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HomeMy WebLinkAbout04-01-11r NOTICE OF CLAIM (Filed Pursuant to 20 Pa. C. S . § 3532} COURT OF COMMON PLEAS OF Cumberland COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF Earl Mays ,DECEASED To the Clerk of the Orphans' Court Division: Enter the claim of Shippensburg Health Care Center 43 749.0$ (Clninrant} amount of $ ~ ,against the above entitled Estate. in the The Decedent, who resided at 121 VVal~nrt Bot#om Rd. Shippensburg, PA 17257 (StreetAdd,•ess} died o~i December 1, .2010 .Written notice of (Date afDeatlr} said claim was given to Deborah Fitzsimmons (Persona! Representatiti~e or his/her cornrsel} at I05 SME Shippesbur~, PA 17257 (Address} on March 29, 2011 (Date} Allison Klimotivicz Coin. Ous. Ctr Director (Clainrmrt) 1710 Underpass Way, Ste 201 {Street Address) Hagerstown, MD 21740 (City; State, Zip) (Claintar~t's Corrnse!} (Supreme Corrrl L D. A'o.} (rfddress} (Telephone} RI:CORDL~:D OFI~1(;L Oi. lZI~:C~ISTRI';R OI~ WII,].S 2011 APR 1 Fornr OC-07 rev 10.13.Ob (;LE;Rh C)F ORPf-LENS CC)UK"i" (;UMHI~;R],ANll COURT, I',?~ rM:: ~~~~~~~ NIAG N~LIA MANAGEMENT 1 NC 1710 Underpass Way, suite 2a1 3/29/209'! Hagerstovm, MD 21740 301-745-8700, ext. 1245 Shippesburg Health Care Center TO: Earl Mays CIO Deborah Fitzsimmons 145 SME Shippesburg, PA 17257 For: Earl Mays Page 1 :-DATE; FROM _ _-: DATE TO ---: - - - N 'Q . _ :- -. __ DESCRIPTION.;- _ _ : . ._: __ CHARGE _ - PAYMEtJT __- _ BALANCE ,` 2124110 2/28/10 Room ft Board -Semi Private Room $1,020.(}0 - =- ~~~ $1,020.00 311!10 3/31110 Roam ft Board -Semi Private Room $6,324.00 - _ x$7;344.00 4/1/10 4/30/10 Room f3 Board -Semi Private Room $6,120.00 $13,4b4.00 513110 5/1/10 Room ft Board - Hospita[ Leave $204.00 $13,6b8.00 5/2/10 5/16!10 Roam Et Board -Semi Private Room $3,060.00 _$1b,728.00 5/17/10 5119/10 Room & Board -Hospital Leave $b12.00 $17,340.00 7/7110 7/31110 Room & Board -Semi Private Room $5,100.00 $22;440.00 8/1/10 8/31!10 Room & Board -Semi Private Room $6,324.00 - . $28,7b4.00 911110 9/30/10 Room 8t Board -Semi Private Room ~ ~--~^_ $6,120.00 " $34,884.00 10/1/10 10/31110 Room f3 Board -Semi Private Room $6,324.00 $41,208.00 11!1110 1 i/30110 Room £t Board -Semi Private Room $6,120.00 ' ; $47,328.00 }}k}}}}}!f}k ANCILLARY CHARGES }'}'}}`}'}'} ~ ~~ - - 10/13/10 Flu Adminfstration $11.37 $47,339.37 101131 i0 Flu Vaccine $25.61 - $47,3b4.98 f}Ak}}}!}• THERAPY CHARGES ""}"`"'} 10/27110 10/29/10 October2010Charges $250.25 ~ $47,615.23 11/1/10 1114/10 November 2010 Charges $160.82 $47,776,05. }}k}i}tA}i•M PAYMENTS ""'}}`}"}" _.~.....~. 3/19/10 Payment $100.00 - $47,676.05 9/2/i0 Payment $500.00 :. - = ;:~'.: $47;176.05 1018/ 10 Payment $917.30 ~- ' ~:.$4b,258.75 , 11/8/10 Payment $5fl0.00 ;_`$45,758.75: 11/9/10 Payment $917.30 '~ `-=$44,841.45 1219/10 Payment $917.30 - - - $43,424.1.5 1 ! 18! 11 Payment $175.07 ~ ' ` $43,74.08 BALANCE ©UE -. _-::-:_$43;749.08