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HomeMy WebLinkAbout10-3310DIALYSIS CORPORATION OF AMERICA IN THE COURT OF COMMON PLEAS OF d/b/a DCA OF CHESAPEAKE, CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff v. THOMAS W. MEDICUS, Defendant • n Docket No.: ~p - 331 Q N _ ~'°- ©1F -~ . !r ~~`I ~~ Civil Action -Law ~-~ ~ ~_~' ~•' , ,c7 t i ~, f' ) ' ~_'i r 'f'ry COMPLAINT ~' ~' '` -~ ~~ tff -c NOW COMES, Dialysis Corporation of America d/b/a DCA of Chesapeake, 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: Plaintiff, Dialysis Corporation of America d/b/a DCA of Chesapeake ("DCA of Chesapeake"), is a registered Pennsylvania corporation having its principal place of business at 27 Miller Avenue, Lemoyne, Cumberland County, Pennsylvania 17043. 2. DCA of Chesapeake is an operating subsidiary of Dialysis Corporation of America ("DCA"). 3. Defendant Thomas Medicus ("Patient" or "Defendant") is an adult individual with a last known address at 3517 Castle Way, Davidsonville, Maryland 21035-2324. 4. DCA of Chesapeake provides dialysis treatments and services to its patients. 5. On or about March 25, 2008, Defendant executed a Consent for Hemodialysis Agreement ("Consent Agreement") to allow Defendant to receive regular dialysis treatments from DCA of Chesapeake as scheduled by his physician and DCA of Chesapeake. A true and correct copy of the Consent Agreement is attached hereto and incorporated herein as Exhibit «A.„ O ~Qa . DO PU ATt~1 C~~ O'1.1~~3 2# a~{a.3oa 6. On or about March 25, 2008, 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 Chesapeake. 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 Chesapeake 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 Chesapeake, 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 Chesapeake, be paid and remitted directly to DCA of Chesapeake...." 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 Chesapeake 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 Chesapeake...." 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 Chesapeake." [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 Chesapeake, the Patient shall be responsible for any and all charges and costs billed by DCA of Chesapeake for dialysis treatments and related services ...and that DCA of Chesapeake is authorized to bill the Patient directly for payment of such charges and costs." 12. DCA of Chesapeake, at the special insistence and request of Defendant during the period March 25, 2008 through April 12, 2008 ("Dates of Service"), provided numerous separate dialysis treatments ("Dialysis") at the rates and on the dates set forth in DCA of Chesapeake'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 $18,604.09. 14. On October 28, 2009 and December 3, 2009, DCA of Chesapeake's counsel mailed to Defendant demand letters, which provided information on how to pay the debt owed to DCA of Chesapeake. A true and correct copy of the demand letters are 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 Chesapeake. 18. Defendant's insurance provider did not always pay 100% of DCA of Chesapeake's claims, which resulted in Defendant owing a co-pay to DCA of Chesapeake ("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 Chesapeake on a monthly basis. 