HomeMy WebLinkAbout11-7199U.S. RENAL CARE, INC. f/k/a IN THE COURT OF MMON PLEAS OF
DIALYSIS CORPORATION OF AMERICA CUMBERLAND COOTY, PENNSYLVANIA
d/b/a DCA OF CHESAPEAKE,
Plaintiff
V.
LINDA J. REYES,
Docket No.: //-
Defendant : Civil Action - Law
NOTICE TO DEFEND
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You have been sued in court. If you wish to defend against the claims s t forth in the following
pages, you must take action within twenty (20) days after the complaint d notice are served, by
entering a written appearance personally or by attorney and filing in wri 'ng with the court your
defenses or objections to the claims set forth against you. You are warne that if you fail to do so
the case may proceed without you and a judgment may be entered against ou by the court without
further notice for any money claimed in the complaint or for any other cl 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 ON E. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO O TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN ET LEGAL HELP.
LAWYER REFERRAL SERVICE
Cumberland County Bar Association
32 S. Bedford St.
Carlisle, PA 17013
(800) 990-9108
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AVISO
Le han demandado a usted en la corte. Si usted quiere defenderse de stas de estas demandas
expuestas an las paginas signientes, usted tiene veinte (20) dias de plazo 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 objeci' nes a las demandas en
contra de su persona. Sea avisado que si usted no se defiende, le corte t' mara medidas y puede
continuar la demanda en contra suya sin previo aviso o notificacion. demas, 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 i portantes para usted.
LLEVE ESTA DEMANDA A UN ABOGADO INMEDIATAME TE, SI NO TIENE
ABOGADO O SI NO TIENE EL DINERO SUFICIENTE DE PA GAR TAL SERVICIO.
VAYA EN PERSONA O LLAME POR TELEFONO A L OFICINA CUYA
DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVE IGUAR DONDE SE
PUEDE CONSEGUIR ASISTENCIA LEGAL.
LAWYER REFERRAL SERVICE
Cumberland County Bar Association
32 S. Bedford St.
Carlisle, PA 17013
(800) 990-9108
Respectfully
CAPOZZI & ASSOCIATES. P
Date: j /
t •? .4111V 11 V, L
Pa. I if # 86341
2933 North Front Stn
Harrisburg, PA 1711
(717) 233-4101
Attorneys for Plaintif
t
U.S. RENAL CARE, INC. f/k/a IN THE COURT OF
DIALYSIS CORPORATION OF AMERICA CUMBERLAND C(
d/b/a DCA OF CHESAPEAKE,
Plaintiff
V. : Docket No.:
LINDA J. REYES,
Defendant Civil Action - Law
COMPLAINT
4ON PLEAS OF
, PENNSYLVANIA
NOW COMES, U.S. Renal Care, Inc. f/k/a Dialysis Corporation ?f America d/b/a DCA
of Chesapeake ("U.S. Renal Care"), by and through its attorney, Capozzi & Associates, P.C., and
makes the following Complaint for a money judgment against
respectfully avers as follows:
1. Plaintiff, U.S. Renal Care is a registered Pennsylvania limited
having its principal place of business at Camp Hill, Cumberland County,
2. Defendant, Linda Reyes ("Patient" or "Defendant") is an
known address of 5126 Brookwood Road, Brooklyn Park, Maryland 21
3. The clinic formerly known as DCA of Chesapeake is an
Renal Care with a dialysis clinic located at 305 College Pkwy, Arnold,
and in support thereof,
iability corporation
'ennsylvania.
individual with a last
>.
ing subsidiary of U.S.
) 21012.
4. U.S. Renal Care provides dialysis treatments and services to itJ patients.
5. On or about September 1, 2008, Defendant executed a
Agreement ("Consent Agreement") to allow Defendant to receive regular
from U.S. Renal Care, as scheduled by her physician and U.S. Renal
copy of the Consent Agreement is attached hereto and incorporated
for Hemodialysis
treatments
A true and correct
is Exhibit "A."
