HomeMy WebLinkAbout10-3306DIALYSIS CORPORATION OF AMERICA
d1b/a DCA OF ROYSTON,
Plaintiff
v.
WANDA CHRISTIAN,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
Docket No.:
Civil Action
COMPLAINT
NOW COMES, Dialysis Corporation of America d/b/a L
its attorney, Capozzi & Associates, P.C., and makes the following Complaint for a money
judgment against Defendant, and in support thereof, respectfully avers as follows:
1. Plaintiff, Dialysis Corporation of America d/b/a DCA of Royston ("DCA of
Royston"), is a registered Pennsylvania corporation having its principal place of business at 27
Miller Avenue, Lemoyne, Cumberland County, Pennsylvania 17043.
2. DCA of Royston is an operating subsidiary of Dialysis Corporation of America
("DCA").
3. Defendant Wanda Christian ("Patient" or "Defendant") is an adult individual with
a last known address at 88 Dairy Lane, Bowersville, Georgia 30516.
4. DCA of Royston provides dialysis treatments and services to its patients.
On or about February 3, 2007, Defendant executed a Consent for Hemodialysis
Agreement ("Consent Agreement") to allow Defendant to receive regular dialysis treatments
from DCA of Royston as scheduled by her physician and DCA of Royston. A true and correct
copy of the Consent Agreement is attached hereto and incorporated herein as Exhibit "A."
~Qol.OO P•P A't'r`f
elC~' a t'T~ 9
~~ a~ aaQB
6. On or about February 3, 2007, Defendant executed a Patient Assignment and
Authorization of Payment of Insurance Benefits Agreement ("Assignment and Authorization
Agreement"), which required the Defendant to assign and forward insurance benefits that she
received for the dialysis treatments from DCA of Royston. A true and correct copy of the
Assignment and Authorization Agreement is attached hereto and incorporated herein as Exhibit
«B „
7. Paragraph 1 of the Assignment and Authorization Agreement provides that
Defendant "hereby assigns, transfers and sets over to DCA of Royston monies and/or benefits to
which the Patient is (or maybe) entitled from any insurance ...provider ...as well as any others
who maybe financially liable for the Patient's dialysis treatments and services and related
medical care by and/or at DCA of Royston, including health insurance benefits ...for which the
Patient is entitled, to cover the costs of dialysis treatment and services ...."
8. Paragraph 2 of the Assignment and Authorization Agreement provides that
Defendant "hereby authorizes and directs that payment of all insurance benefits...relating to any
charges and costs incurred as a result of dialysis treatments and related services and medical care
provided to the Patient by and/or at DCA of Royston, be paid and remitted directly to DCA of
Royston...."
9. Paragraph 3 of the Assignment and Authorization Agreement provides that
Defendant "hereby acknowledges that the monies or benefits to be paid by the Patient's
insurance provider ...for the charges, costs and fees incurred by DCA of :Royston in its
provision of dialysis treatments and related services and medical care to the Patient is and shall at
all times remain, the property of DCA of Royston...."
2
10. Paragraph 3 of the Assignment and Authorization Agreement further provides that
Defendant "hereby covenants and agrees that in the event that any payment of insurance benefits
... is sent to the Patient...that the [Defendant] will promptly and unconditionally forward such
payment directly to DCA of Royston." [emphasis added]
11. Paragraph 5 of the Assignment and Authorization Agreement further provides that
Defendant "hereby acknowledges that, not withstanding the foregoing assignment and
authorization of benefit payments to DCA of Royston, the Patient shall be responsible for any
and all charges and costs billed by DCA of Royston for dialysis treatments and related services .
..and that DCA of Royston is authorized to bill the Patient directly for payment of such charges
and costs."
12. DCA of Royston, at the special insistence and request of Defendant during the
period February 3, 2007 through January 31, 2008 ("Dates of Service"), provided numerous
separate dialysis treatments ("Dialysis") at the rates and on the dates set forth in DCA of
Royston's business records ("Account Statement"). A true and correct copy of the Account
Statement is attached hereto and incorporated herein as Exhibit "C."
13. To date, Defendant has failed and refused to pay as required pursuant to the
Assignment and Authorization Agreement and the Account Statement in the amount of
$241,393.88
14. On October 29, 2009 and December 3, 2009, DCA of Royston's counsel mailed
to Defendant demand letters, which provided information on how to pay the debt owed to DCA
of Royston. A true and correct copy of the demand letter is attached hereto and incorporated
herein as Exhibit "D."
3
COUNT I -BREACH OF CONTRACT
15. Paragraphs 1 through 14 are incorporated herein by reference.
16. The rates and total charges set forth in the Account Statement are just and
reasonable and are the rates that Defendant agreed to pay for the Dialysis.
17. The total amount of principal that has become due and owing by Defendant to
DCA of Royston is $241,393.88.
18. To date, Defendant has failed and refused to pay the total amount due as provided
under the Account Statement and the Assignment and Authorization Agreement.
19. DCA of Royston has been financially damaged in the amount of $241,393.88,
plus interest and costs of collection.
20. Defendant's failure to cure her default with DCA of Royston pursuant to the
Assignment and Authorization Agreement constitute a breach of contract.
WHEREFORE, Plaintiff, Dialysis Corporation of America d/b/a DCA of Royston,
demands judgment against Defendant in the sum of $241,393.88, plus interest at the legal rate of
6% per annum from the date of the judgment.
COUNT II -QUANTUM MERUIT -UNJUST ENRICHMENT
If this Honorable Court should find that an express contract did not exist between DCA
of Royston and Defendant, which is denied, then, in that event, DCA of Royston pleads the
following alternative cause of action in quantum meruit against the Defendant.
21. Plaintiff incorporates paragraphs 1 through 20 of this Complaint as if set forth at
length herein.
4
22. Having requested DCA of Royston to provide the dialysis treatments and DCA of
Royston having done so to the benefit of Defendant, Defendant became liable to DCA of
Royston for the just and reasonable charges for the Dialysis.
23. The Defendant has been unjustly enriched by accepting the Dialysis.
24. The rates reflected in the Account Statement as Exhibit C are the just and
reasonable rates for dialysis treatments and services.
25. The total value by which Defendant has become enriched on account of the
Dialysis is $241,393.88, as is more specifically reflected in the Account Statement.
26. DCA of Royston has demanded Defendant pay this amount, but Defendant has
failed to do so.
27. To date, the Defendant has not paid the total amount due.
WHEREFORE, Plaintiff, Dialysis Corporation of America d/b/a DCA of Royston,
demands judgment against Defendant in the sum of $241,393.88, plus interest at the legal rate of
6% per annum from the date of judgment.
Respectfully submitted,
Capozzi & Associates, P.C.