20. The amounts that Defendant received from CareFirst pursuant to the claims submitted by DCA of Chesapeake 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 $18,604.09 from CareFirst for the Dialysis treatments during the Dates of Service. 22. During the Dates of Service, Defendant did not transfer any monies received from CareFirst for the Dialysis treatments to DCA of Chesapeake. 23. The total amount of principal that has become due and owing by Defendant to DCA of Chesapeake as a result of his failure to transfer the insurance payments that he received and his failure to pay his Co-pay is $18,604.09 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 Chesapeake has been financially damaged in the amount of $18,604.09, 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 Chesapeake pursuant to the Assignment and Authorization Agreement constitute a breach of contract. WHEREFORE, Plaintiff, Dialysis Corporation of America d/b/a DCA of Chesapeake, demands judgment against Defendant in the sum of $18,604.09, 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 Chesapeake and Defendant, which is denied, then, in that event, DCA of Chesapeake 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 Chesapeake to provide the dialysis treatments and DCA of Chesapeake having done so to the benefit of Defendant, Defendant became liable to DCA of Chesapeake 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 $18,604.09, as is more specifically reflected in the Account Statement. 32. DCA of Chesapeake 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 Chesapeake, demands judgment against Defendant in the sum of $18,604.09, plus interest at the legal rate of 6% per annum from the date of judgment. COUNT III -CONVERSION OF MONEY 34. DCA of Chesapeake 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 Chesapeake pursuant to the Assignment and Authorization Agreement, the insurance payments Defendant received from CareFirst properly belonged to DCA of Chesapeake. 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 Chesapeake for the Dialysis it provided to him. 37. During the Dates of Service, Defendant's insurance provider paid to him $18,604.09. 38. During the Dates of Service, Defendant did not transfer any insurance payments made by CareFirst payable to Defendant to reimburse DCA of Chesapeake. 6 39. Defendant intentionally and permanently retained possession of the monies owed to DCA of Chesapeake by failing to transfer a total of $18,604.09 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 Chesapeake for the Dialysis provided to Defendant constitutes conversion. 41. DCA of Chesapeake has been financially damaged by Defendant's conversion in the amount of at least $18,604.09. WHEREFORE, Plaintiff, Dialysis Corporation of America d/b/a DCA of Chesapeake, demands judgment against Defendant for conversion in the sum of $18,604.09, plus interest at the legal rate of 6% per annum from the date of judgment. Respectfully submitted, Capozzi & Associates, P.C. Dated: S f iH f f J B /~'r/. Y~ Michael M. Jerominski, Esquire Attorney I.D. No. 92977 2933 N. Front Street Harrisburg, PA 17110 (717)233-4101 Attorneys for Plaintiff 7 a~ts~s c~:~u~PoT~ta~T a~ R~~~~ca CQ?V~l/1~'I' ~'f.~T~ .H~l°VIObIALXSIS Patferlt. ` ~ . u ~:..:"~---~~' t. ~ 1~TefmUcr; ~~, ~, `(.,rl(~_ ~ ~ Date: ~ ~ , i, the ~ndersfgrned gatiiertt, ~ . i, tha ttrtdersigy~eci parent cr' guardian of~e abav~e patient whn is urrdet 1 g year's of agb ox utilGr~Wisevica~abte at'consenfi€n~; hereby i'etluest and authorize Dr. y a.