HomeMy WebLinkAbout10-3308I~
DIALYSIS CORPORATION OF AMERICA
d/b/a DCA OF WEST BALTIMORE,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v.
WILLIAM CROSBY,
Defendant
Docket No.: D - iV 1 c.:,
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Civil Action -Law ti ~i
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COMPLAINT ~ -; ~~ ~`{
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NOW COMES, Dialysis Corporation of America d/b/a DCA of West Baltimore, by and .~
through 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 West Baltimore ("DCA
of West Baltimore"), is a registered Pennsylvania corporation having its principal place of
business at 27 Miller Avenue, Lemoyne, Cumberland County, Pennsylvania 17043.
2. DCA of West Baltimore is an operating subsidiary of Dialysis Corporation of
America ("DCA")
3. Defendant William Crosby ("Patient" or "Defendant") is an adult individual with
a last known address at 1503 N. Hilton Street, Baltimore, Maryland 21216.
4. DCA of West Baltimore provides dialysis treatments and services to its patients.
5. On or about March 31, 2006, Defendant executed a Consent for Hemodialysis
Agreement ("Consent Agreement") to allow Defendant to receive regular dialysis treatments
from DCA of West Baltimore as scheduled by his physician and DCA of West Baltimore. A true
and correct copy of the Consent Agreement is attached hereto and incorporated herein as Exhibit
«A „
O
~4a. oo P o A~
~~ a~~al
~,~' a~ a 300
6. On or about March 31, 2006, 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 he
received for the dialysis treatments from DCA of West Baltimore. 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 West Baltimore monies and/or
benefits to which the Patient is (or may be) 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 West Baltimore, 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 West Baltimore, be paid and remitted directly to
DCA of West Baltimore...."
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 West Baltimore 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 West Baltimore...."
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 West Baltimore." [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 West Baltimore, the Patient shall be responsible for
any and all charges and costs billed by DCA of West Baltimore for dialysis treatments and
related services ...and that DCA of West Baltimore is authorized to bill the Patient directly for
payment of such charges and costs."
12. DCA of West Baltimore, at the special insistence and request of Defendant during
the period March 31, 2006 through July 4, 2008 ("Dates of Service"), provided numerous
separate dialysis treatments ("Dialysis") at the rates and on the dates set forth in DCA of West
Baltimore'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
$119,232.09.
14. On October 28, 2009 and December 3, 2009, DCA of West Baltimore's counsel
mailed to Defendant demand letters, which provided information on how to pay the debt owed to
DCA of West Baltimore. A true and correct copy of the demand letter is attached hereto and
incorporated herein as Exhibit "D."
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. Under the terms of Defendant's policy with his insurance provider, CareFirst,
Defendant received monthly checks from CareFirst pursuant to the claims filed by DCA of West
Baltimore.
18. Defendant's insurance provider did not always pay 100% of DCA of West
Baltimore's claims, which resulted in Defendant owing a co-pay to DCA of West Baltimore
("Co-pay„~.
19. Pursuant to the Assignment and Authorization Agreement attached as Exhibit B,
Defendant was required to transfer the payments he received from CareFirst directly to DCA of
West Baltimore on a monthly basis.
20. The amounts that Defendant received from CareFirst pursuant to the claims
submitted by DCA of West Baltimore are indicated in the third column of the Account
Statement, which is marked "CareFirst Paid To Patient."
21. As provided from CareFirst's records, Defendant received a total of $118,422.09
from CareFirst for the Dialysis treatments during the Dates of Service.
22. During the Dates of Service, Defendant transferred from CareFirst a total of only
$90.00 for the Dialysis treatments, as referenced in Exhibit C.
23. The total amount of principal that has become due and owing by Defendant to
DCA of West Baltimore as a result of his failure to transfer the insurance payments that he
received and his failure to pay his Co-pay is $119,232.09
4
24. 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.
25. DCA of West Baltimore has been financially damaged in the amount of
$119,232.09, plus interest and costs of collection.
26. Defendant's failure to pay his Co-pay, his failure to transfer the insurance
payments, and his failure to cure his default with DCA of West Baltimore pursuant to the
Assignment and Authorization Agreement constitute a breach of contract.
WHEREFORE, Plaintiff, Dialysis Corporation of America d/b/a DCA of West
Baltimore, demands judgment against Defendant in the sum of $119,232.09, 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 West Baltimore and Defendant, which is denied, then, in that event, DCA of West Baltimore
pleads the following alternative cause of action in quantum meruit against the Defendant.
27. Plaintiff incorporates paragraphs 1 through 26 of this Complaint as if set forth at
length herein.
28. Having requested DCA of West Baltimore to provide the dialysis treatments and
DCA of West Baltimore having done so to the benefit of Defendant, Defendant became liable to
DCA of West Baltimore for the just and reasonable charges for the Dialysis.
29. The Defendant has been unjustly enriched by accepting the Dialysis.
30. The rates reflected in the Account Statement as Exhibit C are the just and
reasonable rates for dialysis treatments and services.
5
31. The total value by which Defendant has become enriched on account of the
Dialysis is $119.232.09, as is more specifically reflected in the Account Statement.
32. DCA of West Baltimore has demanded Defendant pay this amount, but Defendant
has failed to do so.
33. To date, the Defendant has not paid the total amount due.
WHEREFORE, Plaintiff, Dialysis Corporation of America d/b/a DCA of West
Baltimore, demands judgment against Defendant in the sum of $119,232.09, plus interest at the
legal rate of 6% per annum from the date of judgment.
COUNT III -CONVERSION OF MONEY
34. DCA of West Baltimore incorporates Paragraphs 1 through 33 of this Complaint
as if set forth herein.
35. Defendant was aware that due to the contractual relationship between Defendant
and DCA of West Baltimore pursuant to the Assignment and Authorization Agreement, the
insurance payments Defendant received from CareFirst properly belonged to DCA of West
Baltimore.
36. Defendant had a legal and contractual duty to safeguard and forward the insurance
payments by CareFirst made payable to Defendant to reimburse DCA of West Baltimore for the
Dialysis it provided to him.
37. During the Dates of Service, Defendant's insurance provider paid to him
$118,422.09
38. During the Dates of Service, Defendant transferred a total of only $90.00.
6
39. Defendant intentionally and permanently retained possession of the monies owed
to DCA of West Baltimore by failing to transfer a total of $119,232.09 of the insurance benefits
CareFirst paid to him as required under the Assignment and Authorization Agreement.
40. Defendant's intentional possession of and his failure to forward the CareFirst
insurance monies to DCA of West Baltimore for the Dialysis provided to Defendant constitutes
conversion.
41. DCA of West Baltimore has been financially damaged by Defendant's conversion
in the amount of at least $119,232.09.
WHEREFORE, Plaintiff, Dialysis Corporation of America d/b/a DCA of West
Baltimore, demands judgment against Defendant for conversion in the sum of $119,232.09, plus
interest at the legal rate of 6% per annum from the date of judgment.
Respectfully submitted,
Capozzi & Associates, P.C.
Dated: s~~~~~v
~~~
By:
Michael M. Jerominski, squire
Attorney I.D. No. 92977
2933 N. Front Street
Harrisburg, PA 17110
(717) 233-4101
Attorneys for Plaintiff
7
C€3NSE2~'T,~OR. 73~~aDI~.;
Pstienf: L`.w?,~T.~,T,~ 4-~i1„i ~R~.y~ TD NU~a~~': _ ~5~~'j~,~ 3?e"tc:.~~~ f0
• (~ `t, the iuderai~cd paricnt;
( } I, flee uadersigx~ed parent ar gnardia~: of the above paficnt ~~l?o is ttndcr
I S years Df agc or vt$e~c YllC3p8t .e Of COASeTIfinF;
i•
L.
hereby request and authorize Dr. ~r,.~~~a2~___,._an ~ wh~nevar Ise or she ro,ay
dtsig~ate as his or bcr associate or sss~stant to administer to rt;e (or to the a'~ave named
patien~) gte procedure lawn es hemodia~ysis, under such con iitions as shall be dtte~nined
o}- thaphysxcia~ (s) in a~ttendarrce, I agree to ebid~e Iry• die pali~:ies, zvles, and rcgulatians
established by the above named iialysis Unit in carrying out i~:; hemodiaiysis pra~am.