Dated: ~1`+llJ
By. /~~
Michael M. Jerominski, Esquire
Attorney I.D. No. 92977
2933 N. Front Street
Harrisburg, PA 17110
(717)233-4101
Attorneys for Plaintiff
5
82/84/2007 12.:38 7062d56d50 ~~ 22
.. .
' DIALYS~#S C+U1~'QRA'I'~ON bF .4M,1~~CA
.~. ~ T~CA C1F ~tOYSE'FON ~ ~ '.
~,~.~NT FOR HEl • D s LK~9I$
I, t~.+e,~tt~eZSig~ned t or gt~erdi•tn of tbt above pstic~t who is ~ttcler . •.
• l8 years~of sge~or/ o~erwise aicsp,•~ble of con9etrtiAg; _ ~ .
hZrtb~+ rcqutst sad a~ortu Dr. ~1 ~ t-1`fl ~-"- and whcmnevet~~e or she may .
desig~tabrs as bis ar her asso~ate ar assistemt to a~i5tea` tc° me {ar te> tiic a~bovt a,argied
pasietrt~ tht 1~rbccduM lmown as hemudialysis„ undar such c ~nd~tians ag shad be did,.
~ ~~+~~ (s) in ace. x awe to abide by the p ~liCie~s, rules, and.regi~lat3,oe~
e3ta~itshed by the above aamtd piaiysis t3tit in carrs-iag rn x its hemo~lisiysis pragt~..
. It bsis beet2 t^splait~ed to me that l~emodia3ysis is a praceduin usod.iafihe east ofpstie~ with
impaumart of fa3luatz of kidaey #inattia~'by which certain c• xno~ans of the blood are
steed by ~ ~ pe~teable st~t~ee whic~.Pemaits the ~asshge of crartaia maiecule3 aad '
lsind~ets that crf others when. the 'blood is airc'~tlated through Fn artifrcia•1 icitlru~y, called a.
dialyxear. I tuo~derd t .th$rs arei diffeoeut pees of eq~riF aunt emplvycd .for the .dialysis . , .
tr+eatm~t sst+d diced ty~ of ar~icial lddaeys (diatYtcrs. use in the ~roccss.. .
I eciraaowTt~ge tl~ the passs'ble risks an8 oamplic~atioaa of 1-e~taciialpsis 'such a~ bui not
.. - Iimit+ed to~ leaicag,~e of the tUsly2~; c~aegas itt blood pressmr~c .ate mali~cti~ ofegwi~ment
• a beep e~piaiued to a;e by the ~+gfassiauat persamset of 3~-Dialysis Utdt• ~d•I aooept, on
of myself eacVor the above patient ttLC ~ tt~ ~ with: ali Potential ~sk~ sad .
r ~S..~al1•.__. i _Y__ _.__. y _ . _ • .. _ _ _ _ _ .
tre~rment sx~d on .myself durtag the tame that # am receiving a dxalyarrisr trr~trnent but tharE this
ii~t d~.taot mean thatalre dialysis sat had ariytiting t ~ da with the daveiopm~t of the
problem zrla~+tl to this ~. 1 fiudiar amsnut to true act~isttatioa of~ilxh drugs
lotsst.of blood or Mood: comPor~eats, oa' arq' otb~er`tra ~ment ~d tes~;g, iucluu3ing HIV
trestitag, .deemed necessary or deszr~,ble~in-the juri~amt o#~~ php-sician (s)• ire atda~sce. ~ ' .
I am awsoce that tl~•ps~ce of madicine is nat ~`araat sce~ ice; and I aclao~awl«ige ~ ma ~ .
~~~ wary ofripa~eseutatian whatsoever bas bees c•ffora~d oor made m me ox atiy~c
as may bt~a1#rcaicaait~g tha rtsults ~#~ hemv~lialysis ~:. ~ ..
sure: ~/~..,,- _~r~,~ rn ~ ~ ~ - ~ ~ .
Leg,,, oo~~ or p.ra,t '
l~,crran~c:..~ ~~rt__. sue: ~-.~, ~..:,__ ~'~ ~ :~
. __._._
'~-•'' ncr-~ataa9
boa ior+oa
EXHIBIT
01164/207 11:39 79t;~4554~8
" AU~.YS~ CO~`OKA'Y'ION 01~.#'~iCA ~'~~ "~~~ ~~ ~ ~ ,
~'~'~'~'~ ~4G1~I~iT A.~'~tD•Al iT~iORiZ~1,1"~f~t - ~ ~~~• ,
'~ hereby ttaoa~ sett avor ~ DMA a!' aaaocdes aQaot~//or bib to
wLtt~r i~r P.a~iettt b iocamtglr ba) Sd i{+oAo< tttt y imsaoaaee ttt~ltx hatit$l ar+c Qtcrvi~x titr ~oma~, sltrlt;
cucmty at loril ~avr~ttma~am~ a>~Y: inolod{ad:9ye Medic iar aant+o~ pno~rnn, >ws roedl:s asryr o8uets ;
• .~btio amtd- be ~aro+etatbr I~bte ~ flue pidlcoR'>1 dittos tre+dnaaab s~ ~ zelato~! taoa~iraa! ~
bg a~'~ at EGA oy Rdystcre, l~ncaoca bmd'+ts, QoE • ~ afbbr
ttia> aoraaa~s or a~x pn~ a foot+ovllo~t l~e7'~a6deot'b e~lidicct, a og„er8~e coats of
aQOrd aea'vit:~ ood ~ QaoctGc~ seie taieadei:d to tiuc Paeimd by aaatd~or at DCA of
Z. AtlXBtDR~1•A'~t7iiy'•OF PAXMi~N'T t~$ IN$QR~i1~GT ~AIB~TxS • . ~ ,
T$a timtid'~by srt~Oates aged ~d6+xtt ~ ofa~ i:ramraaaa 8 ,•
•beztafm. if appl'uabTa„ reto~ m ttaary sad~aosts ~ac>Dted• ~s• x of d aootd'
_ :+ettmt:d sav~cei~ etd meelieal +cs:c pacrri3ed• b tbe' Aatioaudt' iQy snd ax' at DMA ttf ~ be ~.
9 to '., of IEoJseou ~ aooasdwanoe wkf- i~a~~rre p~cividetl ~ ~ 1x yevvlded by atn ~'
. Ifdlt tamt3od's paS~* aa' pengtse~ d~oa ~i- ram ~~` f
in 1!k ttsnts of ` • ~`
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s nsnme aad to' de~v+ot: said= to DCA af' ltoyicos-•st its sus; sst°'t #a ffie ~ .
pavvided or m be prarid~ad 1~y ~ o+r tepa+es~vie of~iCA ut'8,a~6oa. .. .
3. ~ Ill~~ttY' OR~~'FA7~JI~~TS ~' EU l~itt~ PT~E~ ~ : .