~d ~~laoarte~-er he a~• sba may desgraata ~ his or laar• associate aY• assistent to aclmirtista• to nae {ot• to tl~e above named ' patients the priaratlure ititrvwx~ as ,he~nadfalys:{s, tarider zuch condit~atias as shall be d~~hlecl i;y the physician, ts~ in atitenclance. I agree co abide by ilZe paIicies= t~Ies, axrd regelatirna.s estahlis?~ed 6y`#lre above nested Dfalysig t3nit i~a cats+irag ant i;t$ hernodialysisprom. It 1Y~ beerl.expla9i~ed to r>~e~tlaat hem4dialysis is s pz~oeedut~ u3ecl in the case oI•pa#:eaxts ~vitix inxpaurarc~s#: oI~~,iYure afl<idncy tlxaction by'wluc>x certain components ofthc•blaad ara seperateet~lay a senu.-perza;eable sulastance ~~vHiclS pamit9 the ~aasega of ceriain rnalce~les artd hinders chat +of atlaez~s when the bl.vod is ciz~ulated tlaraugIl ran at~i~cial kidney; callod a ri3aly`~a. Y €tndexSt~d the mete ~ dir~'et'eni; t}-~aas ai eguipmcnt employed for t7ie dialysis treatmcrrt and da~`ereza't types of art~e3ai' kitlsteys (ttialyzers} user! in the pre~cess, I eckriQV'rledge that the possible risks end CornpNcatfrn~ t~f be~aciial~+sg such as ~S~' nbt limited to leal~ag~ Of floe dialyzes, cbaes ira bland ~'cssure,llat'nc~lysis (breakdowzr of reri t}}trod cells), hypoxerrifa tr~ductaxx at' ox~+gen in the 6totrtl~, hee7-t st7'1~-tJan~.ias, and mRlfzn.Gtiozz o!`~gtitipruent fiawe been, e~aleabtd td me by tl~e prtat`essioaa} laersornael af~Ehe • Dialysis U~xit a»d z eP~ on:~rah~f ofrnyselfapdCarthe 5~bove nstierat the di.slysis tr~eatm~ent ~ - witlx ~Il patcrrtial risks eza3 c~i~'n~iXrcafi~uYS. I. also undcrst$nd then arty dsordei, which afflicts • me, cat's have e~`ects crn my treatrc;erat and Qn rzrysclf, dui floe #im,e flirt' i em receiving a cusis ttea~riie~'biat~at tl~i`s~.a`ct`~e~ 3.ac~m`een r~aaf~~as . sir :r`eatmen ~iiig to cis with tha cievelopzi~eiat of the ptoblcin rotated to this contlil~oti. I ~rtlier consent t:o xhe~ admiinastratynzx of such drubs, tr~au,s~vaious of blood or blood c4naponen~, or attyr o~ttaer _ trea#~i~rit goad est3n~, inclvdirig HI~J testing, deemed necessary ar desirable ira the judgment oft13~ ~.ysician {s~ in et#endanre, T am e~vat~ rhat the pr~ct3c~ a~`~iodicuie is not an exact scian~cey, encl ! ackzao+iv3edge that no guaxauxtee, l~vanent~~ cif re~rzt':sentatiou'wh~ztsoeve~r has beau, o~~'®cI rn• made tome or ariyvne ©n my behalf crnicerztiztg the results of the IZCrncxi*a~yais prace~u e. _ . .., . 1 Paiicnt Lognl Guarala~i of )+eront Print l~iame;~' ~ ld'r~~ -~t',~~:~. l~~i( n~,t~rt#a: ~,~d,~' 1~%tnegs:~~~~,~'C'~ ~. ~_ bate: `'3~ ~d~ - ~_ - - + EXHIBIT / J ~1It1.IaYSIS Cdl~'~1~tTjv0~10~'Ah.~:Cr~ „~.~' ,...-~ Fx~ri]ir,Y: ~~~ di i;:~esancake ]~ntc: _ -,,.~.._ FstienE Nstrn'e':~1.~."t ~~'~(', lt^~~ ~'aritil5:i Ib~': „7, fP3ease?rint j ~e urldersigrtd het'eFry assigns, transf'.•rs and sat;;n~. to DC~c of Chcsapea~e utnniex endl~r• lwite~ts tc> which t1t~ Patient. is (err rnsy ~j titled isom any ias7u~nce art~or health care. prrvickr t+r naifnanli . county or 1~1 gov~:r'tinra»t~ rgcncy, in~~l+:aitrg thn Mt+ctirart it~urance inbiir~ tts vrefi as tmy othars •~1tc- may oe fSnbrcirJiy lkable for the Fmicnt's dialysis tret'ments on,! seavic~s rnrt4 >'eiatod i».aslica) cerC by ~d~~r. at :f~CA of Ck~csapaal;:t, i.