It has been plaiued to me that lie~nadialysis is a procedure us :d izt the case afpaticnts with
iaapai~~: of fei}urc of kidney iua~an by which certain come onents of taE blood aze
separased by a s~ peable substance ~•,;lirh pew `fie pat se~;e of certain rao3eoules and
hinder that of othezs when, #ha blood is cixculated through au a tiff vial kidney, e~lled a
diaiyzer. I rntdexstand that there are di$'erent types of equepmer; i employed far the dialysis
treatment and diext types of arb~cla7 kida~s (dialysers) use~3, in the process.
~ acknowled that the poss~'ble risks and complications of hemc~3ialysis ssacb as but nat
l~ted to I$akagc al the dialy~ar, changes hi biaod pre5snre, het:iolysis (brealCda~c~ of'red
blood ceps), hypoxcmia (redttctiou of oxygen zu the blood), hears ai~hytlunias, anal
mal.~vnotiafl of e~uip¢nenthave been expl$inedto me by~~e prallsssional peisaunei afthe
Dialysis Unit and I acctpt, an b~a1f vfmYself andl~r-thy abcr;~y; a~-~a~e,di~~is-tre~eut
~ittrt~li pa and complications, I also undc~d that imy disorder, which fiats
me, can hate effects on my 4reatmcut and an myself daring the tu:1e that I are receiviao a
dialysis treatment but. that this fact does net mean t:~at the d~ysi. tzeatrne~t had any`~hng to
do ~r~ith the de~~e3opment of the problea- xelated to this condition. I further canseut to fhe
administ:-a~on ofsuch drugs, traasfitsions a: blood orblaod camp moots, ar any ottDer
txeattnent and. tes~g; ~cluding~iIV testing, deraned necessary or desiiablt in the jud~Dnt
afthe phry~ieiaa (s) iA attendance.
I an at~tate the,r t?~eprac#ce ofmiedicine is not an e~ot;c;ence; an j I acka~oti,~iet~e that Lo
guarantees ~rarraniv of reprz5entatior~ whatsacwcr has b~ offerLd oz made to me or ~}ronc
on my behalf cflnc~niz~ the results of the hemvdialysis gocedure,
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EXHIBIT
9
nxA~xsa~ ca~RA~rroH aF ~~;~+~A
~'A~~'IENT A.S~9x~NNx' A~D~ ~1-~~;~~tl'ZA7`~ON
U~` PAYMR~'~' OR X~iSU~t.ANCE B:t.N~k~'~'S
~to~~
Facility: A_of iii~tlBatiimo,~ Dnte• ~, ~ ' off,,,/ `L') !!i-
Patiettr 3~Iaane; (~~„~t~~,.~11..L1~rY~.,,._ Pacieat l3)#: ) rf v~nY„"r
Icasa Print)
~. ~4~it{GNM~k~'
'The undcres`gned h,ertby agxi~s, tr~usstors and sel:~ aver fa INCA of'Jest 8alsfenor+e mvt:ies andfor
bcna(3tix to which the Patient ~ (or s»~t be) antiticxi from a»y insurance andJar hcaitis care provider ar
nasiasaal, state, +catorty yr local govetrtcneritei a,~ttcy, iACludireg the iHedar~~ insvrarice programs, as wei!
as any athcrK who may be flcsasscirrlly liable far dse Patient's diaiy~s3s trca{rrsetrts and scrviocs a»d nEund
medi+cat crsrc b?' astd/or aS nGA of"~W't~at Baitirnoce, incittdirtg health instrrancs, bdtefsta, major mtd'ical
isenefib and other medical payment ccvcrage or other poticy coverage far which rite Ptttiant # erstitied, to
corer the sos~ of dia]ysiS treattinertt stud sr~riaes and atiy othtrr medics? rssre rendered trr the Patient by
ttridlcst st DCA of West 8altimer+e.
2. AIITH!t~RxZA~"tAN OF PAYNiE3V7' OF 17MTSUxANC'~ ig,l;tl~lt'X'~`S
The undersigrscci lset~i~y avtharizr~ and directs that payment afa[! insttran :e befits, ibseirydirig i~tedicart
hcncfits, if appiicabia, ratsting tsy lacy charges tsnd costs imeusred as a rc wlt of dialysis treatencrti:e and
relaxed xervir~es ass$ snedicai coca praYided ~ the PaticM by and/ar apt f~'A of Wept BaPtin~are, b~e paid
atsd remitted directly to l~A ai`' 'i14%~t $alt#mane In a~ccordartce with +itstnict<rmc prrrvidtd or td $e
provider} by sn agent or repteacrstativc ofDCrh of West >lai#imore:
if the undersigned's inscr~iice pal;~, ax a ~ does not vide for ar~neflts
`~e~~ pl"-'GD'est .B tisnorr;, the tsndersigtted berct~y f»rtis~:' atrtitorizes and instructs tisr;
irisvrancc praovids:s• er agency respor~f bIQ for pB.yMteitt of tha applicable t:~RUtsntce honc~t~ to issue 'the
payssssast 3n the Patient's ngsnt: and M delivtr said paymzrst to DCA of W9e,~: l~altitrtoxe at its euddtvsss as set
Cnrth its she instrnctiatts prnvfded as• to be provided h7' ap Agent or re);rescnfative at' T)CA ~f Wit
$ehimore.
3. ~~~tX OF BEA'EPTi' .'PAYMEN'~'3 RLCETVEx3 ~Di~ ~iOYIDER
'T'he nndelrst~gaed bewef-y arkntrtvlccJgsst that the rriostiea ar beaefits to be paiQ ny tha ~tient'a
irancc provider or govcrnnseat alttacy for tha chArgcsy casts And few isscarrw by DCA of 'Vest
$attimort: in its pra~visioa of diaty'is oate~thnen~ a»d x~elAflsssi Ret•vit:es tsrrd medicat care b the Ps#leot
is sad shall at sli fames s-Qtetain, the prapeH,y of DCA alt Weot T3A1!tfppaar•e, And is fitrtharsnae that~ouf
the »tpdersignr~ 1lcrcby covesaasrfrs rod agrt~ tt+at iq t1Ne watt that srey~ Payment off' isnatsran~cc
bea+efits, iseritudiAg Medicsre bsn~tar which rrslate directly to tfie charms casts aad face inevrresl
try DMA o£ Nest Bsltimos'e as st resoft of ite provistoa otdialpsis #zcsrpaea#s &nd ~~tcd s~d~iecS
and. medi¢.al care fa the Patient a sent to dte Patknt ar sac1, l~s,ticnt's l;aardiian, attr~r~uey its-fact or
r+epreaeatative~ as the case trssy tse, iusrdveri+eatlp or otherwise, fbafi tt~a uridergigaed wip pramp~
and uncc-nditiaaalfy lorward stxtrh pa'y'atent directly to DCA of West 8sritimgre.