1
6. On or about September 1, 2008, Defendant executed a Pat??ent .Assignment and
Authorization of Payment of Insurance Benefits Agreement ("Assignmenj and Authorization
Agreement"), which required the Defendant to assign and forward insurance benefits that she
received for the dialysis treatments from U.S. Renal Care. A true and cor?ect copy of the
Assignment and Authorization Agreement is attached hereto and incorporated herein as
Exhibit "B."
7. Paragraph 1 of the Assignment and Authorization Agreem nt provides that
Defendant "hereby assigns, transfers and sets over to U.S. Renal Care mo ies and/or benefits to
which the Patient is (or may be) entitled from any insurance ... provider, ..as well as any others
who may be financially liable for the Patient's dialysis treatments and se ices and related
medical care by and/or at U.S. Renal Care, including health insurance benefits ... for which the
Patient is entitled, to cover the costs of dialysis treatment and services ...?" See Exhibit "B" as
previously identified and incorporated herein.
8. Paragraph 2 of the Assignment and Authorization Agreem 'nt provides that
Defendant "hereby authorizes and directs that payment of all insurance be?efits...relating to any
charges and costs incurred as a result of dialysis treatments and related se?vices and medical care
provided to the Patient by and/or at U.S. Renal Care, be paid and remitted?directly to
U.S. Renal Care...." See Exhibit "B" as previously identified and incorp? rated herein.
9. Paragraph 3 of the Assignment and Authorization Agreement provides that
Defendant "hereby acknowledges that the monies or benefits to be paid b the Patient's
insurance provider ... for the charges, costs and fees incurred by U.S. Re 'al Care in its
provision of dialysis treatments and related services and medical care tl?e Patient is and shall at
2
all times remain, the property of U.S. Renal Care...." See Exhibit "B" aj previously identified
and incorporated herein.
10. Paragraph 3 of the Assignment and Authorization
that Defendant "hereby covenants and agrees that in the event that any
benefits ... is sent to the Patient ...that the [Defendant] will promptly
forward such payment directly to U.S. Renal Care." [emphasis added]
previously identified and incorporated herein.
11. Paragraph 5 of the Assignment and Authorization Agreement
Defendant "hereby acknowledges that, notwithstanding the foregoing
authorization of benefit payments to U.S. Renal Care, the Patient shall be
,nt further provides
ment of insurance
unconditionally
e Exhibit "B" as
provides that
;nment and
esponsible for any and
all charges and costs billed by U.S. Renal Care for dialysis treatments an4 related services ...
and that U.S. Renal Care is authorized to bill the Patient directly for
and costs." See Exhibit "B" as previously identified and incorporated
12. U.S. Renal Care, at the special insistence and request of
the period of September 1, 2008, through September 16, 2008, ("Dates of
numerous separate dialysis treatments ("Dialysis") to Defendant, at the
forth in U.S. Renal Care's business records ("Account Statement"). A
the Account Statement is attached hereto and incorporated herein as
13. On October 29, 2009, U.S. Renal Care's counsel mailed to
letter, which provided information on how to pay the debt owed to U.S.
correct copy of said demand letter is attached hereto and incorporated
COUNT I - BREACH OF CONTRACT
14. Paragraphs 1 through 13 are incorporated herein by reference.
nt of such charges
in.
cant during
service"), provided
s and on the dates set
and correct copy of
t "C.
-,ndant a demand
nal Care. A true and
n as Exhibit "D."
3
15. The rates and total charges set forth in the Account Statement Ore just and
reasonable, and are the rates that Defendant agreed to pay for the
16. Under the terms of Defendant's policy with her insurance prodder, CareFirst,
Defendant received a monthly check from CareFirst pursuant to the clai filed by U.S. Renal
Care.
17. Defendant's insurance provider did not pay 100% of U.S. Ren 1 Care's claims, which
resulted in Defendant owing a co-pay to U.S. Renal Care ("Co-pay").
18. Pursuant to the Assignment and Authorization Agreement, Defendant was required
to transfer the payments she received from CareFirst directly to U.S. Renal Care on a monthly
basis. See Exhibit "B" as previously identified and incorporated herein.
19. The amounts that Defendant received from CareFirst, pursuant to the claims
submitted by U.S. Renal Care, are indicated in the "Amount Paid"
20. As provided from CareFirst's records, Defendant received a to?al of $21,523.91 from
CareFirst for the Dialysis treatments during the Dates of Service.