~clUding health insuraraca t~t:iits, ups}cr madiaai banailYa and uchcr ttYadi~! ~iyit~ent c~vcra~e nr bt#srr policy ccvtragc fnr which the ~'afinnt }s ~nttdeci, to cc3ver tlcr aas~.s of dialysis tT2af~etTt anti `rrvis is'td ~ trthar rtresl~el c~[ra randerad to tf1~ti P'a.'deiit by atrdrtar wt L?CA of C#~~n, ~. ~!~`I'H-+C~~2X7..~.';1'~O~f t?~' PAYM~~'T t7~' ~'NSU~L~tC~ I3~l~f~I~T'S . ilic ruzctcrsigpad h~c~ sutu~rirxs ~,~t r>;ire~is tihat pa~rnrrri ni ai1 izssu: arrce batra~fts, r+cludi~ 1~ndicera baneiiis, if' e~Uc~rirle, relrring to Genf urges and costs inc~ucred as a resuh of dialysis ilroota~ezrta and relatctl sE:'vices tir~ci rnec23r~a1 care frr+ovidr~t to the Patient by &isdlor tit ISCA of Ghcsapeslc~, be ~atd aid rttrtitted d.YVCtIy to ~~~ of trhesepe in accord~ar with i~s+:xuctions provi~~:c.d r,± to be ~ovided by went Or rG'~rCSZrt'I8tlYC G'f I}CA Of G`~sapeale. Ift1~a cirldern~ttad'9 insura!rce 1selfoy'or prag~atn does 11Ct ~roVicte f'or riayrnent of thm ntoi~ia~ nr 1~9l7M3ik . irr the name of DCA of CYresap4akc, the vurJ~igneci hertby ftit~ar zatlroti~es a~,d tnstructs dra Fnscuance .- ~t#~-~ ~+csposfsial+€'for payna~`o~'"tire p a-iast:tr~~zras `a3ii~ia s9~setct ~s ~iia 1~~rtisnt's rsamc ~d to deliver said puymtrt w INCA of ~bes~c et:.~#s atddrass us set £ds~r iss ttre iristrt~ticr~provided arto bepravi3td by an 47~iepreStnttitivt oS 1~G~. of'C~Iaa~irealce. ~, ;i)~.3~'3' dF ~~'IT >E'A~'."~.l~i~~ 17 ~ ~1~~~~ Tltc uttderst~tQtf braab~' aclt>sowledgcs that tftc moaiat or boisei?tt~r to bn pzici by tfia P4ticnt'& fnxuranae pribvfdar ur gir~•erpment agency' ~r tlro cber~a,p, eas#s and f'ee3 ftr.auri~aci by ACA of CJ,+~apealca in frs pa'~ision of disigsf3 trt~,tr~nmats and related: serQfccs and ~ad~eal. care i4 the Pstia~t fa and slr+~lt s# rill t-mrs rcarra#n, the propu~ ~i'vcA oi` C'be+rapaalte. and in fwrtboranca thereof #ba andcrsigue3 heraby ceveaapta Brad sgreas that fia fiy~ tvrnt tbaf ratty paygreul of ist~uran'ca bentfita, hrcfttdabg Mcdfcare berrcflis; tYliielr rCt~te dfrectl~' CA the c?aairgasy costs attd 1'C~g iacvr><ed by DC~1 of Chesapenk¢ as t rr~nlt of its provSsfaa of ttfflyai# tr•e~rtritcista and raletrsf services s»rI Bres3icaf care tb tics ParieAt is mart to the Patient ~r sue1~ Patient'°Q gteerdfan, ettoracy- in~i"act ttr rspaescutacive, ae tia:t rarse paa~r bc, 3na~ezictrtty or bt~eria, that: the uridcrxi~itdd ~ pramlitly and utrcotrditidnslly for-~rrsrd tnc1~ puymerft d1r~t2y rn bCA, oi' C'irasaf~eake. Pegs Y. aft EXHIBIT ~, ~~t~c~is>r a>~ ~>~~nn~, ~...~ Tl~r uatdt!'sigt'l+sd !•~artby :~tatfya~i9zts and a:tv~Serns to thrs rC)case '~+ 1~C:~ of Gha~areaY,c, ar ariy of its • ngarrlts or r~lsra;g~ntatives, cif ~1i c~!' pal~- of nary irlfarlnnla», -rocoi'd5 or repcuty, ci1'~cT latiediC;~i ar flnauGia~ in r.~ttare~ fr; ar t~itlt an~r petsa~r rxsrrarstlorl ar go~~Crrunr=r~F ~+~;Cy,. 1b.*,°ud`i~,~ try t~lird-partfy° tns~~raryce andlar htalt,'~ ctue {ar~ovider, n+bo is fJrerrc#~}!} t#sh:a: for lht Pstic,~t`s di~iysis trra~~ln~ts r+:latrd s~rces ea ~vxl3 us rnaoical cure, w;'ucfi ittfol7nariie~ is rrax~,rtcy fair r)~t subxtaarltiatia><a,. verifiaa~an asndlar CO!)J'~1>'~bt7 a)f" i~YUiaitt af' Cl~rgas CG5`~ t~s bCA •1)f ~a:5apeal<e taT the prcwi.siarr! to the Pbtit:!'rt 4f` stteh dl~ilrsis troaltnonti anal l~aytast+~3 si;ivicals ns we#1 as tnsdaall ire. 3. :lSia~J-TIS~B)Ll'~''X FC)~ P~4X~TS ~•.... ,,~....; T1te arndersig~cd Iacrchv ackrrYw~fiadgas ih~f, ayayttc~i#b~.at~drlg iliac foregoing asaffa:rlt and attKlzartz~ios~t • at' bs=rtaft i.aylricrtes tr; L)artl tsf ~hesapa;ake, the Fgii:~t siiali lhir.i~iot~sbi'e far any 84tCd r:ll c>*srs~ ate. costs l}idird by ACA cst Cl~3sale f'ar analysis . trtaa~e7lt5 a~ ttI> ser~iccs ~+ovicibd and. 'na1 otT~ertivlst cavertr! ar ~aia3 >yy such t}tird•polty pttyay!' ar gavl+~tal a~~tir+y+a irfcludi~g, va~itlravt limitttilaiu asil tledtaa~ible, ao-ist9ltrsnaa: and eC•P~?'metii almaa~ltgrtS, muti thai bf:A a1F Cbesapcsyx is a€rt~tari~d to hill the P$sicrxt dixa:dtiy' fog payrncrrt afsuwh cF.arges arld casts. 6. ~'t~~'?C.~,t3JCt.tI1"~" ~a tstadcrsigt~a~l hereby asctahawicciga;s that tins PAT''T ASS~CrNA2£NT` ~ AUT,~I~R:t~,~03J ~F ~,AY~+fII3"1` t~F INSURi4~YCl~ 3EN.l~t"~~'S hey r,~'. be itvbka~3 a~iicss revti~in is accnmpaai~ hY t?se ~vr•~er! corsc7lt o such ra;vacatitrtz by LDGA ai` ptasairea„kas. ~. 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Pori l~Tottsa;: `P4'lfii~ss: Uxtar: Pagc 2 a:sf 2 DIALYSIS CORPORATION of A M E R I C A Thomas Medieus g217t;FIE DOS T I es Carefirst Pafd To P DCA .Amt Pt Owes r k Total Account Bala n 03/25-29 2008 $ 5,606.07 $ _ 5,606.07 $ - $ 5,606.07 _ $ ~v 5,606.07 04/03.12/2008 _ $ 12,998.02 $ 12,998.0 $ $ 12,998.02 $ 12,998.02 TOTALS: $ 18 604.09 $ 18,604.0 $ $ 18,604.09 18 604.09 214 Senate Avenue, Suite 300, Camp Hill, PA 17011 • Phvne (717) 730-6164 • Fax (717) 730-9133 www, dialysiscorporation.com EXHIBIT C Itemized U B04 Statement User JSTINE Date: 2/3/09 Page 1 of 3 Facility: DCA-CHESAPEAKE 305 COLLEGE PARKWAY ARNOLD, MD 210122912 (866) 390-0376 Provider Number: 22SX Insurer: CAREFIRST BCBS Group Number:OFWE Policy NumberXIP903626402 Claim # Description of Service Patient: MEDICOS, THOMAS W. 3517 CASTLE WAY DAVIDSONVILLE, MD 21035 132074-1 03!25/08-03/29/08 1st 2nd Rev. Date IC09 ICD9 HCPC Code NDC Billing Number Quantity Charges ADMIN SUPPLIES 03/25/08 A4657 270 1 13.85 03/25/08 A4657 270 1 13.85 03/27/08 A4657 270 1 13.85 03/27/08 A4657 270 1 13.85 03/29108 A4657 270 1 13.85 03/29/08 A4657 270 1 13.85 Treatment Item Subtotal: 6 $83.10 EPOETIN<10000/100 UNITS 100 UT 03/25/08 285.21 04081 634 88 768.24 IV 03!27/06 285.21 04081 634 88 768.24 03!29/08 285.21 04081 634 88 766.24 Treatment Item Subtotal: 264 $2,304.72 HEMODIALYSIS TREATMENT 03/25/08 585.6 90935 821 1 1,048.00 03/27/08 585.6 90935 821 1 1,048.00 03/29/08 585.6 90935 821 1 1,048.00 Treatment Item Subtotal: 3 $3,144.00 NEEDLE AND SYRINGE 03/25/08 A4657 270 1 0.50 03/27/08 A4657 270 1 0.50 03/29/08 A4657 270 1 0.50 Treatment Item Subtotal: 3 $1.50 ZEMPLAR 1 MCG IV 03/25/08 588.81 J2501 636 1 24.25 03127!08 588.81 J2501 636 1 24.25 03/29/08 588.81 J2501 636 1 24.25 Treatment Item Subtotal: 3 $72.75 Cialm Subtotal: 279 55,605.07 QMS Focus Release: 6.7.02 Itemized UB04 Statement User JSTINE Date: 2/3/09 Page 2 of 3 Facility: DCA-CHESAPEAKE 305 COLLEGE PARKWAY ARNOLD, MD 210122912 (866)390-0376 Provider Number: 22SX Insurer: CAREFIRST BCBS Group Number:OFWE Policy NumberXIP90362fi402 Claim # Description of Service Patient: MEDICOS, THOMAS W. 3517 CASTLE WAY DAVIDSONVILLE, MD 21035 132075-1 04/03/08-04/12/08 1st 2nd Rev. Date ICDB ICDB HCPC Code NDC Billin® Number Quantity Charges ADMIN SUPPLIES 04/03/08 A4657 270 1 13.85 04/03!08 A4657 270 1 13.85 04/03!08 A4657 270 1 13.85 04/05/08 A4657 270 1 13.85 04/05/08 A4657 270 1 13.85 04!05/08 A4657 270 1 13.85 04108!08 A4657 270 1 13.65 04/08!08 A4657 270 1 13.85 04/08!08 A4657 270 1 13.85 04/10!08 A4657 270 1 13.85 04/10/08 A4657 270 1 13.85 04110!08 A4657 270 1 13.85 04/12/08 A4657 270 1 13.85 04/12/08 A4657 270 1 13.85 04/12/08 A4657 270 1 13.85 Treatment Item Subtotal: 15 $207.75 EPOETIN<10000/100 UNITS 100 UT 04/03/08 285.21 Q4081 634 88 768.24 IV 04/05/08 265.21 Q4081 634 88 768.24 Treatment Item Subtotal: 176 $1,536.48 EPOETIN>10000/100 UNITS 100 UT 04/08/06 285.21 Q4081 635 166 1,449.18 IV 04/10/08 285.21 Q4081 635 166 1,449.18 04/12/08 285.21 Q4081 635 166 1,449.18 Treatment Item Subtotal: 498 $4,347.54 HEMODIALYSIS TREATMENT 04/03!08 585.6 90935 821 1 1,048.00 04/05/08 585.6 90935 821 1 1,048.00 04/08/08 585.6 90935 821 1 1,048.00 QMS Focus Release: 6.7.02 Itemized UB04 Statement User JSTIHE Date: 2/3/09 Page 3 of 3 Facility: DCA-CHESAPEAKE 305 COLLEGE PARKWAY ARNOLD, MD 210122912 (866)390-0376 Provider Number: 22SX Insurer: CAREFIRST BCBS Group Number:OFWE Policy NumberXiP903626402 Claim # Description of Service 1st 2nd Rev. Date ICD9 ICD9 HCPC Code NDC Billing Number Quantity Charges Patient: MEDICOS, THOMAS W. 3517 CASTLE WAY DAVIDSONVILLE, MD 21035 132075-1 04/03!08-04l12/08 HEMODIALYSIS TREATMENT NEEDLE AND SYRINGE VENOFER 1 MG IV ZEMPLAR 1 MCG IV 04/10/08 585.6 90935 821 1 1,048.00 04!12/08 585.6 90935 821 1 1,048.00 Treatment Item Subtotal: 5 $5,240.00 04!03/08 A4657 270 1 0.50 04/03/08 A4657 270 1 0.50 04/05/08 A4657 270 1 0.50 04/05/08 A4657 270 1 0.50 04/08/08 A4657 270 1 0.50 04/08/08 A4657 270 1 0.50 04/10/08 A4657 270 1 0.50 04/10/08 A4657 270 1 0.50 04/12/08 A4657 270 1 0.50 04/12/08 A4657 270 1 0.50 Treatment Item Subtotal: 10 $5.00 04/03/08 280.9 J1756 636 100 308.00 04/05/08 280.9 J1756 636 100 308.00 04!08/08 280.9 J1756 636 100 308.00 04!10/08 280.9 J1756 636 100 308.00 04/12/08 280.9 J1756 636 100 308.00 Treatment Item Subtotal; 500 $1,540.00 04/03/08 588.81 J2501 636 1 24.25 04/05/08 588.81 J2501 636 1 24.25 04/08/08 588.81 J2501 636 1 24.25 04/10/08 588.81 J2501 636 1 24.25 04/12/08 588.81 J2501 636 1 24.25 Treatment Item Subtotal: 5 $121.25 Clafm Subtotal: 1,209 512,998.02 Grand Totai: 1,488 518,604.09 QMS Focus Release: 6.7.02 Louis 7. 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 GiII, Paralegal • (licrnsed in PA, NJ and MD) ~' (licensed in PA and MD) Thomas W. Medicus 3517 Castle Way Davidsonville, MD 21035-2324 Ca oz~~ & ~ sso_ crates, P C. ~;~~- ~ . ~~~,.~ ~- a~ n a ~ °~ _~ r +~ 4-~r :o , October 28, 2009 Re: Account with Dialysis Corporation of America Account Balance: $1$,604.09, plus costs of collection Our Matter No.: 1087-08 Dear Mr. Medicus: 2933 North Front Street Harrisburg, PA 17110 Telephone: (717) 233-4101 Fax: (7{7)233-4103 www. c apo zzi ass oci 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 ti~st that you will give this Notice your immediate attention. Yours truly,,/ G~i~~li~Wy~ ~~f Michael M. Jerominski /kjg EXHIBIT cc: Lisa A. Laudeman, DCA }~ Louis J. Capozzi, Jr., Esquire+ Daniel K. Natirbofl; Esquire Donald R eave E wire 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, NJ and MD) •• (licemed in PA and MD) Ca & ~sso,~es P, ~, ~~ ~' ~. k .i ~~ ~ s, ; :~ ~I , a i~. ~ t Y ~~~~ 4 "~, ~ > r~ ~~, rr- December 3, 2009 Thomas W. Medicos 3517 Castle Way Davidsonville, MD 21035-2324 Re: Account with Dialysis Corporation of America Account Balance: $18,b04.09 plus costs of collection Our Matter~No.: 1087-08 Dear Mr. Medicos: 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 regazding 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, ~221r~r~ ~~ • . Michael M. Jerominski ~jg cc: Lisa A. Laudeman, DCA THIS LETTER AND ANY FUTURE LETTERS FROM OUR FIItM ARE AN ATTEMPT TO COLLECT A DEBT, AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. DIALYSIS CORPORATION OF AMERICA d/b/a DCA OF CHESAPEAKE, v. Plaintiff THOMAS W. MEDICUS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 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`~''u Lisa Laudeman Reimbursement Manager Dialysis Corporation of America 214 Senate Avenue, Suite 300 Camp Hill, PA 17011 46 DIALYSIS CORPORATION OF AMERICA D/B/A DCA OF CHESAPEAKE Plaintiff vs. THOMAS W MEDICUS Defendant Person to be served (Name and Address): THOMAS W MEDICUS 3517 CASTLE WAY DAVIDSONVILLE MD 21035 By serving: THOMAS W MEDICUS Attorney: MICHAEL M JEROMINSKI ESQ Papers Served: NOTICE TO DEFEND, COMPLAINT, EXHBITS Service Data: [ Served Successfully Date/Time: Xelivered a copy to him/her personally [ J Not Served i 7 2 Court OL? t enue Docket Number: 10 3310 AFFIDAVIT OF SERVICE (For Use by Private Service) Cost of Service pursuant to R. 4:4-3(c) [ J Left a copy with a competent household member over 14 years of age residing Attempts: Date/Time: therein (indicate name & relationship at right) Date/Time: Date/Ti me: [ ] Left a copy with a person authorized to accept service, e.g. managing agent, registered agent, etc. (indicate name & official title at right) Name of Person Served and relationship/title: Description of Person Accepting Servicce?: SEXVL AGE: I _ HEIGHT: ?ty WEIGHT: Unserved: [ ] Defendant is unknown at the address furnished by the attorney [ ] All reasonable inquiries suggest defendant moved to an undetermined address [ J No such street in municipality [ ] Defendant is evading service [ ] No response on: Date/Time: Date/Time: Date/Time: Other: Served Data: Subscribed and Sworn to me this day of _ (NOCsicDS + 20 t ?'y Notary Signature: orb ? n Lotwr?Ce 7 ?3I.? I 1 Name of tary Commission Expiration SKINkj& k_ HAIR OTHER: Q Zr Q was at the i of service a competent adult, over the age of lnnot having a direct interest in the itigation. I decl re under penalty that the 1 f egoing is tru rect. _ 0 ature of Pr cess Server Date B.S. \0 NP DIALYSIS CORPORATION OF AMERICA d/b/a DCA OF CHESAPEAKE, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. THOMAS W. MEDICUS, Defendant Docket No.: 10-3310 Civil Action - Law PRAECIPE TO ENTER DEFAULT JUDGMENT TO THE PROTHONOTARY/CLERK OF SAID COURT: tJ m Tri rT1 +r«,-? rVI 70 C:) (DC by (= 2f ?_ C (D 7) Pursuant to Pa.R.Civ. P. No. 1037(b), enter judgment in favor of Plaintiff, Dialysis Corporation of America d/b/a DCA of Chesapeake, and against Defendant, Thomas W. Medicus, 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: $18,604.09 Attorney Fees: $ 622.50 Costs as of 9-21-10: $ 211.95 TOTAL: * $19,438.54 * 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: Thomas Medicus 3517 Castle Way Davidsonville, MD 21035-2324 &is f rowl o? e our ??- c s 44.w a e l?a?FSr?o IJcrh?, ?.o? 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. 4*4 *. ) . I Date: September 21, 2010 By: /Z Michael M. Jerominski, Esquire Attorney I.D. No. 92977 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff DIALYSIS CORPORATION OF AMERICA D/B/A DCA OF CHESAPEAKE Plaintiff vs. THOMAS W MEDICUS Defendant Person to be served (Name and Address): THOMAS W MEDICUS 3517 CASTLE WAY DAVIDSONVILLE MD 21035 By serving: THOMAS W MEDICUS Attorney: MICHAEL M JEROMINSKI ESQ Papers Served: NOTICE TO DEFEND, COMPLAINT, EXHSITS Service Data: ( Served Successfully [ J Not Served Date/Time: elivered a copy to him/her personally ( ] Left a copy with a competent household member over 14 years of age residing therein (indicate name & relationship at right) ( J Left a copy with a person authorized to accept service, e.g. managing agent, registered agent, etc. (indicate name & official title at right) Description of Person Accepting Service. SEX ?X AGE: i _ HEIGHT: WEIGHT: 2 0 1 0 0 7 2 0 1 2 6 5 r(l} 1 N1 . G Court Oi %P ' ; lit' ?rly?rnnnrNenue Docket Number. 10 3310 AFFIDAVIT OF SERVICE (For Use by Private Service) Cost of Service pursuant to R. 4.4-3(c) Attempts: Date/Time. Date/Time: Date/Time. Name of Person Served and relationshipititle: SKIN s ' 'k ? HAIR: OTHER: It - J, i Unserved: ( ] Defendant is unknown at the address furnished by the attorney ( ] All reasonable inquiries suggest defendant moved to an undetermined address ( ( No such street in municipality ( J Defendant is evading service [ ) No response on: Date/Time: Date/Time: Date/Time: Other. Served Data: Subscribed and Sworn to me this day of {VCi? + 20 i? ,,,:..4 ..r-nom rx Notary Signature. Name of Wotary Commission Expiration was at th0i of service a competent adult, over the age of nd not having a direct interest in the i 'ct. Mature Xcess enalty of-ptTiiq that the 0 er Date Exhibit A DIALYSIS CORPORATION OF AMERICA d/b/a DCA OF CHESAPEAKE, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. : Docket No.: 10-3310 THOMAS W. MEDICUS, Defendant : Civil Action - Law TO: Thomas Medieus 3517 Castle Way Davidsonville, MD 21035-2324 DATED: September 9, 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 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. BEDFORD STREET CARLISLE, PA 17013 1-800-990-9108 717-249-3166 Exhibit B NOTICIA IMPORTANTE TO: Thomas Medicus 3517 Castle Way Davidsonville, MD 21035-2324 DATED: September 9, 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 17013 1-800-990-9108 717-249-3166 /Move f??r• Michael M. Jeromins i, Esquire I.D. No. 92977 Capozzi & Associates, P.C. 2933 N. Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff Exhibit B DIALYSIS CORPORATION OF AMERICA d/b/a DCA OF CHESAPEAKE, Plaintiff V. THOMAS W. MEDICUS, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Docket No.: 10-3310 Civil Action - Law CERTIFICATE OF RESIDENCE I hereby certify that the name and address of the proper person(s) to receive this Notice under Pa. R. Civ. 236 is: Thomas Medicus 3517 Castle Way Davidsonville, MD 21035-2324 Date: September 21, 2010 Capozzi & Associates, P.C. By: 4? /M. 67?' Michael M. Jerominski, squire Attorney I.D. No. 92977 2933 North Front Street Harrisburg, PA 17110 (717) 233-4101 Attorney for Plaintiff