Page 1 of 2
EXHIBIT
~~~~~
A. ~LF,AS~ OF Ii~'C1RMA'~`XflN
The undarsig~ed ha+elry authari~ ;usd coesscssr$ tti the rcteasc h'y DCA ;-f West F38ltimorC, Or any ttf its
agents or ttiprescritativc~,, of ati or pert of any information, rerords ar re+{:~ss ert3ser medical or t3nanciaT
fit naiue~ t:o yr wins any person, corporation ox gcsvemtnertt sgertey, irrclud#trg any tleird-party insurance
arwd/cr he:alth care provider, wha i+Q ~nassGially liabto fvr des Paticest"s dialysis treanrrasst~a an3 rciated
S~TYICC$ as well aS triedi~cal CBRC, which infas^ssssuon is ntcG9Sary for the fi~63tRr1tt~e601r, VCFif~SCatiorl erKtJpr
corsfirmatioa of payttinent oaf elrarges a+td costs ties DCA of Wtet Baltitswr~, for the provtaiorr to tlst t'atierst
ufsucb dialysis treatments aced Tclrstecl services ~ wep tts rnorlica! cart
'~• 1~5PO~1~F3tfB~.LI7'~ Ft~R 1PAk'NIEi~'I'S
'i`he undt~igneel keretay acknov~tlsdg~ that'; rsotvyethstarsdirsgtbe foragoireg assignment arzd authorization
of benefit payments to DCA of West 13attimare, the Patiesst shalt ba rasa+~tgr'b~le for at:y and at1 ctsarges
and costs bi}ltd by DCA ~ Wan Bsllimora far dialysis treatrea~ents and re;atad scrvicas provided and riot
csthttwise cavared ar paid by suoJs third party payor or ~-OVetreeesept:rl agency, line{utiitsg, wi8sant.
limitaxiatt all dednatil+le, ccs-ies,~trranr~• and ces-p~a~-mant nmoun~t, artd rr:tt TaCA of West Italtimrsre is
azrthettzed m bllC tine Patient. directly !'ta payment of sods charges and cost':;,
K. ~vnrAS~,nr~-
tttet3ersigned tteroby acknowtetiges tf>$t tlsis PATI~V'1' ASS1Gi~lME`1'!' ~l?~iD AUTHQRf?~TIO~
QF PAV'lviE13T OF .NSi.JRANCii 8E'N€~FITS may not be t'+avoke~,t tt4leas gush ttivacatlon is
accrmtganied by the written amseret tcs such tevocati4n !ry DCA of West l~,:.ltimore.
z. .P>~tv~ro~:vrs
errraersigtsed bore
tl»t a ptatowpy vP thiR ~~~; t ~~s~ra~ AND
AUYHCyRI7A~'iCJN t3F' PE4Yh+l~T1'~' ~3F 1'l3StIRAN~E BFt~EF7`i:5 shalt be rattgid~d as vatid as ~
oriFtine-! far vnrnoses hsc+ecsf grad ~~n- t~ ~!~d~zt.-glace-tai the-or-ue~l--v-~r--r~ec~t-to~-eechrof-iti~
uiruagn ~ avove.
Si~ature:
Print Nsxtsc: ~~.,L~,°r1~..~,.~.,,(.~c~.~.ll-.1~'9.~.~'T
Aatet ~~,.~' ,~,,,~cz,
Ifyou are sigrsing sR a getardiatt, attesrney-its fa~t:gr tept'escntative oi"a paticyrt; plea,4e indieaDe h'Y rrrarCciteg
the bmt axtd crnnple~e the ittfbrrnatititt lorlow: ~]
t:ER~GA~.TIOI~l` E3~ GUA;RA~AhiIA'1°i`ORN~Y-~N->F`A.G"~J~~~';[xESEI~AT'I'V.E
T~ arclersigrsed tsereisy ccrii~es that helshe #s the duly alepvinted ~t~dlart, attorney-ir+-fact andlar
rapraserrtative of thG atao~r~merniontrd iraEiasst, and tisat taelstss has Pirtl autfsesrity to execsete this ~rM an
baTsalf of such depeesdeest patient.
~ig>natarr:
Print 1Vatrte:
Da#e•
Page 2 of 2
DIALYSIS
CORPORATION
Uf A M E R I C A
_ William Crosby, Jr. #48W8
DOS
a Char Careflrst Paid To
Pt P Amt Owed
r r t Ck Total Account
l n e
03/01-31/2006 $ 900.00 $ 90. $ 90.00 $ 810.OD $ 810.00
06/01-29 2007 $ 32,027.94 $ 32,027.94 $ $ 32,027.94 $ yY 32,027.94
10/1-31/200_7
03/03-31/2008 5 17,557.46
$ 18,479.37 $ ~17_,557A~
$ 18,479.32 $ _ _ -
$ ~
M-- $ 17,557.46
$ 18,479.37 $ 17,557A6
$ 18 479.37
04/02-30/2008 $ 21,818.11 $ 21,818.1 _-
$ -~ $ 21,818.11 $ 21,818.11
06/02.30/2008 $ 24,716.16 $ 24,716.1 $ - $ 24,716.16
~ 5 ~~ 24,716.16
07/02-04/2008 $ 3,823.05 $ 3,823.05 $ _- $
3,823.05 $ 3,823.05
TOTALS: $ 119,322.09 $ 118,422.09 90.00 119,232.09 119,232.09
214 Senate Avenue, Suite 300, Camp Nill, PA 17011 ^ Phone (717) 730-6164 ^ Fax (717) 730-9133
www.dialysi scorporation.com
EXHIBIT
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 1 of 3
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866)390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:
Policy NumberAPK238786316
Claim #
Description of Service
1st 2nd Rev.
Date ICD9 ICD9 HCPC Code
NDC Billing
Number Quantity Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
89100-1 06/01 /07-08/29/07
ADMIN SUPPLIES
EPOETIN<10000/100 UNITS 100 UT 06/01/07 285.21
IV
06/04/07 285.21
O6/O6/07 285.21
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11,40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11,40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
Treatment Item Subtotal: 22 $250.80
Q4081 634 22 165.00
Q4081 634 88 660.00
04081 634 88 660.00
06/01 /07
06!01 /07
06/04/07
06!04/07
06/06!07
06/06/07
06/11 /07
06/11/07
06/16/07
06/16/07
06/18/07
06/18/07
06/20/07
os/2ao7
06/22/07
06/22/07
06/25/07
06/25/07
06/27/07
06/27/07
06/29/07
06/29/07
QMS Focus
Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 2 of 3
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866)390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:
Policy NumberAPK238786316
Claim #
Description of Service
te
t 2nd
ICD9 ICD9
PC
v. NDC
Code Number
antity
lling
Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
89100-1 06/01 /07-06/29/07
EPOETIN<10000/100 UNITS 100 UT 06/11/07 285.21 Q4081 634 88 660
00
IV .