21. Defendant failed to transfer the insurance checks, that she received from CareFirst for
the Dialysis treatments, to U.S. Renal Care.
22. After the dates of service, on or about January 4, 2010, Defend4nt did pay to U.S.
Renal Care the sum of seven thousand dollars ($7,000.00).
23. The total amount of principal that has become due and owing Oy Defendant to U.S.
Renal Care, as a result of her failure to transfer the insurance payments that she received and her
failure to pay her co-pay, is $14,523.91.
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
4
25. U.S. Renal Care has been financially damaged in the amount Of $14,523.91, plus
interest and costs of collection.
26. Defendant's failure to pay her Co-pay, her failure to transfer tfe insurance payments,
and her failure to cure her default with U.S. Renal Care, pursuant to the ?signment and
Authorization Agreement referenced above, constitute a breach of contra.
WHEREFORE, Plaintiff, U.S. Renal Care, Inc. f/k/a Dialysis Corporation of America
d/b/a DCA of Chesapeake, demands judgment against Defendant in the som. of $14,523.91, plus
interest at the legal rate of 6% per annum from the date of the judgment.
- QUANTUM MERUIT - UN.
If this Honorable Court should find that an express contract did n
of Chesapeake and Defendant, which is denied, then, in that event, DCA
the following alternative cause of action in quantum meruit against the I
27. U.S. Renal Care incorporates paragraphs 1 through 26 of this
at length herein.
28. Having requested U.S. Renal Care to provide the dialysis
Care having done so to the benefit of Defendant, Defendant became lia
the just and reasonable charges for the Dialysis.
29. The Defendant has been unjustly enriched by accepting the
making full payment to U.S. Renal Care for said Dialysis treatments.
30. The rates reflected in the Account Statement are the just and r
dialysis treatments and services. See Exhibit "C" as previously identified
herein.
31. The total value by which Defendant has become unjustly enri
exist between DCA
Chesapeake pleads
as if set forth
, and U.S. Renal
to U.S. Renal Care for
is, and not
ble rates for
incorporated
pursuant to the
5
Dialysis, is $14,523.91. See Exhibit "C" as previously identified and incorporated herein.
32. U.S. Renal Care has demanded Defendant pay said amount, bot Defendant has failed
to do so.
33. To date, the Defendant has not paid the total amount due to U.$. Renal Care.
WHEREFORE, Plaintiff, U.S. Renal Care, Inc. f/k/a Dialysis
d/b/a DCA of Chesapeake, demands judgment against Defendant in the
plus interest at the legal rate of 6% per annum from the date of judgment.
COUNT III -CONVERSION OF MONEY
34. U.S. Renal Care incorporates Paragraphs 1 through 33 of this
herein.
35. Defendant was aware that due to the contractual relationship
U.S. Renal Care, pursuant to the Assignment and Authorization
payments Defendant received from CareFirst properly belonged to U.S
"B" as previously identified and incorporated herein.
36. Defendant had a legal and contractual duty to safeguard and
payments by CareFirst, made payable to Defendant, to reimburse U.S.
Dialysis it provided to her.
37. During the Dates of Service, Defendant's insurance provider
of $21,523.91.
ion of America
of $14,523.91,
as if set forth
Defendant and
the insurance
Care. See Exhibit
the insurance
Care for the
to her the amount
38. Defendant intentionally and permanently retained possession o?the monies owed to
U.S. Renal Care, by failing to transfer a total of $14,523.91 of the insuran?e benefits CareFirst
paid to her, as required under the Assignment and Authorization
6
39. Defendant's intentional possession of, and her failure to fofward, the CareFirst
insurance monies to U.S. Renal Care for the Dialysis provided to Defends it constitutes
conversion.
40. U.S. Renal Care has been financially damaged by Defendant's conversion in the
amount of at least $14,523.91.
WHEREFORE, Plaintiff, U.S. Renal Care, Inc. f/k/a Dialysis Co oration of America
d/b/a DCA of Chesapeake, demands judgment against Defendant for con rion in the sum of
$14,523.91, plus interest at the legal rate of 6% per annum from the date Tfisudgment.