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rrr7ea~sdtti0trallt.forwsrd ~ pagtment dirrseaw~to:bC.A ofR~erystoe. • ',
EXHIBIT
PAS L6
•` `
• ~ PAGE 11
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- ~ ar pidd bg sorAps~tty P+~Ya' ~~ ~"1~ i~gi~6o;~, •wSlfaOnt Nlosi~ion d! ~ba~1o, oaw • ,
aad r~parymecrr aaro~rtmhr„ snd tbet DCA o~'Roysbaa is ao d6ori~od +po bgi ~hc Pte' di[eddy ~t
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bF PAY~T CfF' 1NSU~lit'~ • B~ ~-• mot be • >ss~ :~ t 'it
- ~~' ~ oorr~t t+o s~ rievooo tsy'DC}L o#7tcrystaa - ~ ,
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- A~'i20N OF PAY't~F ~iStl~t{~.8T1 S.a~][ be ce4u`dsscd are va~'rd as ffi
. ~ P ,t~r+ad' aratl•mo~y • ba ased is glaoo o~ ~ ~.~ei1 ~ :fit •t+~ aac$ sd imemos ~ .
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t6a'timi sa~~oamo~e ffi:" oabebar D =
. -
. c~1tZIP'~ATIO~T' OF G'~'A1tri~A1~tAT~0~R3~Y~N-~FAC~' ~ .
The i~aed' oeatif3as' $id belie is t~ d~ a4 ~adi+ra, at~atna9-~-~ sadlar ~ .
sae of tie ~tEaarex~'patoiartt. aad ~ bdshe 1bq~ ~irll - a7 eeaoorrta tfidu fatm va ~ . .
• - ofat~.~iaot. ,
S~a#are: ~ Wimaass:„ ~ ~ .
;-` • Pa~e2 aft ~ ~ ~ .
,Make check payable to:
DIALYSIS CORPORATION OF AMERICA
214 SENATE AVENUE
SUITE 300
CAMP HILL, PA 17011
(866) 390-0376
OFFICE HOURS 8 A.M.-5 P.M.
Statement Date: 09/15/08
Service Period: 02/03/07 to 02/27/07
ACCT:178R
Name: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
ACCT: 178R
Name: CHRISTIAN, WANDA
DCA-ROYSTON
FOR OUT-OF-NETWORK SERVICES, DCA MAY NOT CHARGE
PATIENTS THE FULL AMOUNT OF THE INVOICE.
TO PAY BY CREDIT CARD PLEASE
SEE THE BACK OF THIS STATEMENT
Balance Due: ; 526,808.2 MEMO:'
STATEMENT#1
( Send above portion with your payment )
-------------------------------------------------------------
( Please retain this portion for your records )
Service Service
Claim# Rendered By Date Description
111957 ROYSTON 02!03107-02/27/07 HEMODIALYSIS TREATMENT
TOTAL:
September August July June Before June
$0.00 $0.00 $0.00 $0.00 $26,808.28
--------------------------------------------
Statement Date: 09/15/08
Service Period: 02/03/07 to 02/27/07
Balance
Charges Payments Adjustments Due
$26,808.28 $0.00 $0.00 $26,808.28
$26,808.28 $0.00 $0.00 E26,808.2
Please pay this amount
Total
$26,808.28
EXHIBIT
C
. -Make check payable to:
DIALYSIS CORPORATION OF AMERICA
214 SENATE AVENUE
SUITE 300
CAMP HILL, PA 17011
(866) 390-0376
OFFICE HOURS 8 A.M.-5 P.M.
Statement Date: 09!15108
Service Period: 03/01 /07 to 03/31/07
ACCT: 178R
Name: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
ACCT:178R
Name: CHRISTIAN, WANDA
DCA-ROYSTON
FOR OUT-OF-NETWORK SERVICES, DCA MAY NOT CHARGE
PATIENTS THE FULL AMOUNT OF THE INVOICE.
TO PAY BY CREDIT CARD PLEASE
SEE THE BACK OF THIS STATEMENT
Balance Due: ;42,864_._0 MEMO:
STATEMENT#1
( Send above portion with your payment )
( Please retain this portion for your records )
Service Service
Claim# Rendered By Date Description
111958 ROYSTON 03/01/07-03/31/07 HEMODIALYSIS TREATMENT
TOTAL:
September August July June Before June
$0.00 $0.00 $0.00 $0.00 $42,864.04
Statement Date: 09/15/08
Service Period: 03/01!07 to 03/31/07
Balance
Charges Payments Adjustments Due
$42,864.04 $0.00 $0.00 $42,864.04
$42,864.04 $0.00 $0.00 542,664.04
Please pay this amount 1
Total
S42,864.04
Make check payable to:
DIALYSIS CORPORATION OF AMERICA
214 SENATE AVENUE
SUITE 300
CAMP HILL, PA 17011
(866) 390-0376
OFFICE HOURS 8 A.M.-5 P.M.
Statement Date: 09!15108
Service Period: 04/03/07 to 04/28/07
ACCT: 178R
Name: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
ACCT: 178R
Name: CHRISTIAN, WANDA
DCA-ROYSTON
FOR OUT-OF-NETWORK SERVICES, DCA MAY NOT CHARGE
PATIENTS THE FULL AMOUNT OF THE INVOICE.
TO PAY BY CREDIT CARD PLEASE
SEE THE BACK OF THIS STATEMENT
Balance Due:: $37,387.2 MEMO:',I -~
STATEMENT#1
i
I
( Send above portion with your payment )
(Please retain this portion for your records )
Service Service
Claim# Rendered By Date Description
111959 ROYSTON 04/03/07-04!28/07 HEMODIALYSIS TREATMENT
TOTAL
September August July June
$0.00 $0.00 $0.00 $0.00
Before June
$37,387.22
Statement Date: 09/15/08
Service Period: 04/03/07 to 04/28/07
Balance
Charges Payments Adjustments Due
$37,387.22 $0.00 $0.00 $37,387.22
$37,387.22 $0.00 $0.00 ~_ $37,3.8.7_._2__
Please pay this amount
Total
$37,387.22
Make check payable to
DIALYSIS CORPORATION OF AMERICA
214 SENATE AVENUE
SUITE 300
CAMP HILL, PA 17011
(866) 390-0376
OFFICE HOURS 8 A.M.-5 P.M.
Statement Date: 09!15/08
Service Period: 05/03/07 to 05!29/07
ACCT: 178R
Name: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
ACCT: 178R
Name: CHRISTIAN, WANDA
DCA-ROYSTON
FOR OUT-OF-NETWORK SERVICES, DCA MAY NOT CHARGE
PATIENTS THE FULL AMOUNT OF THE INVOICE.
