HomeMy WebLinkAbout06-02-11IN THE CIRCUIT COURT FOR CUMBERLAND COUNTY
IN RE: ESTATE OF: DOROTHY STEVENS
Deceased.
PROBATE DIVISION
File Number 21-11-0193
Division Probate
STATEMENT OF CLAIM BY: Heartland Healthcare Services
The undersigned hereby presents for filing against the above estate this statement of claim and
alleges:
1. The basis for the claim is delinquent pharmacy charges.
2. The social security or tax identification number of the claimant is 34-1766299 the
name and address of the claimant is Heartland__Healthcare Services, 4755 South Ave,
Toledo, OH 43615.
3. The amount of the claim is $2229.05 which amount is now due, or, if not due, will
become due on now.
4. The claim (is)^ (is not)® contingent or unliquidated. If contingent or unliquidated,
the nature of the uncertainty is __
5. The claim (is)^ (is not)® secured. If secured, the security consists of
Under the penalties of perjury, I declare that I have read the foregoing, and the facts alleged are
true, to the best of my knowledge and belief.
Signed on 5/16/201 1.
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Valerie Latimer, R.e~~
Heartland Healthcare Services
Claimant
Copy mailed to attorney for
the Personal Represenl:ative on
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CLERK OF THE CIRCUIT COURT
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GL Statement Invoice Number
PHARIvIAC Y OF PENNSYLV.4.NIA 0 5/ 16 / 11 I n f o rma t i c> n a l
7010 Snowdrift Road
Allentown, PA 18106
800-270-6351 EXT 6050 Total Amount Due
$ 2 , 19 6.11
Pay Plan : SFPA PENDING MEDICAID PENNSYLVANIA
TO THE ESTATE OF DOROTHY STEVENS
3709 ROSEMONT AVE
CAMP HILL,PA 17011
Customer Name Customer ID
DOROTHY STEVENS 302853
Remit To:
HEARTLAND HEALTHCARE SERVICES
PO BOX 72413
CLEVELAND, OH 44192-0002
Ship Date Rx # Product Description NDC ID Qty Amount: Code Type
01/02/2011 50135].271 OMEPRAZOLE 20 MG CAPSULE DR~ 007812?_3310 30 EA 5.00 C RX
01/03/2011 501460852 ENULOSE 10 GM/15 ML SOLUTION 00472136016 473 ML 5.00 C RX
01/13/2011 501368028 ENABLEX 7.5 MG ER TAB 00078041915 60 EA 55.00 C RX
01/13/2011 501378175 MIRTAZAPINE 15 MG TABLET 00093720656 30 EA 5.00 C RX
01/17/2011 501460852 ENULOSE 10 GM/15 ML SOLUTION 00472136016 473 ML 5.C)0 C RX
01/21/2011 501378179 CITALOPRAM HBR 20 MG TABLET ~ 00093474150 30 EA 4.05 C RX
01/25/2011 501549775 CLONAZEPAM 0.5 MG TABLET 00228300350 30 EA 2.1.0 C RX
01/28/2011 501351271 OMEPRAZOLE 20 MG CAPSULE DR~ 00781223310 30 EA 5.00 C RX
01/28/2011
01/28/2011 501.558903 IV DEXTROSE 5o-1/2NS IV SOLN
IV DEXTROSE 5%-1/2NS IV SOLN 00338008504
00338008504 8000 ML
-2000 ML 98.98
-23.74 IVRX
IVRX
01/28/2011 501558905 IV CEFEPIME 1GM 100 NS MBP 99999999999 1400 ML 1950.48 IVRX
01/28/2011 501559077 FLORASTOR 250 MG CAPSULE 04142000007 50 EA 44.63 OTC
01/31/2011
01/31/2011 501558903 IV DEXTROSE 5%-1/2NS IV SOLN
IV DEXTROSE 5o-1/2NS IV SOLN 00338008504
00338008504 6000 ML
-3000 ML 75.23
-35.62 IVRX
IVRX
$2, 196.17_
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