Respectfully submi
Dated: / '//I I
By:
Capozzi & Associate, P.C.
Philip Q Warholic, qi
Attorn I.D. No. 86141
2933 N. Front Street
Harrisburg, PA 1711
(717) 233-4101
Attorneys for Plainti
7
U.S. RENAL CARE, INC. f/k/a
DIALYSIS CORPORATION OF AMERICA
d/b/a DCA OF CHESAPEAKE,
Plaintiff
V.
LINDA J. REYES,
Defendant
IN THE COURT OF
CUMBERLAND CC
VERIFICATION
I, Joanne Zimmerman, Vice President of Clinical Services, of U.S.
LION PLEAS OF
, PENNSYLVANIA
Care, Inc., owner
and operator of DCA of Chesapeake, do hereby verify under penalties of penury and upon
personal knowledge that the contents of the foregoing Complaint are tr?e and correct.
Date: /
Vice President of Chi
U.S. Renal Care, Inc.
214 Senate Avenue,
Camp Hill, PA 1701
8
c
Services
300
DIALYSIS CORPORATION OF AMERICA
ACA, OPr?-
-tCOUNT NOR lV QPj6l~.=S
Patient: ID Number, I
(? I, tlat tmden Egncd patie?;
L the undersigned parent or guardian of the, ebovf
18 yeaa s of age or otherwise incapable of consent
herby request and authorize Drs and whurneve
designate a:a his or leer associate o asaistetnt to edmini r to me (or to tae
patient) the prooed= known as bertodialysis, tuvi u such conditions as a
by the phys cien (a) in attendance. I tree to abide by the policies, rules,
cstabli ad by the above named Dialysis Unit in carrying out its h--modal
It has been explained to me that hemcdialysis is a procedure used in the cr
impairment of failure of kidney function by which yr components of
separated by a semi-permeable substance, which permha the passage of m
hinders that of others when the blood is circulated H ugh an artificial kid
dialym. I under stand that there arc dif a nt types of equipment employe
treatment erad different types of artificial lsldneys (diatyzers) used in the pi
I acknowledge that the possible risks and couT icauons ofhemodialy'sis ai
limited to leakage of the dialyzer, changes in blood prassure, be molysis
blood cells,. (reduction of oaxygea in the blood), heart arrhytho
malfunction of equipment have been explained to me by the professional p
Dialysis Unit and I' soceprt, beWf ofroysolf and/or the above patient the
with all potential risks and c licadms. I also and d ttw any distm
me, pm have effects on my treatment and on myself during the time that I
dialysis treatment but that this fact does not mean that the dialysis trcatmez
do with the development of the problem related to this condition. I fiziber
administration of such drugs, transfusions of blood or blood components, a
treatment and tesft inputting HIV testing, dtrmed ntcesswy or dwirabli
of the physician (a) in attendance.
I am aware that:the pmcdee of medicine: is not an exact science, and I
guarantee, warrar,.ty ofreprtsentat on whatsoever his been offered or
on, behalf concerning the rem ]% of the hemodislysis procedure.
Print Name: Date,
Witness: Date:
patient who is under
he or she may
boys named
tH be determined
id regulations
sis rtrogram,
e of psti=u with
rc blood are
tin molecules and
ej, called a
for the dialysis
ch as but not
,akdown of read
As, end
normel of the
dialysis treatment
ei, which &Zkts
ai receiving a
had aznythrng to
=Mt to tilt
any outer
in the judgment
fee that no
me or anyone
EXHIBIT
DJAL.YSIS CORPORA77ON OF AMZRTCA
PATIENT ASSIGNMENT AND AUT
OF PAYMENT OF INS iANCrE
TION
Facility: DCA gt rata Nke Date:
Patient Name: j, 'f g Patient MO:
e riot)
I. ASSIGNhVNT
2. AUTHORIZATTQN OF PAYhM7 OF INSURANCE
I andtor benefits to
x or ntftw, sow,
Wall as Jay Gibm
Dated and rare
benefltt and otear
wear the coats of
ash at ACA of
Tbe undersigned :eareby authorizes areal d eu tba payraws of all insurance bena ts. ilns , Medicare
be neflts, If applicable, rtiatltrg to any urges and cow iuc? as a result of W sis treatments and
relatad mvicas and medical care provided to the Patieut by =d/or at DCA of Chas p4ce, be paled wA
rutted directly to DCA of Chesapeake is accordance with ins"etlow provided or be provided by sir
agent or represmAntivt of DCA of ChswNske.