Treatment Item Subtotal: 286 $2,145.00
EPOETIN>10000/100 UNITS 100 UT 06/16/07 285.21 Q4081 635 344 2
580.00
IV ,
06/18/07 285.21 Q4081 635 344 2,580.00
06/20/07 285.21 Q4081 635 344 2,580.00
06/22/07 285.21 Q4081 635 344 2,580.00
06/25/07 285.21 Q4081 635 344 2,580.00
06127/07 285.21 Q4081 635 344 2,580.00
06/29/07 285.21 Q4081 635 344 2,580.00
Treatment Item Subtotal: 2,408 $18,060.00
HEMODIALYSIS TREATMENT 06/01!07 585.6 90935 821 1 900.00
06/04/07 585.6 90935 821 1 900.00
06/06/07 585.6 90935 821 1 900.00
06/11/07 585.6 90935 821 1 900.00
06/16/07 585.6 90935 821 1 900.00
06/18/07 585.6 90935 821 1 900.00
06120!07 585.6 90935 821 1 900.00
06/22/07 585.6 90935 821 1 900.00
06/25/07 585.fi 90935 821 1 900.00
06!27/07 585.6 90935 821 1 900.00
06/29!07 585.6 90935 821 1 900.00
Treatment Item Subtotal: 11 $9,900.00
NEEDLE AND SYRINGE O6/01107 A4657 270
1 0.50
06/04/07 A4657 270 1 0.50
QMS Focus Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 3 of 3
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866)390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:
Policy NumberAPK238786316
Claim # 1st 2nd Rev. NDC Billing
Description of Service Date ICD9 ICD9 HCPC Code Number Quantity Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
89100-1 06/01 /07-06/2 9/07
NEEDLE AND SYRINGE 06/06/O7 A4657 270 1 0.50
06/11/07 A4657 270 1 0.50
06/16/07 A4657 270 1 0.50
06!18/07 A4657 270 1 0.50
06!20107 A4657 270 1 0.50
06!22/07 A4657 270 1 0.50
06!25/07 A4657 270 1 0.50
06/27/07 A4657 270 1 0.50
06/29/07 A4657 270 1 0.50
Treatment Item Subtotal: 11 $5.50
ZEMPLAR 1 MCG IV 06/01/07 588.81 J2501 636 7 140.56
06/04/07 588.81 J2501 636 7 140.56
O6/06!07 588.81 J2501 636 7 140.56
06/11/07 588.81 J2501 636 7 140.56
06/16/07 588.81 J2501 636 8 160.64
06/18/07 588.81 J2501 636 8 160.64
06/20/07 588.81 J2501 636 8 160.64
06/22/07 588.81 J2501 636 7 140.56
06/25/07 588.81 J2501 636 8 160.64
06/27/07 588.81 J2501 636 8 160.64
06/29!07 588.81 J2501 636 8 160.64
Treatment Item Subtotal: 83 $1,666.64
Claim Subtotal: 2,821 $32,027.94
Grand Total: 2,821 $32,027.94
QMS Focus Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 1 of 4
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866) 390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:
Policy NumberAPK238786316
Claim #
Description of Service
1st 2nd Rev. NDC Billing
Date ICD9 ICD9 HCPC Code Number Quantity Charges
r~attent: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
97805-1 10/01 /07-10/ 31 /07
ADMIN FEE FLU
ADMIN SUPPLIES
10/19/07
10/01/07
10/03/07
10/05/07
10/08/07
10/10/07
10/12/07
10/15/07
10/17/07
10/17/07
10/ 19/07
10/19/07
10/22/07
10/22/07
10/24/07
10/24/07
10/26/07
10/26/07
10/29!07
10/29/07
10/31 /07
10/31 /07
EPOETIN<10000/100 UNITS 100 UT 10/17/07 285.21
IV
10/19/07 285.21
10/22/07 285.21
QMS Focus
G0008 771 1 11.40
Treatment Item Subtotal: 1 $11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11 40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 1140
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
A4657 270 1 11.40
Treatment Item Subtotal: 21 $239.40
04081 634 44 330.00
04081 634 44 330.00
04081 634 44 330.00
Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3109
Page 2 of 4
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866) 390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:
Policy NumberAPK238786316
Claim #
Description of Service
te
t 2nd
ICD9 ICD9
PC
v. NDC
Code Number
antity
lling
Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
97805-1 10f 01 /07-10/31107
EPOETIN<10000/100 UNITS 100 UT 10/24/07 285.21 Q4081 634 44 330.00
IV
10/26/07 285.21 Q4081 634 44 330.00
10/29/07 285.21 Q4081 634 44 330.00
10/31/07 285.21 Q4081 634 44 330.00
Treatment Item Subtotal: 308 $2,310.00
HEMODIALYSIS TREATMENT 10/01/07 585.6 90935 821 1 900.00
10/03/07 585.6 90935 821 1 900.00
10/05/07 585.6 90935 821 1 900.00
10!08/07 585.6 90935 821 1 900.00
10/10/07 585.6 90935 821 1 900.00
10/12/07 585.6 90935 821 1 900.00
10/15/07 585.6 90935 821 1 900.00
10/17/07 585.6 90935 821 1 900.00
10/19/07 585.6 90935 821 1 900.00
10/22/07 585.6 90935 821 1 900.00
10/24/07 585.6 90935 821 1 900.00
10/26/07 585.6 90935 821 1 900.00
10/29/07 585.6 90935 821 1 900.00
10/31/07 585.6 90935 821 1 900.00
Treatment Item Subtotal: 14 $12,600.00
INFLUENZA VIRUS VACCINE PER 10/19/07 V04.81 90658 636 1 39
80
DOSAGE IV .
Treatment Item Subtotal: 1 $39.80
NEEDLE AND SYRINGE 10/01/07 A4657 270 1 0.50
10/03/07 A4657 270 1 0.50
10/05/07 A4657 270 1 0.50
10/08/07 A4657 270 1 0.50
QMS Focus Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 3 of 4
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866) 390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:
Policy NumberAPK238786316
Claim # 1st 2nd Rev. NDC Biding
Description of Service Date ICD9 ICD9 HCPC Code Number Quantity Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
97805-1 10/01 /07-10/31 /07
NEEDLE AND SYRINGE 10/10/07 A4657 270 1 0.50
10/12/07 A4657 270 1 0.50
10/15/07 A4657 270 1 0.50
10/17/07 A4657 270 1 0.50
10/19/07 A4657 270 1 0.50
10/19/07 A4657 270 1 0.50
10/22/07 A4657 270 1 0.50
10/24/07 A4657 270 1 0.50
10/26/07 A4657 270 1 0.50
10/29/07 A4657 270 1 0.50
10/31 /07 A4657 270 1 0.50
Treatment Item Subtotal: 15 $7.50
ZEMPLAR 1 MCG IV 10/01/07 588.81 J2501 636 8 160.64
10/03/07 588.81 J2501 636 8 160.64
10/05/07 588.81 J2501 636 8 160.64
10/08/07 588.81 J2501 636 8 160.64
10/10!07 588.81 J2501 636 8 160.64
10/12/07 588.61 J2501 636 8 160.64
10/15/07 588.81 J2501 636 8 160.64
10/17/07 588.81 J2501 636 8 160.64
10/19/07 588.81 J2501 636 8 160.64
10/22/07 588.81 J2501 636 8 160.64
10/24/07 588.81 J2501 636 8 160.64
10/26/07 588.81 J2501 636 8 160.64
10/29/07 588.81 J2501 636 8 160.64
QMS Focus Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 4 of 4
Faclllty: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866)390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:
Policy NumberAPK238786316
Claim # 1st 2nd Rev. NDC Billing
Description of Service Date ICD9 ICD9 HCPC Code Number Quantity Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
97805-1 10/01 I07-10/31107
ZEMPLAR 1 MCG IV 10131/07 588.61 J2501 636 13 261.04
Treatment Item Subtotal: 117 $2,349.36
Claim Subtotal: 477 517,557.46
Grand Total: 477 517,557.46
OMS Focus Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 1 of 7
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866)390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:715959600
Policy NumberAPK056496266552
Claim #
Description of Service
1st 2nd Rev.
Date ICD9 ICD9 HCPC Code
NDC Bllling
Number Quantity Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
132042-1 03/03/08-03/31 /08
ADMIN SUPPLIES
EPOETIN<10000/100 UNITS 100 UT
IV
03/14/08 A4657 270 1 13.85
03/14/08 A4657 270 1 13,85
03/14/08 A4657 270 1 13.85
03/17/08 A4657 270 1 13.85
03/17/08 A4657 270 1 13.85
03/19/08 A4657 270 1 13.85
03/19/08 A4657 270 1 13.85
03/19/08 A4657 270 1 13.85
03/21 /08 A4657 270 1 13.85
03/21/08 A4657 270 1 13.85
03/24/08 A4657 270 1 13.85
03/24/08 A4657 270 1 13.85
03/26/08 A4657 270 1 13.85
03/26/08 A4657 270 1 13.85
03/26/08 A4657 270 1 13.85
03/28/08 A4657 270 1 13.85
03/28/OS A4657 270 1 13.85
03/31/08 A4657 270 1 13.85
03/31!08 A4657 270 1 13.85
Treatment Item Subtotal: 19 $263.15
03/14/08 285.21 04081 634 33 268.09
03/17/08 285.21 04081 634 33 288.09
03/19/08 285.21 04081 634 33 288.09
03/21/08 285.21 04081 634 33 288.09
03/24/08 285.21 04081 634 33 288.09
03/26/08 285.21 Q4081 634 33 288.09
OMS Focus
Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 2 of 7
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866) 390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:715959600
Policy NumberAPK056496266552
Claim # 1st 2nd Rev.