TO PAY BY CREDIT CARD PLEASE
SEE THE BACK OF THIS STATEMENT
Balance Due: 516,181.7 MEMO:
(STATEMENT#1
( Send above portion with your payment )
---------------------------------------------- --------------
{ Please retain this portion for your records )
Service Service
Claim# Rendered By Date Description
111960 ROYSTON 05!03!07-05/29/07 HEMODIALYSIS TREATMENT
TOTAL:
September August July June Before June
$0.00 $0.00 $0.00 $0.00 $16,181.74
Statement Date: 09/15/08
Service Period: 05/03/07 to 05/29/07
Balance
Charges Payments Adjustments Due
$16,181.74 $0.00 $0.00 $16,181.74
$16,181.74 $0.00 $0.00 616,181.7
Please pay this amount
Total
$16,181.74
Make check payable to
DIALYSIS CORPORATION OF AMERICA
214 SENATE AVENUE
SUITE 300
CAMP HILL, PA 17011
{866)390-0376
OFFICE HOURS 8 A.M.-5 P.M.
Statement Date: 09/15/08
Service Period: O6/02/07 to 06/28/07
ACCT: 178R
Name: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
---------------------------------------------------
ACCT: 178R
Name: CHRISTIAN, WANDA
DCA-ROYSTON
FOR OUT-OF-NETWORK SERVICES, DCA MAY NOT CHARGE
PATIENTS THE FULL AMOUNT OF THE INVOICE.
TO PAY BY CREDIT CARD PLEASE
SEE THE BACK OF THIS STATEMENT
Balance Due: $10,625.9_; MEMO:
STATEMENT#1
( Send above portion with your payment )
----------------------------------------------------------------
( Please retain this portion for your records )
Service Service
Claim# Rendered By Date Description
111961 ROYSTON 06/02/07-06/28/07 HEMODIALYSIS TREATMENT
TOTAL:
September August _ _ __July
$0.00 $0.00 $0.00
June Before June
$0.00 $10,625.90
--------------------------------------------------
Statement Date: 09/15/08
Service Period: 06/02/07 to 06/28/07
Balance
Charges Payments Adjustments Due
$10,625.90 $0.00 $0.00 $10,625.90
$10,625.90 $0.00 $0.00 $10,625.90
Please pay this amount
_ ___ Total
$10,625.90
Make check payable to
DIALYSIS CORPORATION OF AMERICA
214 SENATE AVENUE
SUITE 300
CAMP HILL, PA 17011
(866) 390-037fi
OFFICE HOURS 8 A.M.-5 P.M.
Statement Date: 09/15/08
Service Period: 07/03/07 to 07/24/07
ACCT: 178R
Name: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
ACCT: 178R
Name: CHRISTIAN, WANDA
Statement Date: 09/15/08
Service Period: 07/03/07 to 07/24/07
Service Service Balance
Claim# Rendered By Date Description Charges Payments Adjustments Due
111962 ROYSTON 07/03/07-07/24/07 HEMODIALYSISTREATMENT $8,124.46 $0.00 $0.00 $8,124.46
TOTAL: $8,124.46 $0.00 $0.00 I 28124.46
Please pay this amount
September August July June Before June
$0.00 $0.00 $0.00 $0.00 $8,124.46
DCA-ROYSTON
FOR OUT-OF-NETWORK SERVICES, DCA MAY NOT CHARGE
PATIENTS THE FULL AMOUNT OF THE INVOICE.
TO PAY BY CREDIT CARD PLEASE
SEE THE BACK OF THIS STATEMENT
Balance Due: E 218 4 4& MEMO:
( Send above portion with your payment )
------------------------------------------------------------------
( Please retain this portion for your records )
;8,124.46
Total
Make check payable to:
DIALYSIS CORPORATION OF AMERICA
214 SENATE AVENUE
SUITE 300
CAMP HILL, PA 17011
(866) 390-0376
OFFICE HOURS 8 A.M.-5 P.M.
Statement Date: 09/15/08
Service Period: 08/02/07 to 08!25/07
ACCT: 178R
Name: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
-----------------------------------------------------
ACCT: 178R
Name: CHRISTIAN, WANDA
DCA-ROYSTON
FOR OUT-OF-NETWORK SERVICES, DCA MAY NOT CHARGE
PATIENTS THE FULL AMOUNT OF THE INVOICE.
TO PAY BY CREDIT CARD PLEASE
SEE THE BACK OF THIS STATEMENT
Balance Due: ~ x4,605.9 MEMO:I
STATEMENT#1
( Send above portion with your payment )
( Please retain this portion for your records )
Service Service
Claim# Rendered By Date Description
111963 ROYSTON 08/02107-08/25/07 HEMODIALYSIS TREATMENT
TOTAL:
September August July June
$0.00 $0.00 $0.00 $0.00
Before June
------------------------------------------------------------
Statement Date: 09/15/08
Service Period: 08/02/07 to 08/25/07
Balance
Charges Payments Adjustments Due
$4,605.96 $0.00 $0.00 $4,605.96
$4,605.96 $0.00 $0.00 x4,605.96'.
Please pay this amount
$4,605.96 x4,605.96
Make check payable to:
DIALYSIS CORPORATION OF AMERICA
214 SENATE AVENUE
SUITE 300
CAMP HILL, PA 17011
(866) 390-0376
OFFICE HOURS 8 A.M.-5 P.M.
Statement Date: 09/15/08
Service Period: 09/01/07 to 09/20/07
ACCT: 176R
Name: CHRISTIAN, WANDA
86 DAIRY LANE
BOWERSVILLE, GA 30516
ACCT: 178R
Name: CHRISTIAN, WANDA
DCA-ROYSTON
FOR OUT-OF-NETWORK SERVICES, DCA MAY NOT CHARGE
PATIENTS THE FULL AMOUNT OF THE INVOICE.
TO PAY BY CREDIT CARD PLEASE
SEE THE BACK OF THIS STATEMENT
Balance Due: ,_ .__.$4,482_.3_ MEMO:
.STATEMENT#1
( Send above portion with your payment )
( Please retain this portion for your records )
Service Service
Claim# Rendered By Date Description
111964 ROYSTON 09/01/07-09/20/07 HEMODIALYSIS TREATMENT
TOTAL:
September _ .August July June
$0.00 $0.00 $0.00 $0.00
Before June
$4,482.32 $4,482.32
Statement Date: 09/15/08
Service Period: 09/01/07 to 09/20/07
Balance
Charges Payments Adjustments Due
$4,482.32 $0.00 $0.00 $4,482.32
$4,482.32 $0.00 $0.00 $4,482.3
Please pay this amount
Make check payable to:
DIALYSIS CORPORATION OF AMERICA
214 SENATE AVENUE
SUITE 300
CAMP HILL, PA 17011
(866) 390-0376
OFFICE HOURS 8 A.M.-5 P.M.
Statement Date: 09/15/08
Service Period: 10/02/07 to 10/30/07
ACCT: 178R
Name: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
ACCT:178R
Name: CHRISTIAN, WANDA
DCA-ROYSTON
FOR OUT-OF-NETWORK SERVICES, DCA MAY NOT CHARGE
PATIENTS THE FULL AMOUNT OF THE INVOICE.