If the wsdeselguatt's l mtencs policy or progm does not provide fu payment ofth monles or bandts
In the came of DC:A of C lwgpCake, the. uadusigned hereby ft-ther sawwriz?es and the kwomwe
p'miidet or tgenoY resporgNet for gaymr;Qr of appliOM hnureaft bam is to tks ? in
the Patieott'a name ad to deliver said payrneart to ACA of Chesapeake at its addres as set i?ortb in the
insuvotions provided or to be provided by in qmt ter rep of DCA. of akc.
3. DFLIMY OF BENMT PAYIyWT3 RECIT ILI3 FROM
no uadersigited hereby aemaMedges that the monimr or benefits to be pei by the Patiant'a
tmanrsmee provider or prVernmeat svftq for the zbertas, cotta and fs red by DCA of
Chumpeake It its prtr'rision of dialysis treatments end related aerviaee and m dical care to the
patient Is and shall at &B times rewfu, the property of DCA of C7rersapeaks, d to A therertce
tha€rwf the undesired hereby covenants and agretet that in tkt event that lay paymaaaet of
to uranae benefits, lacludixg Medicare benefits, which releta directly to the char es, cost and fees
Incurred by DCA of Chetspeab is a reault of tb provision of d aiyadx trey errtt sad related
sexy leas and medical care to the patieat is sent to the Patitmt or such Pettent"a t dian, aftorsep-
in•fut or repteseutedvo, is the case may be, Inadvertently or otherwise, that th und+em pad will
prrnmptly and uacanditionally forward srrcb paymm=t directly to DCA of Cesepe a
Page I oft
EXHIBIT
00 -
d.
o? u
RELEASE OF WORMATION
The tmdersiped hereby authorizes and consent8 to the rsloase by DCA of Cher;
aVats or reyweswtatives, of all or part of my infoanratiM records or reports, eithz
in r fimm to or 101h any person, CMIXNW(or govemaat agesacy, including any
uWor health we provider, who is firs ciallye liablik far tbt Padiem's dialysis tr
savior as wag as m4cAl me, which k ftrust oc is ttecena y for the suwimnatic
confiirmaticn of payment of charges and costs to DCA of Chesapeake for the prom
melt dialysis ucauneast and m3abd services as well as medical care
5. RESFONM BUJ TX FOR. PAYMINTS
ipeake, or amy of its
medicat or finvx*
third-party insures
„itnatms and Me*
n, warlfiuWan a AhV
Don to the Patient of
lbo uudercigtnad hereby ac cnotMadges th4 notwid stanft the fotegping Wilms t and authtsiz4on
of boxilt pacctnents to DCA of Cbeu"ke, the P be ro.WetsiWe for tr and nli cbmw and
cosh bflW by DCA of Chesapeake fur dWysie treaentezt and reieted sexvi provided end not
otherwise covsred or paid by such third-party poor or govermov atl a y ! incttzd & withcvt
oc all dedancttblo, co- ce and oo•patymag nuotmts, and that DC of Cheaapeeko is
etrthorized to bill the Patient directly for paymerit of sraoh charges and costa.
6. REVOCABMITY
Tt* undexaoad haanby arlrnowladgaa dart !?b PAT#lW ASSI W AND ??UMOMAMOW
OF PAI'MENT OF INSURANCE BS 41MTS may spot be revoked tmlass ch revoc gon Is
cmpanisd V the twrimso cameo to s xb raaocation by € Ch of Cbeuae bs
7. PHOTOCOPIES
CERMICATfON OF GUARD AMAX". ORKRY-V.-F,
The toad hw*y ofttif= that Wsbc is ha duly minted gurdian, att. "'m-fw twor
re.ve of the WWM-M=tittttad patiol, mW dtd hWahe has fi l sAwity to cute this farm on
behalf of such dependant patient.
Signature. Witness:
print Nstme: Agate:
Page 2 of 2
Itemized UB04 Statement
Facility: DCA-CHESAPEAKE
305 COLLEGE PARKWAY
ARNOLD, MD 210122912
(866) 390-0376
Provider Number: 22SX
Insurer: CAREFIRST BCBS
Group Number:05PC
Policy NumberXIC900504326
Claim #
Description of Service
1st 2nd Rev.
Date ICD9 ICD9 HCPC Code
User JSTINE
Date: 2/3/09
Page 1 of 3
Billing
Quantity Charges
Patient: REYES, LINDA J.
5126 BROOKWOOD ROAD
BROOKLYN PARK, MD 21225
130511-1 09/02/08-09/16/08
ADMIN FEE HEP B 09/11/08 G0010 771 1 13.85
Treatment Item Subt tal: 1 $13.85
ADMIN SUPPLIES 09/02/08 A4657 270 1 13.85
09/04/08 A4657 270 1 13.85
09/06/08 A4657 270 1 13.85
09/06/08 A4657 270 1 13.85
09/06/08 A4657 270 1 13.85
09/09/08 A4657 270 1 13.85
09109/08 A4657 270 1 13.85
09/09/08 A4657 270 1 13.85
09/11108 A4657 270 1 13.85
09/11/08 A4657 270 1 13.85
09/11/08 A4657 270 1 13.85
09/13/08 A4657 270 1 13.85
09/13/08 A4657 270 1 13.85
09/13/08 A4657 270 1 13.85
09/16/08 A4657 270 1 13.85
09/16/08 A4657 270 1 13.85
09116/08 A4657 270 1 13.85
Treatment Item Sub tai: 17 $235.45
EPOETIN>10000/100 UNITS 100 UT 09/02/08 285.21 Q4081 635 188 1,641.24
IV
09/04/08 285.21 04081 635 188 1,641.24
09/06/08 285.21 04081 635 188 1,641.24
09/09/08 285.21 04081 635 188 1,641.24
09/11/08 285.21 Q4081 635 188 1,641.24
QMS Focus EXHIBIT
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:05PC
Policy NumberXIC900504326
Claim #
Description of Service
let 2nd Rev.
Date IC09 IC09 HCPC Code
DC
Nu ber Quantity
Billing
Charges
Patient: REYES, LINDA J.
5126 BROOKWOOD ROAD
BROOKLYN PARK, MD 21225
130511-1 09102/08-09/16108
EPOETIN>10000/100 UNITS 100 UT 09/13/08 285.21 Q4081 635 188 1,641.24
IV
09/16/08 285.21 Q4081 635 188 1,641.24
Treatment Item Subt 'tal: 1,316 $11,488.68
HEMODIALYSIS TREATMENT 09/02/08 585.6 90935 821 1 1,048.00
09/04/08 585.6 90935 821 1 1,048.00
09106/08 585.6 90935 821 1 1,048.00
09109/08 585.6 90935 821 1 1,048.00
09111/08 585.6 90935 821 1 1,048.00
09/13/08 585.6 90935 821 1 1,048.00
09/16/08 585.6 90935 821 1 1,048.00
Treatment Item Subt tal: 7 $7,336.00
HEP B VACCINE 40 MCG IV 09/11/08 V05.3 90747 636 1 443.68
Treatment Item Sub tai: 1 $443.58
NEEDLE AND SYRINGE 09/06/08 A4657 270 1 0.50
09/06/08 A4657 270 1 0.50
09/09/08 A4657 270 1 0.50
09/09/08 A4657 270 1 0.50
09/11/08 A4657 270 1 0.50
09/11/08 A4657 270 1 0.50
09/11/08 A4657 270 1 0.50
09/13/08 A4657 270 1 0.50
09/13/08 A4657 270 1 0.50
09/16/08 A4657 270 1 0.50
09/16/08 A4657 270 1 0.50
Treatment Item Sub tal: 11 $5.50
VENOFER 1 MG IV 09/06/08 280.9 J1756 636 100 308.00
09/09/08 280.9 J1756 636 100 308.00
QMS Focus Release: 6.7.02
Itemized UB04 Statement
User JSTINE
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:05PC
Policy NumberXIC900504326
Claim #
Description of Service
1st 2nd Rev.