Description of Service Date ICD9 ICD9 HCPC Code
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
132042-1 03/03/08-03/31 /08
EPOETIN<10000/100 UNITS 100 UT 03/28/08 285.21
IV
03/31 /08 285.21
HEMODIALYSIS TREATMENT
03!03/08 585.6
03/05/08 585.6
03/07/08 585.6
03!10/08 585.6
03/12/08 585.6
03/14/08 585.6
03/17/08 585.6
03/19/08 585.6
03/21/08 585.6
03/24/08 585.6
03/26/08 585.6
03/28!08 585.6
03/31 /08 585.6
NEEDLE AND SYRINGE
03/14/08
03/14/08
03/17/08
03/19/08
03/19/08
03/21 /08
03/24!08
03/26/08
03/26/08
03/28/08
04081 634
04081 634
NDC Billing
Number Quantity Charges
Treatment Item Subtotal:
90935 821
90935 821
90935 821
90935 821
90935 821
90935 621
90935 821
90935 821
90935 821
90935 821
90935 821
90935 821
90935 821
Treatment Item Subtotal:
A4657 270
A4657 270
A4657 270
A4657 270
A4657 270
A4657 270
A4657 270
A4657 270
A4657 270
A4657 270
33 288.09
33 288.09
264 $2,304.72
1 1, 048.00
1 1,048.00
1 1,048.00
1 1,048.00
1 1,048.00
1 1,048.00
1 1, 048.00
1 1,048.00
1 1,048.00
1 1,046.00
1 1,048.00
1 1,048.00
1 1,048.00
13 $13,624.00
1 0.50
1 0.50
1 0.50
1 0.50
1 0.50
1 0.50
1 0.50
1 0.50
1 0.50
1 0.50
QMS Focus Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 3 of 7
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866)390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:715959600
Policy NumberAPK056496266552
Claim #
Description of Service
1st 2nd Rev.
Date ICD9 ICD9 HCPC Code
NDC Billing
Number Quantity Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
132042-1 03/03/08-03!31108
NEEDLE AND SYRINGE 03!31!08 A4657 270 1 0.50
Treatment Item Subtotal: 11 $5.50
VENOFER 1 MG IV 03/14/08 280.9 J1756 636 100 308.00
03/19!08 280.9 J1756 636 100 308.00
03!26/08 280.9 J1756 636 100 308.00
Treatment Item Subtotal: 300 $924.00
ZEMPLAR 1 MCG IV 03/14!08 588.81 J2501 636 10 242.50
03/17/08 588.81 J2501 636 6 145.50
03!19/08 588.81 J2501 636 6 145.50
03/21/08 588.81 J2501 636 6 145.50
03/24/08 588.81 J2501 636 6 145.50
03/26/08 588.81 J2501 636 8 194.00
03/28/08 588.81 J2501 636 8 194.00
03/31/08 588.81 J2501 636 6 145.50
Treatment Item Subtotal: 56 $1,358.00
Claim Subtotal: 883 $18,479.37
QMS Focus Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 4 of 7
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866)390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:715959600
Policy NumberAPK056496266552
Claim #
Description of Service 1st
Date ICD9 2nd
ICD9 HCPC Rev,
Code NDC
Number Quantity Billing
Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
132043-1 04/02108-04/30/08
ADMIN SUPPLIES 04/02/08 A4657 270 1 13.85
04/02/08 A4657 270 1 13.85
04/02/08 A4657 270 1 13.85
04/04/08 A4657 270 1 13.85
04/04!08 A4657 270 1 13.85
04!07/08 A4657 270 1 13.85
04/07/08 A4657 270 1 13.85
04/09/08 A4657 270 1 13.85
04!09/08 A4657 270 1 13.85
04/09/08 A4657 270 1 13.85
04/11/08 A4657 270 1 13.85
04/11/08 A4657 270 1 13.85
04/14/08 A4657 270 1 13.85
04/14!08 A4657 270 1 13.85
04/t 6/08 A4657 270 1 13.85
04/16/08 A4657 270 1 13.85
04/16!08 A4657 270 1 13.85
04/18/08 A4657 270 1 13.85
04/18/08 A4657 270 1 13.85
04/21/08 A4657 270 1 13.85
04/21/08 A4657 270 1 13.85
04/23/08 A4657 270 1 13.85
04/23!08 A4657 270 1 13.85
04/23!08 A4657 270 1 13.85
04/25/08 A4657 270 1 13.85
04/25/08 A4657 270 1 13.85
04/28/08 A4657 270 1 13.85
04/28/08 A4657 270 1 13.85
04/30/08 A4657 270 1 13.85
QMS Focus
Release: 6.7.02
Itemized UB04 Statement
User JST{NE
Date: 2/3/09
Page 5 of 7
Facility; DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866) 390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:715959600
Policy NumberAPK056496266552
Claim #
Description of Service
Date 1st 2nd
ICD9 ICD9
HCPC Rev. NDC
Code Number
Quantity Blliing
Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
132043-1 04/02!08-04/30/08
ADMIN SUPPLIES 04/30/08 A4657 270 1 13.85
04/30/08 A4657 270 1 13.85
Treatment Item Subtotal: 31 $429.35
EPOETIN<10000/100 UNITS 100 UT 04/02/08 285.21 Q4081 634 33 288
09
IV .
04/04/08 285.21 Q4081 634 33 288.09
04/07/08 285.21 Q4081 634 33 288.09
04/09/08 285.21 Q4081 634 33 288.09
04/11/08 285.21 Q4081 634 33 288.09
04/14/08 285.21 Q4081 634 33 288.09
04/16/08 285.21 Q4081 634 33 288.09
04!18/08 285.21 Q4081 634 33 288.09
04/21 /OS 285.21 Q4081 634 33 288.09
04/23/08 285.21 Q4081 634 33 288.09
04/25/08 285.21 Q4081 634 33 288.09
04/28/08 285.21 Q4081 634 33 288.09
04/30/08 285.21 Q4081 634 66 576.18
Treatment Item Subtotal: 462 $4,033.26
HEMODIALYSIS TREATMENT 04/02/08 585.6 90935 821 1 1,048.00
04/04/08 585.6 90935 821 1 1,048.00
04/07/08 585.6 90935 821 1 1,048.00
04/09/08 585.6 90935 821 1 1,048.00
04/11/08 585.6 90935 821 1 1,048.00
QMS Focus
Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 6 of 7
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866) 390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:715959600
Policy NumberAPK056496266552
Claim #
Description of Service
Date 1st
ICD9 2nd
ICD9 HCPC Rev. NDC
Code Number
Quantity Billing
Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
132043-1 04!02/08-04/30!08
HEMODIALYSIS TREATMENT 04/14/08 585.6 90935 821 1 1,048.00
04/16/08 585.6 90935 821 1 1,048.00
04/18/08 585.6 90935 821 1 1,048.00
04/21/08 585.6 90935 821 1 1,048.00
04/23/08 585.6 90935 821 1 1,048.00
04/25/08 585.6 90935 821 1 1,048.00
04/28/08 585.6 90935 821 1 1,048.00
04/30/08 585.6 90935 821 1 1,048.00
Treatment Item Subtotal: 13 $13,624.00
NEEDLE AND SYRINGE 04/02/08 A4657 270 1 0.50
04/02/08 A4657 270 1 0.50
04/04/08 A4657 270 1 0.50
04!07/08 A4657 270 1 0.50
04!09/08 A4657 270 1 0.50
04/09/08 A4657 270 1 0.50
04/11/08 A4657 270 1 0.50
04/14/08 A4657 270 1 0.50
04/16/08 A4657 270 1 0.50
04/16/08 A4657 270 1 0.50
04/18/08 A4657 270 1 0.50
04/21 /08 A4657 270 1 0.50
04/23/08 A4657 270 1 0.50
04/23/08 A4657 270 1 0.50
04/25/08 A4657 270 1 0.50
04/28/08 A4657 270 1 0.50
04/30/08 A4657 270 1 0.50
04/30/08 A4657 270 1 0,50
Treatment Item Subtotal: 18 $9.00
VENOFER 1 MG IV 04!02/08 280.9 J1756 636 100 308.00
OMS Focus Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3109
Page 7 of 7
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866) 390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:715959600
Policy NumberAPK056496266552
Claim #
Description of Service
1st 2nd Rev. NDC Billing
Date ICDB ICD9 HCPC Code Number Quantity Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
132043-1 04102!08-04!30108
VENOFER 1 MG IV
ZEMPLAR 1 MCG IV
04/09/08 280.9 J1756 636 100 308.00
04/16/08 280.9 J1756 636 100 308.00
04/23/08 280.9 J1756 636 100 308.00
04/30/08 280.9 J1756 636 100 308.00
Treatment Item Subtotal: 500 $1,540.00
04/02/08 588.81 J2501 638 6 145.50
04/04/08 588.81 J2501 636 8 194.00
04/07!08 588.81 J2501 636 6 145.50
04/09/08 588.81 J2501 636 6 145.50
04/11/08 588.81 J2501 636 6 145.50
04/14/08 568.61 J2501 636 6 145.50
04/16/08 588.81 J2501 636 6 145.50
04/18!08 588.81 J2501 636 6 145.50
04/21/08 588.81 J2501 636 6 145.50
04/23/08 588.81 J2501 636 8 194.00
04/25/08 588.81 J2501 fi36 8 194.00
04/28/08 588.81 J2501 636 8 194.00
04/30/08 588.81 J2501 636 10 242.50
Treatment Item Subtotal: 90 $2,182.50
Claim Subtotal: 1,114 $21,818.11
Grand Total: 1,777 $40,287.46
QMS FOCUS
Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 1 of 5
FaciUty: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866) 390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:715959600
Policy NumberAPK056496266552
Claim #
Description of Service
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
132044-1 06/02/08-06/30/08
ADMIN SUPPLIES
1st 2nd Rev. NDC Billing
Date ICD9 ICD9 HCPC Code Number Quantity Charges
06/02/08 A4657 270 1 13.85
06/02/08 A4657 270 1 13.85
06/04/08 A4657 270 1 13.85
06/04/08 A4657 270 1 13.85
06/04/08 A4657 270 1 13.85
06106/08 A4657 270 1 13.85
06!06/08 A4657 270 1 13.85
06!09/OS A4657 270 1 13.85
06/09/08 A4657 270 1 13.85
06/11 /08 A4657 270 1 13.85
06711!08 A4657 270 1 13.85
06/11/08 A4657 270 1 13.85
06/13/08 A4657 270 1 13.85
06/13/08 A4657 270 1 13.85
06116/OS A4657 270 1 13.85
06/16/08 A4657 270 1 13.85
06/18/08 A4657 270 1 13.85
06/18/08 A4657 270 1 13.85
06/18/08 A4657 270 1 13.85
06/20/08 A4657 270 1 13.85
06/20/08 A4657 270 1 13.85
06/23/08 A4657 270 1 13.85
06/23/08 A4657 270 1 13.85
06/25/08 A4657 270 1 13.85
06/25/08 A4657 270 1 13.85
06/25/08 A4657 270 1 13.85
06/27/08 A4657 270 1 13.85
06/27/08 A4657 270 1 13.85
06/30/08 A4657 270 1 13.85
QMS Focus Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 2 of 5
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866) 390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:715959600
Policy NumberAPK056496266552
Claim # 1st 2nd Rev. NDC Billing
Description of Service Date ICDB ICD9 HCPC Code Number Quantity Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
132044-1 06/02/08-06/30/08
ADMIN SUPPLIES 06!30108 A4657 270 1 13.85
Treatment Item Subtotal: 30 $415.50
EPOETIN<10000/100 UNITS 100 UT 06/02/08 285.21 Q4081 634 66 576
18
IV .
06/04/08 265.21 Q4081 634 66 576.18
06/06/08 285.21 Q4081 634 66 576.18
06/09/08 285.21 Q4081 634 66 576.18
06/11/08 285.21 Q4081 634 66 576.18
06/13/08 285.21 Q4081 634 66 576.18
06/16/08 285.21 Q4081 634 66 576.18
06/18/08 285.21 Q4081 634 55 480.15
06/20/08 285.21 Q4081 634 55 480.15
06/23/08 285.21 Q4081 634 55 480.15
06/25/08 285.21 Q4081 634 55 480.15
06/27/08 285.21 Q4081 634 55 480.15
06/30/08 285.21 Q4081 634 55 480.15
Treatment Item Subtotal: 792 $6,914.16
HEMODIALYSIS TREATMENT 06/02/08 585.6 90935 821
1 1,048.00
06/04/08 585.6 90935 821 1 1,048.00
06/06/08 585.6 90935 821 1 1,048.00
06/09/08 585.6 90935 821 1 1,048.00
06/11 /08 585.6 90935 821 1 1,048.00
06/13/08 585.6 90935 821 1 1,048.00
QMS Focus
Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 3 of 5
Facility; DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866)390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BClBS 100
Group Number:715959600
Policy NumberAPK056496266552
Claim #
Description of Service Date
t
ICD9
d
ICDB HCPC
v. NDC
Code Number
antity
lling
Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
132044-1 08!02/08-08/30108
HEMODIALYSIS TREATMENT O6/16/08 585.6 90935 821 1 1,048.00
06/18/08 585.6 90935 821 1 1,048.00
06/20/08 585.6 90935 821 1 1,048.00
06/23/08 585.6 90935 821 1 1,048.00
06!25108 585.6 90935 821 1 1,048.00
06/27/08 585.6 90935 821 1 1,048.00
06/30/08 585.6 90935 821 1 1,048.00
Treatment Item Subtotal: 13 $13,624.00
NEEDLE AND SYRINGE 06/02/08 A4657 270 1 0.50
06/04/08 A4657 270 1 0.50
06!04!08 A4657 270 1 0.50
06!06/08 A4657 270 1 0.50
06!09/08 A4657 270 1 0.50
06/11/08 A4657 270 1 0.50
06/11/08 A4657 270 1 0.50
06/13/08 A4657 270 1 0.50
06/16/08 A4657 270 1 0.50
06/18/08 A4657 270 1 0.50
06/18/08 A4657 270 1 0.50
06/20/08 A4657 270 1 0.50
06/23/08 A4657 270 1 0.50
06/25/08 A4657 270 1 0.50
06/25!08 A4657 270 1 0.50
06/27/08 A4657 270 1 0.50
06/30/08 A4657 270 1 0.50
Treatment Item Subtotal: 17 $8.50
VENOFER 1 MG IV 06/04/08 280.9 J1756 636 100 308.00
06/11/08 280.9 J1756 636. 100 308.00
06/18!08 280.9 J1756 636 100 308.00
QMS Focus Release: 6.7.02
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 4 of 5
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866) 390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:715959600
Policy NumberAPK056496266552
Ciaim #
Description of Service
1st 2nd Rev.
Date ICD9 ICD9 HCPC Code
NDC Billing
Number Quantity Charges
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
132044-1 06!02!08-08/30/08
VENOFER 1 MG IV
ZEMPLAR 1 MCG IV
06!25/08 280.9 11756 636 100 308.00
Treatment Item Subtotal: 400 $1,232.00
06/02/08 588.81 12501 636 8 194.00
06!04/08 588.81 12501 636 8 194.00
06!06/OB 588.81 12501 636 8 194.00
06/09/08 588.81 12501 636 8 194.00
06/11108 588.81 12501 636 8 194,00
06/13/08 588.81 12501 636 8 194.00
06/16/08 588.61 12501 636 8 194.00
06/18/08 588.81 12501 636 8 194.00
06/20/08 588.81 12501 636 8 194,00
06/23/08 588.81 12501 636 8 194.00
06/25/08 588.81 12501 636 8 194.00
06/27/08 588.81 12501 636 8 194.00
06/30/08 588.81 12501 636 g 194,Op
Treatment Item Subtotal: 104 $2,522.00
Claim Subtotal: 1,356 524,716.16
QMS Focus Release: 6.7.02
r
Itemized UB04 Statement
User JSTINE
Date: 2/3/09
Page 5 of 5
Facility: DCA-WEST BALTIMORE
22 SOUTH ATHOL STREET
BALTIMORE, MD 212293405
(866)390-0376
Provider Number: 20MJ
Insurer: CAREFIRST BC/BS 100
Group Number:715959600
Policy NumberAPK056496266552
Claim #
Description of Service
Patient: CROSBY, WILLIAM
1503 NORTH HILTON ST
BALTIMORE, MD 21216
132045-1 07/02/08-07/04/08
1st 2nd Rev.
Date ICD9 ICD9 HCPC Code
NDC Billing
Number Quantity Charges
ADMIN SUPPLIES 07/02/08 A4657 270 1 13.85
07/02/08 A4657 270 1 13.85
07/02/08 A4657 270 1 13.85
07/04/08 A4657 270 1 13.85
07/04!08 A4657 270 1 13.85
Treatment Item Subtotal: 5 $69.25
EPOETIN<10000/100 UNITS 100 UT 07!02/08 285.21 Q4081 634 55 480
15
IV .
07104!08 285.21 Q4081 634 55 480.15
Treatment Item Subtotal: 110 $960.30
HEMODIALYSIS TREATMENT 07/02/08 585.6 90935 821 1 1,048.00
07/04/08 585.6 90935 821 1 1,048.00
Treatment Item Subtotal: 2 $2,096.00
NEEDLE AND SYRINGE 07/02/08 A4657 270 1 0.50
07/02/08 A4657 270 1 0.50
07/04/08 A4657 270 1 0.50
Treatment Item Subtotal: 3 $1.50
VENOFER 1 MG IV 07!02/08 280.9 J1756 636 100 308.00
Treatment Item Subtotal: 100 $308.00
ZEMPLAR 1 MCG IV 07/02/08 588.81 J2501 636 8 194.00
07/04/08 588.81 J2501 636 8 194.00
Treatment Item Subtotal: 16 $388.00
Claim Subtotal: 236 x3,823.05
Grand Total: 1,592 x28,538.21
QMS Focus Release: 6.7.02
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
Timothy Ziegler, Reimb. Analyst
Karen L. Fisher, Paralegal
Jennifer Kain, Paralegal
Keyoung Gill, Paralegal
{licensed ii PA, N1 and MU)
"'~ Uiccrscd in PA and MD)
William Crosby
1503 N. Hilton Street
Baltimore, MD 21216
Ca~a~_ & 1~~ ssocates, P C.
f~
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October 28, 2009
Re: Account with Dialysis Corporation of America
Account Balance: $90,136.05, plus costs of collection
Our Matter No.: 1087-08
Dear Mr. Crosby:
2933 Nonh Front Street
Harrisburg, PA ] 71 l 0
Telephone: (717) 233-4101
Fax: (717)233-4103
www.capozziassociates.com
Craig 1. Adler, Esq.
Of Counsel
Please be advised that our- law frm 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,
/kJg
cc: Lisa A. Laudeman, DCA
~~~ ~.~
Michael M. Jerominski
EXHIBIT
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, Nl and MD)
•' (licensed in -A aid MD)
' ~ ,~,_ .
December 3, 2009
William Crosby
1503 N. Hilton Street
Baltimore, MD 21216
Re: Account with Dialysis Corporation of America
Account Balance: $90,136.05, plus costs of collection
Our Matter No.: 1087-08
Dear Mr. Crosby:
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 28,
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,
Michael M. Jerominski
/kj g
cc: Lisa A. Laudeman, DCA
THIS LETTER AND ANY FUTURE LETTERS FROM OUR FIRM ARE AN ATTEMPT TO COLLECT A
DEBT, AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
DIALYSIS CORPORATION OF AMERICA IN THE COURT OF COMMON PLEAS OF
d/b/a DCA OF WEST BALTIMORE, CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v.
WILLIAM CROSBY,
Defendant
Docket No.:
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: ~ ~V W
~~ ~~
Lisa Laudeman
Reimbursement Manager
Dialysis Corporation of America
214 Senate Avenue, Suite 300
Camp Hill, PA 17011
T ~, ,
DIALYSIS CORPORATION OF AMERICA
d/b/a DCA OF ROYSTON,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
v. Docket No.: 10-03308
WILLIAM CROSBY,
n
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Defendant Civil Action -Law ~ ~ ~ ~~'
.
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AFFIDAVIT OF SERVICE '~ A -~ ` r~: ; `;__
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COMMONWEALTH OF PENNSYLVANIA ) ,
.
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.t„
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 mailed a copy of the attached Complaint upon the
Defendant by putting it in a postage prepaid envelope and mailing it to Defendant William
Crosby, 1503 N. Hilton Street, Baltimore, Maryland 21216 by first class certified U.S. mail.
The Complaint was "Returned to Sender" as "Refused." A true and correct copy of
Defendant's returned certified mail and Complaint is attached hereto as Exhibit "A."
3. On June 14, 2010, a copy of the attached Complaint was mailed to Defendant by first class
regular U.S. Mail, postage prepaid. A true and correct copy of the Certificate of Mailing is
attached hereto as Exhibit "B."
4. It has been over 15 days after mailing the Complaint to the Defendant by ordinary mail. The
Complaint has not been returned to sender.
..
Date: ~ ~~ ~ lU
Michael M. Jerominski, Esquire
Attorney I.D. No. 92977
Capozzi & Associates, P.C.
2933 N. Front Street
Harrisburg, PA 17110
(717) 233-4101
Attorney for Plaintiff
Sworn to before me this '/ ~" day
of July 2010.
Notary P tic
COMMONWEALTH OF PENNSYLVANM
Notarial Seal
Keyounp J. Glq, Notary Public
Suaquehanna TWp., Dauphin County
My Commfaaion t~cplresAprN 1, 2019
Member, Pennsylvania Association of Notaries
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Exhibit A
DIALYSIS CORPORATION OF AMERICA
d!b/a DCA OF WEST BALTIMORE,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v.
Docket No.: 10-03308
WILLIAM CROSBY,
Defendant
Civil Action -Law
NOTICE TO DEFEND
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 the complaint and notice aze served, by
entering a written appeazance personally or by
attorney and filing in writing with the court your
defenses or objections to the claims set forth
against you. You aze 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 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.
CUMBERLAND COUNTY BAR ASSOCIATION
32 S. BEDFORD STREET
CARLISLE, PA 17013
1-800-990-9108
717-249-3166
AVISO
Le han demandado a usted en la Corte. Si usted
quiere defenderse de estas de estas demandas
expuestas an las paginas signientes, usted tiene
veinte (20) dias de plazo al partir de is fecha de la
demanda y is notificacion. Hace falta asentar una
comparencia escrita o en persona o con un
abogado y entregaz a la Corte en forma escrita sus
defensas o sus objeciones a las demandas en contra
de su persona. Sea avisado que si usted no se
defiende, le Corte tomaza medidas y puede
continuaz la demanda en contra suya sin previo
aviso o notificacion. Ademas, la Corte puede
decidir a favor del demandante y requiere que
usted cumpla con todas las provisiones de esta
demanda. Usted puede perder dinero o sus
propiedades u ostros derechos importantes para
usted.
LLEVE ESTA DEMANDA A UN ABOGADO
INMEDIATAMENTE, SI NO TIENE
ABOGADO O SI NO TIENE EL DINERO
SUFICIENTE DE PAGAR TAL SERVICIO.
VAYA EN PERSONA O LLAME POR
TELEFONO A LA OFICINA CUYA
DIRECCION SE ENCUENTRA ESCRITA
ABAJO PARR AVERIGUAR DONDE SE
PUEDE CONSEGUIR ASISTENCIA LEGAL.
CUMBERLAND COUNTY BAR ASSOCIATION
32 S. BEDFORD STREET
CARLISLE, PA 17013
1-800-990-9108
717-249-3166
0
DIALYSIS CORPORATION OF AMERICA IN THE COURT OF COMMON PLEAS OF
d/b/a DCA OF ROYSTON, CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v Docket No.: 10-03308
~ ~, '-~
WILLIAM CROSBY, : .~., _y., ~,- ~
_ ;__ _ Tr_
;, :,
Defendant Civil Action -Law _ ~ ~'
-.z
w -,`
;.
PRAECIPE TO ENTER DEFAULT JUDGMENT ~,? J a
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, William Crosby, 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: $119,232.09
Attorney Fees: $ 665.50
Cost of Court: $ %~a
TOTAL:
~ I I Q ,947.5tiI
* 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
~ I~.00 P 0 AT't-y
e* aao~3
~* ~4~~6
IJo~~~a, I~t.~.~
authorities. I verify that:
1. The last known address for Defendant is as follows:
William Crosby
1503 N. Hilton Street
Baltimore, MD 21216
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."
Capozzi & Associates, P.C.
Date: July 29, 2010 By: ~ i~~Z'u'', ~~ -
Michael M. Jeromins i, Esquire
Attorney I.D. No. 92977
2933 North Front Street
Harrisburg, PA 17110
(717) 233-4101
Attorney for Plaintiff
DIALYSIS CORPORATION OF AMERICA IN TH.E COURT OF COMMON PLEAS OF
d/b/a DCA OF ROYSTON, CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v• Docket No.: 10-03308
• ~ ~ -~
WILLIAM CROSBY, `, ~ j
,.~.,,..~.. c.~
-- t -,-.
Defendant Civil Action -Law -- -- ` ',
~,
r~=
AFFIDAVIT OF SERVICE - ~~~', •
<_~ ~ _ -
COMMONWEALTH OF PENNSYLVANIA ) ~ :,:_
. ,.., - .:
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 mailed a copy of the attached Complaint upon the
Defendant by putting it in a postage prepaid envelope and mailing it to Defendant William
Crosby, 1503 N. Hilton Street, Baltimore, Maryland 21216 by first class certified U.S. mail.
The Complaint was "Returned to Sender" as "Refused." A true and correct copy of
Defendant's returned certified mail and Complaint is attached hereto as Exhibit "A."
3. On June 14, 2010, a copy of the attached Complaint was mailed to Defendant by first class
regular U.S. Mail, postage prepaid. A true and correct copy of the Certificate of Mailing is
attached hereto as Exhibit "B."
4. It has been over 15 days after mailing the Complaint to the Defendant by ordinary mail. The
Complaint has not been returned to sender.
Exhibit A
Date: ~ ~~ ~ ~'~
Sworn to before me this ~ 1-~~ day
of July 2010.
Notary P lic {~ ;v
COMMONWEALTH OF PENNSYLVANW
Nohrial Seal
Keyounp J. Gill, Notary Public
Susquehanna Twp., Dauphin County
My Commission Expires Apri11, 2013
Member, Pennsylvania Association of Notaries
/~r(~
Michael M. Jerominski, Esquire
Attorney I.D. No. 92977
Capozzi & Associates, P.C.
2933 N. Front Street
Harrisburg, PA 17110
(717) 233-4101
Attorney for Plaintiff
Exhibit A
~.;
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001 6332 2273
PS Form 38~ 1, Fetxuary 2004
Domestic Return Receipt 102595-02-M 1540
Exhibit A
Exhibit A
DIALYSIS CORPORATION OF AMERICA IN THE COURT OF COMMON PLEAS OF
dlb/a DCA OF WEST BALTIMORE, CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v. Docket No.: 10-03308
WILLIAM CROSBY,
Defendant Civil Action -Law
NOTICE TO DEFEND
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 the 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 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.
CUMBERLAND COUNTY BAR ASSOCIATION
32 S. BEDFORD STREET
CARLISLE, PA 17013
1-800-990-9108
717-249-3166
AVISO
Le han demandado a usted en la corte. Si usted
quiere defenderse de estas de estas demandas
expuestas an las paginas signientes, usted tiene
veinte (20) dias de plazo al partir de is fecha de la
demanda y is notificacion. Hace falta asentar una
comparencia escrita o en persona o con un
abogado y entregar a la corte en forma escrita sus
defensas o sus objeciones a las demandas en contra
de su persona. Sea avisado que si usted no se
defiende, le corte tomara medidas y puede
continuar la demanda en contra suya sin previo
aviso o notificacion. Ademas, la corte puede
decidir a favor del demandante y requiere que
usted cumpla con todas las provisiones de esta
demands. Usted puede perder dinero o sus
propiedades u ostros derechos importantes para
usted.
LLEVE ESTA DEMANDA A UN ABOGADO
1NMEDIATAMENTE, SI NO TIENE
ABOGADO O SI NO TIENE EL DINERO
SUFICIENTE DE PAGAR TAL SERVICIO.
VAYA EN PERSONA O LLAME POR
TELEFONO A LA OFICINA CUYA
DIRECCION SE ENCUENTRA ESCRITA
ABAJO PARR AVERIGUAR DONDE SE
PUEDE CONSEGUIR ASISTENCIA LEGAL.
CUMBERLAND COUNTY BAR ASSOCIATION
32 S. BEDFORD STREET
CARLISLE, PA 17013
1-800-990-9108
717-249-3166
Exhibit A
DIALYSIS CORPORATION OF AMERICA
d/b/a DCA OF ROYSTON,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
v.
Docket No.; 10-03308
WILLIAM CROSBY,
Defendant
Civil Action -Law
NOTICE OF INTENTION TO ENTER JUDG V~IENT BY DEFAIJrLT
TO: William Crosby
1503 N. Hilton Street
Baltimore, MD 21216
DATED: July 7, 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
3UDGMENT MAY BE 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. BEDFORA STREET
CARLISLE, PA 17013
1-800-990-9108
717-249-3166
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.: 10-03308
WILLIAM CROSBY,
Defendant : Civil Action -Law
NOTICIA IMPORTANTE
TO: WilUam Crosby
1503 N. Hilton Street
Baltimore, MD 21216
DATED: July 7, 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
PARA AVERIGUAR A DONDE USTED PUEDE OBTENER LA AYUDA LEGAL.
CUMBERLAND COUNTY BAR ASSOCIATION
32 S. BEDFORD STREET
CARLISLE, PA 1'1013
1-800-990-9108
717-249-3166
I i~2~~ /vim .
Michael M. Jerominski, Esquire
I.D. No. 92977
Capozzi & Associates, P.C.
2933 N. Front Street
Harrisburg, PA 17110
(717) 233-4101
Exhibit B
DIALYSIS CORPORATION OF AMERICA
d/b/a DCA OF ROYSTON,
Plaintiff
V.
WILLIAM CROSBY,
Defendant
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
Docket No.: 10-03308
Civil Action -Law
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:
William Crosby
1503 N. Hilton Street
Baltimore, MD 21216
Capozzi & Associates, P.C.
Date: July 29, 2010 By: /~
Michael M. Jerominski, esquire
Attorney I.D. No. 92977
2933 North Front Street
Harrisburg, PA 17110
(717) 233-4101
Attorney for Plaintiff