX# -------- 5551209 ---------------------------- CHOLESTYRAMINE REG PKTS ---- -- 30 -------- 8.26 COPAY 4/30/08 RX# 5552418 HYOSCYAMINE SULF DROPS 2 4.14 COPAY 5/01/08 RX# 146965 WASHCLOTH TENA ULTRA 48/T 2 14.40 5/03/08 RX# 5558616 CIPROFLOXACIN 250MG TAB 14 8.09 COPAY 5/09/08 RX# 147110 WASHCLOTH TENA ULTRA 48/T 2 14.40 5/10/08 RX# 5576951 HYOSCYAMINE SULF DROPS 2 4.14 COPAY 5/13/08 RX# 147163 UNDERWEAR(150001)PULLON S 20 13.14 5/13/08 RX# 147164 WASHCLOTH TENA ULTRA 48/T 2 14.40 4/29/08 RX# 146917 WASHCLOTH TENA ULTRA 48/T 2 14.40 5/19/08 RX# 5595951 HYOSCYAMINE SULF DROPS 2 4.14 COPAY 5/20/08 RX# 5600862 PROMETHAZINE 25MG TAB 10 1.07 COPAY 4/28/08 RF 5326756 FLORASTOR 250MG CAP 60 44.00 ** continued on next page ** CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 Name: JAMES HARTY CAROL HARTY 429 GRUBB STREET MIDDLETOWN, PA 17057 Statement date: 3/31/09 Account #: 100044974 BVA - CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 ** S T A T E M E N T Statement Date: 3/31/09 Page: 5 Account #: 100044974 BVA JAMES HARTY CAROL HARTY 429 GRUBB STREET MIDDLETOWN, PA 17057 Date Description Qty Amount -------- -------- 3/29/08 ---- RX# -------- 5432184 ---------------------------- ARICEPT lOMG TAB ---- - 30 - 50.64 COPAY 3/28/08 RX# 5456611 VANCOCIN 125MG CAP UD 14 68.68 COPAY 5/21/08 DOC#5456610 REBILLED TO OI 1 469.47- 5/23/08 RX# 147365 UNDERWEAR(150001)PULLON S 60 31.91 5/28/08 RF 5326756 FLORASTOR 250MG CAP 60 44.00 2/29/08 RX# 5358104 ARICEPT lOMG TAB 30 175.03 5/23/08 RX# 5612163 HYOSCYAMINE SULF DROPS 2 4.14 COPAY 2/28/08 RX# 5371273 VANCOCIN 125MG CAP UD 56 935.19 2/29/08 RX# 5374740 CHOLESTYRAMINE REG PKTS 30 51.37 3/28/08 RX# 5456610 VANCOCIN 125MG CAP UD 28 469.47 5/28/08 RX# 5599859 ARICEPT lOMG TAB 30 50.64 COPAY 5/28/08 RX# 5599860 FERROUS sulf 325MG/5GR TA 30 1.95 ** continued on next page ** CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 Name: JAMES HARTY CAROL HARTY 429 GRUBB STREET MIDDLETOWN, PA 17057 Statement date: 3/31/09 Account #: 100044974 BVA - CONTINUING CARE RX 28 S SECOND ST NEWPORT PA 17074 ** S T A T E M E N T Statement Date: 3/31/09 Page: 6 Account #: 100044974 BVA JAMES HARTY CAROL HARTY 429 GRUBB STREET MIDDLETOWN, PA 17057 Date Description ------ Qty ----- - Amount --------- -------- 5/28/08 --------------------------------- RX# 5599861 DAILY VITE TABLET 30 1.95 5/30/08 RX# 147488 WASHCLOTH TENA ULTRA 48/T 2 14.40 5/30/08 RX# 5628889 CHOLESTYRAMINE REG PKTS 30 8.26 COPAY Ending balance - Pay this amount ---------> 1,083.48 Past Due Past Due Past Due Current 31-60 days 61-90 days 90+ days ----------- ----------- ----------- ----------- .00 .00 .00 1,083.48 QUESTIONS PLEASE CALL 1-800-675-2279 EXT:1304 -------------------------------------------------------------------------------- Please cut here and remit this portion with payment Remit to: CONTINUING CARE RX 5775 ALLENTOWN BLVD SUITE 101 HARRISBURG, PA 17112 Name: JAMES HARTY CAROL HARTY 429 GRUBB STREET MIDDLETOWN, PA 17057 Statement date: 3/31/09 Account #: 100044974 BVA Ending balance: 1,083.48 Amount enclosed: