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HomeMy WebLinkAbout09-13-10e ~ ~ NOTICE OF CLAIM (Filed Pursuant to 20 Pa.C.S. § 3532) COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF ROBIN GERHOLD ,DECEASED No. 21-10-527 To the Clerk of the Orphans' Court Division: Enter the claim of Eastern Regional Medical Center (aka ERMC) by Linda S. Sutterfield in the 45,057.25 (Claimant) amount of $ ,against the above entitled Estate. The Decedent, who resided at 10 Annette Dr.; Enola, PA 17025-1801 (Street Address) died on May 8, 2010 .Written notice of (Date of Death) said claim was given to Donald & Linda Morgan c/o attorney, Murrel R. Walters, III (Persona! Representative or his/her counsel) at 54 E. Main Street; Mechanicsburg, PA 17055 (Address) on September 9, 2010 (Date) ERMC c/o Patient Accounts (Claimant's Counsel) (Address) (Telephone) Farm OC-07 rev. 10.73.06 (Supreme Court I.D. No.) (Claimant) 2610 Sheridan Road, 1st Floor (street Address) Zion, IL 60099-2615 (City, State, Zip) N O_ ~ N rn ~ _ ~~~ w j~© S -o --i .. :n cn tb '~iJ ?J % _'~ rn a .) ~~ < ~ <.~> i n-~ rn ~~ C _' ~"~ :~~ 4n~ ~~~ ,: Cancer Treatment is SDM of erica• EASTERN REGIONAL MED CTR PATIENT ACCODNT LIST SUMMARY HNTITY Printed on: 09/09/10 at 16:13 Page 1 of 1 PAGE: 1 PT NAME: GERNOLD ROEIN MRN: 55203752 ENTITY: PA PRIME: CIGNA SEC: SELF PAY THR: Account AS Visit AR Period Total Tot81 Total Number Code Type Date Range Chazgee Adj uetmente Payments Ealance 550382639 C PAE CLINIC O1/O1/11-01/O1/11 0.00 0.00 0.00 0. 00 550382786 A INPATIENT 04/12/10-05/08/10 323616.23 -69639.69 -208919.29 45057. 25 550382803 C PRE CLINIC O1/O1/11-01/O1/11 0.00 0.00 0.00 0. 00 Total for GERHOLD ROBIN 323616.23 -69639.69 -208919.29 45057. 25 Grand Total 323616.23 -69639.69 -208919.29 45057. 25 BENEFITS ASSIGNED ~t ~ ~ ~ ~ ~ea~flicane ~~ TO THE PROVIDER ?~ ~ http://corppfmwebprdl .ctca.locaUSpfin/0893604.htm1 9/9/2010