TO PAY BY CREDIT CARD PLEASE
SEE THE BACK OF THIS STATEMENT
Balance Due: 515,078. MEMO:
( Send above portion with your payment )
( Please retain this portion for your records )
Service Service
Claim# Rendered By Date Description
111965 ROYSTON 10/02/07-10/30/07 HEMODIALYSIS TREATMENT
TOTAL:
September August July
$0.00 $0.00 $0.00
June Before June
$0.00 $15,078.44 $15,078.44
--------------------------------------------------------------
Statement Date: 09/15/08
Service Period: 10/02/07 to 10/30/07
Balance
Charges Payments Adjustments Due
$15,078.44 $0.00 $0.00 $15,078.44
$15,078.44 $0.00 $0.00 ~ $15,0_78.
Please pay this amount
Make check payable to:
DIALYSIS CORPORATION OF AMERICA
214 SENATE AVENUE
SUITE 300
CAMP HILL, PA 17011
(866}390-0376
OFFICE HOURS 8 A.M.-5 P.M.
Statement Date: 09/15/08
Service Period: 11/01!07 to 11/29/07
ACCT: 178R
Name: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
ACCT: 178R
Name: CHRISTIAN, WANDA
DCA-ROYSTON
FOR OUT-OF-NETWORK SERVICES, DCA MAY NOT CHARGE
PATIENTS THE FULL AMOUNT OF THE INVOICE.
TO PAY BY CREDIT CARD PLEASE
SEE THE BACK OF THIS STATEMENT
Balance Due: x17,658.00' MEMO:
STATEMENT#1
( Send above portion with your payment )
-------------------------------------------------------------------
( Please retain this portion for your records }
Service Service
Claim# Rendered By Date Description
111966 ROYSTON 11/01/07-11/29/07 HEMODIALYSIS TREATMENT
TOTAL:
September August _ July June Before June
$0.00 $0.00 $0.00 $0.00 $17,658.00
Statement Date: 09/15/08
Service Period: 11/01/07 to 11!29/07
Balance
Charges Payments Adjustments Due
$17,658.00 $0.00 $0.00 $17,658.00
$17,658.00 $0.00 $0.00 $17,658.0
Please pay this amount
•Make check payable to:
DIALYSIS CORPORATION OF AMERICA
214 SENATE AVENUE
SUITE 300
CAMP HILL, PA 17011
(866) 390-0376
OFFICE HOURS 8 A.M.-5 P.M.
Statement Date: 09115/08
Service Period: 12/04/07 to 12/31/07
ACCT: 178R
Name: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
ACCT: 178R
Name: CHRISTIAN, WANDA
DCA-ROYSTON
FOR OUT-OF-NETWORK SERVICES, DCA MAY NOT CHARGE
PATIENTS THE FULL AMOUNT OF THE INVOICE.
TO PAY BY CREDIT CARD PLEASE
SEE THE BACK OF THIS STATEMENT
Balance Due: 517,709.7 , MEMO:
STATEMENT#1
( Send above portion with your payment )
------------------------------------------------------------
( Please retain this portion for your records )
S@NICR $eNICe
Claim# Rendered By Date Description
111967 ROYSTON 12/04107-12/31/07 HEMODIALYSIS TREATMENT
TOTAL:
September August July June Before June
$0.00 $0.00 $0.00 $0.00 $17,709.70
----------------------------------------------------------------
Statement Date: 09/15/08
Service Period: 12/04/07 to 12/31/07
Balance
Charges Payments Adjustments Due
$17,709.70 $0.00 $0.00 $17,709.70
$17,709.70 $0.00 $0.00 !r 517,709.70
Please pay this amount ~ J
Total
517,709.70
Make check payable to
DIALYSIS CORPORATION OF AMERICA
214 SENATE AVENUE
SUITE 300
CAMP HILL, PA 17011
(866)390-0376
OFFICE HOURS B A.M.-5 P.M.
Statement Date: 11/24/08
Service Period: 02/03/07 to 12/31/07
ACCT: 178R
Name: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
ACCT: 178R
Name: CHRISTIAN, WANDA
DCA-ROYSTON
FOR OUT-OF-NETWORK SERVICES, DCA MAY NOT CHARGE
PATIENTS THE FULL AMOUNT GF THE INVOICE.
TO PAY BY CREDIT CARD PLEASE
SEE THE BACK OF THIS STATEMENT
Balance Due: $201,526_,0_6 MEMO:
Statement #2
( Send above portion with your payment )
(Please retain this portion for your records )
Statement Date: 11/24/08
Service Period: 02/03/07 to 12!31/07
Service Service Balance
Claim# Rendered By Date Description Charges Payments Adj ustments Due
111957 ROYSTON 02/03/07-02/27/07 HEMODIALYSIS TREATMENT $26,808.28 $0.00 $0.00 $26,808.28
111958 ROYSTON 03/01/07-03/31/07 HEMODIALYSIS TREATMENT $42,864.04 $0.00 $0.00 $42,864.04
111959 ROYSTON 04/03/07-04/28/07 HEMODIALYSIS TREATMENT $37,387.22 $0.00 $0.00 $37,387.22
111960 ROYSTON 05!03/07-05/29/07 HEMODIALYSIS TREATMENT $16,181.74 $0.00 $0.00 $16,181.74
111961 ROYSTON 06/02/07-06/28/07 HEMODIALYSIS TREATMENT $10,625.90 $0.00 $0.00 $10,625.9C
111962 ROYSTON 07/03/07-07/24/07 HEMODIALYSIS TREATMENT $8,124.46 $0.00 $0.00 $8,124.46
111963 ROYSTON 08/02/07-08!25/07 HEMODIALYSIS TREATMENT $4,605.96 $0.00 $0.00 $4,605,96
111964 ROYSTON 09/01/07-09/20/07 HEMODIALYSIS TREATMENT $4,482.32 $0.00 $0.00 $4,482.32
111965 ROYSTON 10/02/07-10/30/07 HEMODIALYSIS TREATMENT $15,078.44 $0.00 $0.00 $15,078.44 -
111966 ROYSTON 11!01/07-11/29/07 HEMODIALYSIS TREATMENT $17,658.00 $0.00 $0.00 $17,658.00
111967 ROYSTON 12/04/07-12/31/07 HEMODIALYSIS TREATMENT $17,709.70 $0.00 $0.00 $17,709.70
TOTAL: $201,526.06
$0.00
$0.00 __._
$201,526_._06
Please pay this amount _I
November October September _____ August Before August Total
$0.00 $0.00 $0.00 $0.00 $201,526.06 $201,526.06
Itemized UB04 Statement
User AHEIKES
Date: 4/24/09
Page 1 of 4
Facility: DCA-ROYSTON
611 COOK STREET
ROYSTON, GA 306623933
(706) 245-0817
Provider Number:
Insurer: PATIENT BALANCE
Group Number:
Policy Number254274026T
Clafm if
Description of Service
te
t 2nd
ICD9 ICD9
PC
v. NDC
Code Number
antity
lling
Charges
Patierrt: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
103784-1 01 /05/06-01!31/08
ADMIN SUPPLIES 01/05/08 A4657 270 1 13.85
01/05/08 A4657 270 1 13.85
01/12/08 A4657 270 1 13.85
01 /12/08 A4657 270 1 13.85
01/19/08 A4657 270 1 13.85
01/19/08 A4657 270 1 13.85
01/26/08 A4657 270 1 13.85
01 /26/08 A4657 270 1 13.85
01 /31 /08 A4657 270 1 13.85
01/31/08 A4657 270 1 13.85
Treatment Item Subtotal: 10 $138.50
EPOETIN>10000/100 UNITS 100 UT 01/05/08 285.21 04081 635 321 802.33
2
IV ,
01/12/08 285.21 04081 635 321 2,802.33
01/19/08 285.21 04081 635 321 2,802.33
01/26/08 285.21 04081 635 277 2,418.21
01/31/08 285.21 04081 635 277 2,418.21
Treatment Item Subtotal: 1,517 $13,243.41
HEMODIALYSIS TREATMENT 01/05/08 585.6 90935 821 1 1,048.00
01/12/08 585.6 90935 821 1 1,048.00
01!19/08 585.6 90935 821 1 1,048.00
01/26/08 585.6 90935 821 1 1,048.00
01 /31 /08 585.6 90935 821 1 1,048.00
Treatment Item Subtotal: 5 $5,240.00
NEEDLE AND SYRINGE 01/05/08 A4657 270 1 0.50
01/12/08 A4657 270 1 0.50
01 /19/08 A4657 270 1 0.50
OMS Focus Release: 6.7.05
Itemized UB04 Statement
User AHEIKES
Date: 4/24/09
Page 2 of 4
Facility: OCA-ROYSTO N
611 COOK STREET
ROYSTON, GA 306623933
(706) 245-0817
Provider Number:
Insurer: PATIENT BALANCE
Group Number:
Policy Number254274026T
Claim #
Description of Service
Patient: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
103784-1 01/05/08-01/31/08
NEEDLE AND SYRINGE
ZEMPLAR 1 MCG IV
1st 2nd Rev.
Date ICD9 ICD9 HCPC Code
01 !26/08
01 /31 /08
01!05/08 588.81
01 /12/08 588.81
01 /19/08 588.81
01/26/08 588.81
01 /31 /08 588.81
A4657
A4657
J2501
J2501
J2501
J2501
J2501
NDC
Number Quantity
270 1
270 1
Treatment Item Subtotal: 5
636 iC
636 14
636 10
636 10
636 10
Treatment Item Subtotal: 54
$1,309.50
Claim Subtotal: 1,591
519,933.91
Bii[ing
Charges
0.50
0.50
$2.50
242.50
339.50
242.50
242.50
242.50
QMS Focus Release: 6.7.05
Itemized UB04 Statement
User AHEIKES
Date: 4/24/09
Page 3 of 4
Facility: DCA-ROYSTON
611 COOK STREET
ROYSTON, GA 306623933
(706) 245-0817
Provider Number:
Insurer: MEDICARE PARTA
Group Number:
Policy Number254274026T
Claim #
Description of Service
te
t 2nd
ICD9 ICD9
PC
v. NDC
Code Number
antity
lling
Charges
Patient: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
111968-1 01 /05/08-01/31 /08
ADMIN SUPPLIES 01!05/08 A4657 270 1 13.85
01/05/08 A4657 270 1 13.85
D1/12/08 A4657 270 1 13.85
01/12/08 A4657 270 1 13.85
01!19/08 A4657 270 1 13.85
01/19/08 A4657 270 1 13.85
01/26/08 A4657 270 1 13.85
01/26/08 A4657 270 1 13.85
01!31/08 A4657 270 1 13.85
01 /31/08 A4657 270 1 13.85
Treatment item Subtotal: 10 $138.50
EPOETIN>10000/100 UNITS 100 UT 01/05/08 285.21 Q4081 635 321 2
802
33
IV ,
.
01/12/08 285.21 Q4081 635 321 2,802.33
01/19/08 285.21 Q4081 635 321 2,802.33
01 /26/08 285.21 Q4081 635 277 2,418.21
01/31/08 285.21 Q4081 635 277 2,418.21
TreatmeMltemSubtotal: 1,517 $13,243.41
HEMODIALYSIS TREATMENT 01/05!08 585.6 90999 821 1 1,048.00
01 /12/08 585.6 90999 821 1 1,048.00
01/19/08 585.6 90999 821 1 1,048.00
01 /26!08 585.6 90999 821 1 1,048.00
01/31/08 585.6 90999 821 1 1,048.00
Treatment Item Subtotal: 5 $5,240.00
NEEDLE AND SYRINGE 01105!08 A4657 270 1 0.50
01 /12/08 A4657 270 1 0.50
01/19/08 A4657 270 1 0.50
QMS Focus Release: 6.7.05
Itemized UB04 Statement
User AHEIKES
Date: 4/24/09
Page 4 of 4
Facility: DCA-ROYSTON
611 COOK STREET
ROYSTON, GA 306623933
(706) 245-0817
Provider Number:
Insurer: MEDICARE PART A
Group Number:
Policy Number254274026T
Claim #
Description of Service
1st 2nd Rev.
Date ICD9 ICD9 HCPC Code
NDC Billing
Number Quantity Charges
Patient: CHRISTIAN, WANDA
88 DAIRY LANE
BOWERSVILLE, GA 30516
111968-1 01 /05/08-01 !31 /OS
NEEDLE AND SYRINGE
ZEMPLAR 1 MCG IV
01 /26/08 A4657 270 1 0.50
01 /31 /08 A4657 270 1 0.50
Treatment Item Subtotal: 5 $2.50
01/05/08 588.81 J2501 636 10 242.50
01/12/08 588.81 J2501 636 14 339.50
01/19/08 588.81 J2501 636 10 242.50
01/26/08 588.81 J2501 636 10 242.50
01/31/08 588.81 J2501 636 10 242.50
Treatment Item Subtotal: 54 $1,309.50
Claim Subtotal: 1,591 ;19,933.91
Grand Total: 3,182 ;39,867.82
QMS Focus
Release: 6.7.05
Dates Amount
Feb-07 $ 26,808.28
Mar-07 $ 42,864.04
Apr-07 $ 37,387.22
May-07 $ 16,181.74
Jun-07 $ 10,625.90
Jul-07 $ 8,124.46
Aug-07 $ 4,605.96
Sep-07 $ 4,482.32
Oct-07 $ 15,078.44
Nov-07 $ 17,658.00
Dec-07 $ 17,709.70
Jan-08 $ 39,867.82
$ 241,393.88
Louis J. Capozzi, Jr., Esquire"`
Daniel K. Natirboff; Esquire
Donald R. Reavev, Esquire
Bruce G. Baron, Esquire
Andrew R. Eisemann, Esquire
Michael M. Jerominski, Esquire
Dawn L. Richards, Esquire
Timothy Ziegler, Reimb. Analyst
Karen L. Fisher, Paralegal
Jennifer Kain, Paralegal
Keyoung Gill, Paralegal
' (licensed in PA, NI and MD)
" (licensed in PA and MD)
Wanda Christian
88 Dairy Lane
Bowersville, GA 30516-2057
C
e_! ~: >:
h . ~:,
December 3, 2009
Re: Account with Dialysis Corporation of America
Account Balance: $201,580.10 plus costs of collection
Our Matter No.: 1087-08
Dear Ms. Christian:
2933 North Front Street
Harrisburg, PA 17110
Telephone: (717) 233-4101
Fax: (717) 233-4103
www. capozziassociates.com
Craig I. Adler, Esq.
Of Counsel
As you are aware, our law firm represents Dialysis Corporation of America regarding the
above-referenced delinquent account. You have failed to respond to my letter, dated October 29,
2009, attempting to resolve this matter in an amicable manner. Accordingly, you have left me no
choice but to advise our client to proceed with a civil Complaint to obtain a Money Judgment for
the full amount owed, plus interest, attorney's fees, and costs of collection.
Please call or write to me immediately if you would rather settle this matter and make
flexible payment arrangements. Otherwise, this will be my final communication to you before we
file the civil Complaint to obtain a money judgment for the full amount owed, plus costs of
collection.
Yours truly,
~jg
cc: Lisa A. Laudeman, DCA
Michael M. Jerominski
THIS LETTER AND ANY FUTURE LETTERS FROM OUR FIItM ARE AN ATTEMPT TO CO EXHIBIT
DEBT, AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
Louis J. Capozzi, Jr., Esquire*
Daniel K. Natirboff, Esquire
Donald R. Reavey. Esquire
Bruce G. Baron, Esquire
Andrew R. Eisemann, Esquire
Michael M. Jerominski, Esquire
Timothy Ziegler, Reimb. Analyst
Karen L. Fisher, Paralegal
Jennifer Kain, Paralegal
Keyoung Gill, Paralegal
• (licensed in PA. NJ and MD)
•' (licensed in PA and MD)
Wanda Christian
88 Diary Lane
Bowersville, GA 30516-2057
Ca
October 29, 2009
Re: Account with Dialysis Corporation of America
Account Balance: $201,580.10 plus costs of collection
Our Matter No.: 1087-08
Dear Ms. Christian:
2933 North Front Street
Harrisburg, PA 171 10
Telephone: (717) 233-410]
Fax: (717) 233-4103
www. capozzi associ ates. com
Craig I. Adler, Esq.
Of Counsel
Please be advised that our law firm represents Dialysis Corporation of America. Dialysis
Corporation of America is proud to provide compassionate and lifesaving services to individuals in
need. However, in certain situations it becomes necessary for them to take stronger measures to enforce
the agreements made by their patients to receive compensation for services rendered.
Your account is now seriously overdue. Dialysis Corporation of America firmly believes that
they are entitled to receive the above-referenced balance. They have instructed me to attempt to settle
this account in an amicable manner, if possible. Although you have 30 days to contact me to dispute the
amount, make payment, or make settlement arrangements, we will have no option but to prosecute a
lawsuit against you if this issue is not resolved.
NOTICE: UNLESS YOU DISPUTE THE VALIDITY OF THIS DEBT, OR ANY
PORTION THEREOF, WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE, THE DEBT
WILL BE CONSIDERED TO BE VALID. IF YOU NOTIFY OUR OFFICE IN WRITING
WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE THAT THIS DEBT, OR ANY
PORTION THEREOF, IS DISPUTED, WE WILL OBTAIN VERIFICATION OF THE DEBT
AND WE WILL MAIL A COPY TO YOU. THE NAME OF THE ORIGINAL CREDITOR OF
THIS DEBT IS IDENTIFIED ABOVE.
THIS LETTER AND ALL OTHER COMMUNICATIONS FROM US ARE ATTEMPTS
TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT
PURPOSE.
Please make arrangements to settle this delinquent account or you may call me if you have any
other questions. I trust that you will give this Notice your immediate attention.
Yours truly,
Michael M. Jerominski
/kj g
cc: Lisa A. Laudeman, DCA
DIALYSIS CORPORATION OF AMERICA IN THE COURT OF COMMON PLEAS OF
d/b/a DCA OF ROYSTON, CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v.
WANDA CHRISTIAN,
Docket No.:
Defendant Civil Action -Law
VERIFICATION
I, Lisa Laudeman, Reimbursement Manager, do hereby verify under penalties of
perjury and upon personal knowledge that the contents of the foregoing Complaint
are true and correct.
Date:
Lisa Laudeman
Reimbursement Manager
Dialysis Corporation of America
214 Senate Avenue, Suite 300
Camp Hill, PA 17011
DIALYSIS CORPORATION OF AMERICA IN THE COURT OF COMMON PLEAS OF
d/b/a DCA OF ROYSTON, CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff N
--~,
~..~} F i
v. Docket No.: 10-03306 ~
'~' o
i•-+
~"
1..-.
~Je.~
~
1 .~
_
. /~ -' ~
. i ~,... 4.- .~~
J
WANDA CHRISTIAN
;
; a° ,
Y ~~fi
, F,
.
~
.'7 J
i ~= 3
_ ~ .
Defendant Civil Action -Law ;A ~ ~
~
~, a
PRAECIPE TO ENTER DEFAULT JUDGMENT AGAINST DEFENDAI~ ~' -`
TO THE PROTHONOTARY/CLERK OF SAID COURT:
Pursuant to Pa.R.Civ. P. No. 1037(b), enter judgment in favor of Plaintiff Dialysis
Corporation of America d/b/a DCA of Royston and against Defendant Wanda Christian for
failing to file an Answer to Plaintiff's Complaint within twenty (20) days from the date of service
of said Complaint and assess Plaintiff's damages certified to be calculable as a sum certain from
the Complaint, I hereby certify that:
Current amount due: $241,393.88
Attorney Fees: $ 548.50
/~, Gong
Costs of Court: $ ~ per
TOTAL: * $241 q~2,.38 L~~~g
* Plus post judgment interest at the legal rate of 6% per annum, plus costs of
collection.
I understand that any false statements therein are subject to the penalties contained in
Title 18 of the Pennsylvania Consolidated Statutes §4904, relating to unsworn falsification to
authorities. I verify that:
1. The last known address for Defendant is as follows: ~I ~. oo P p AT'N
~~ a ra~ro
1 ~,'~au~~
Noire UU~I~
Wanda Christian
88 Dairy Lane
Bowersville, GA 30516
2. It is certified that a written Notice of Intention to Enter Judgment by Default was
mailed to Defendant, against whom this judgment is to be entered, after the default
occurred, and at least 10 days prior to the date of the filing of this Praecipe. A copy
of the Affidavit of Service is attached as Exhibit "A." A copy of the Notice of Intent
to Enter Default Judgment is attached as Exhibit "B."
Date: June 25.2010 i~~. ~-
Michael M. Jerominski, Esquire
Attorney I.D. No. 92977
Capozzi & Associates, P.C.
2933 North Front Street
Harrisburg, PA 17110
(717) 233-4101
Attorney for Plaintiff
2
DIALYSIS CORPORATION OF AMERICA
d/b/a DCA OF ROYSTON,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v. Docket No.: 10-03306
WANDA CHRISTIAN, n ~ _
- ..
- ~~ r,
_.
'~ = ~ r
Defendant Civil Action -Law
AFFIDAVIT OF SERVICE
_ _
COMMONWEALTH OF PENNSYLVANIA ) - ~.., r ,=
:;:`; _,,
.~::-'
~'~,
COUNTY OF DAUPHIN
Michael M. Jerominski, Esquire, being duly sworn, deposes and says:
1. I am over the age of 18 and not a party to this action,
2. On the 20"' day of May, 2010, I served a copy of the attached Complaint upon the Defendant
by putting it in a postage prepaid envelope and mailing it to Defendant Wanda Christian, 88
Dairy Lane, Bowersville, GA 30516 by first class certified U.S. mail.
3. On May 26, 2010, Defendant claimed the attached Complaint. A true and correct copy of
the executed U.S. Postal Service Form 3811 is attached.
Date: ~ jiti1ly
Sworn to before me this /~i` ~~ day
of June 2010.
Notarial Seal
Keyoung J. ~ilU, Notary Pu41ic
Susquehanna Twp., Dauphin County
My Commission Expires April ~, 2013
Michael M. Jerominski, Esquire
Exhibit A
^ Complete items t, 2, and 3. Also complete Signature I
item 4 if Restricted Delivery is desired. ~. ~ ^ Agent
® Print your name and address on the reverse ' rrn./ ddressee
so that we can return the card to you. B Receive d by (P ' e)
ted Nam C. D to of Delivery
® Attach this card to the back of the mailpiece, ! I rN ~~ L
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or on the front if space permits.
D. Is delivery address dliferent from item 1? ^ Yes
1. Article Addressed to: If YES, enter delivery address below: ^ No
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^ Registered C~Return Receipt for Merchandise
O Insured Mail ^ C.O.D. ~
4. Restrtcted Delivery? (Extra Fee) ~ Yes
2. Article Number
(Trans/er from servke label) _ 7 0 8 114 0 0 0 01 6 3 3 2 2 2 5 9
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'` PS Form 3811, February 2004 Domestic Return Receipt to2sss•o2-M-tsao ;
UNITED STA ~ iS~t _.,.~
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Sender: Please print your name, address, and ZIP+4 in this box • .
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Michael M. Jerominski, Esquire,:~~='~'J
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Capozzi & Associates, P.C. ~~•'~ II
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2933 N. Front Street ~ -°
Harrisburg, PA 17110 I ~ ~
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Exhibit A
DIALYSIS CORPORATION OF AMERICA IN THE COURT OF COMMON PLEAS OF
d/b/a DCA OF ROYSTON, CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v.
: Docket No.: 10-03306
WANDA CHRISTIAN,
Defendant Civil Action -Law
NOTICE OF INTENTION TO ENTER JUDGMENT BY DEFAULT
TO: Wanda Christian
88 Dairy Lane
Bowersville, GA 30516
DATED: June 15, 2010
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN
APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE
COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU.
UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A
JUDGMENT MAYBE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY
LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS
NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT
AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE
YOU CAN GET LEGAL HELP:
CUMBERLAND COUNTY BAR ASSOCIATION
32 S. BEDFORD STREET
CARLISLE, PA 17013
1-800-940-9108
717-244-3166
Exhibit B
DIALYSIS CORPORATION OF AMERICA IN THE COURT OF COMMON PLEAS OF
d/b/a DCA OF ROYSTON, CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v.
Docket No.: 10-03306
WANDA CHRISTIAN,
Defendant Civil Action -Law
NOTICIA IMPORTANTE
TO: Wanda Christian
88 Dairy Lane
Bowersville, GA 30516
DATED: June 15, 2010
USTED HA NO COMPLIDO CON EL AVISO ANTERIOR PORQUE HA FALTADO
EN TOMAR MEDIDAS REQUERIDAS RESPECTO A ESTE CASO. SI USTED NO ACTUA
DENTRO DE DIEZ (10) DIAS DESDE LA FECHA DE ESTA NOTICIA, ES POSIBLE QUE
UN FALLO SERIA REGISTRADO CONTRA USTED SIN UNA AUDIENCIA Y USTED
PODRIA PERDER SU PROPIEDAD O OSTROS DERECHOS
IMPORTANTES. USTED DEBE LLEVAR ESTA NOTICIA A SU ABOGADO EN
SEGUIDA. SI USTED NO TIENE ABOGADO O NO TIENE CON QUE PAGAR LOS
SERVICIOS DE UN ABOGADO, VAYA O LLAME A LA OFICINA ESCRITA ABAJO
PARR AVERIGUAR A DONDE USTED PUEDE OBTENER LA AYUDA LEGAL.
CUMBERLAND COUNTY BAR ASSOCIATION
32 S. BEDFORD STREET
CARLISLE, PA 17013
1-800-990-9108
717-249-3166
Michael M. Jerominski, Esquire
I.D. No. 92977
2933 N. Front Street
Harrisburg, PA 17110
(717) 233-4101
2
Exhibit B
DIALYSIS CORPORATION OF AMERICA IN THE COURT OF COMMON PLEAS OF
d/b/a DCA OF ROYSTON, CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v, Docket No.: 10-03306 _
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WANDA CHRISTIAN, ~ `~ ~-- ....~
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Defendant Civil Action -Law ~ ~~: ~ ~ Q
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CERTIFICATE OF RESIDENCE ~ ~~ "' `!~~ ~'
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I hereby certify that the name and address of the proper person(s) to receive this Notice
under Pa. R. Civ. 236 is:
Wanda Christian
88 Dairy Lane
Bowersville, GA 30516
Date: June 25, 2010
Michael M. Jerominski, Esquire
Attorney I.D. No. 92977
Capozzi & Associates, P.C.
2933 North Front Street
Harrisburg, PA 17110
(717) 233-4101
Attorney for Plaintiff