Date ICD9 ICD9 HCPC Code
DC Billing
bar Quantity Charges
Patient: REYES. LINDA J.
5126 BROOKWOOD ROAD
BROOKLYN PARK, MD 21225
130611-1 09/02/08-09116/08
VENOFER 1 MG IV 09/11/08 280.9 J1756 636 100 308.00
09/13/08 280.9 J1756 636 100 308.00
09/16/08 280.9 J1756 636 100 308.00
Treatment Item Sub ' tal: 500 $1,540.00
ZEMPLAR 1 MCG IV 09/06/08 588.81 J2501 636 5 121.25
09/09/08 588.81 J2501 636 3 72.75
09/11/08 588.81 J2501 636 3 72.75
09/13/08 588.81 J2501 636 3 72.75
09/16/08 588.81 J2501 636 5 121.25
Treatment Item Sub tal: 19 $460.75
Claim Su
I tal: 1,872 $21,623.91
Grand
T tal: 1,872 $21,523.91
QMS Focus
Release: 6.7.02
Louis J. Capozzi, Jr., Esquire*
Daniel K. Natirboff, Esquire
Donald R. Reavey. 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, Paralegai
• (licensed in PA, NI and MD)
"• (licensed in PA and MD)
zzi &ssocates. P.C.
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y F tom:
October 29, 2009
Linda J. Reyes
5126 Brookwood Road
Brooklyn park, MD 21225-3012
Re: Account with Dialysis Corporation of America
Account Balance: $21,523.91 plus costs of collection
Our Matter No.: 1087-08
Dear Ms. Reyes:
Please be advised that our law firm represents Dialysis Corporation of
Corporation of America is proud to provide compassionate and lifesaving serv
need. However, in certain situations it becomes necessary for them to take str,
the agreements made by their patients to receive compensation for services rer
2933 North Front Street
Harrisburg, PA 17110
Telephone: (717) 233-4101
Fax: (717) 233-4103
_www. capozziassociates.com
Craig 1. Adler, Esq.
Of Counsel
,rica. Dialysis
to individuals in
r measures to enforce
Your account is now seriously overdue. Dialysis Corporation of Ameri' a firmly believes that
they are entitled to receive the above-referenced balance. They have instructed 'Kite to attempt to settle
this account in an amicable manner, if possible. Although you have 30 days to ontact me to dispute the
amount, make payment, or make settlement arrangements, we will have no opti' n but to prosecute a
lawsuit against you if this issue is not resolved.
NOTICE: UNLESS YOU DISPUTE THE VALIDITY OF THIS DVBT, OR ANY
PORTION THEREOF, WITHIN 30 DAYS AFTER RECEIVING THIS N TICE, THE DEBT
WILL BE CONSIDERED TO BE VALID. IF YOU NOTIFY OUR OFFIC E IN WRITING
WITHIN 30 DAYS AFTER RECEIVING THIS NOTICE THAT THIS D BT, OR ANY
PORTION THEREOF, IS DISPUTED, WE WILL OBTAIN VERIFICAT ON OF THE DEBT
AND WE WILL MAIL A COPY TO YOU. THE NAME OF THE ORIGI NAL CREDITOR OF
THIS DEBT IS IDENTIFIED ABOVE.
THIS LETTER AND ALL OTHER COMMUNICATIONS FROM SUS ARE ATTEMPTS
TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE SED FOR THAT
PURPOSE.
Please make arrangements to settle this delinquent account or you may all me if you have any
other questions. I trust that you will give this Notice your immediate attention.
Yours truly,
/kJ a°
cc: Lisa A. Laudeman, DCA
Michael M. Jerominski
11 EXHIBIT
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U.S. RENAL CARE, INC. f/k/a k?'?,'URT OF COMMON PLEAS OF
DIALYSIS CORPORATION OF AMEf&A-'`'
AND COUNTY, PENNSYLVANIA
d/b/a DCA OF CHESAPEAKE,
Plaintiff
V. : Docket No.: 11-7199
LINDA J. REYES,
Defendant : Civil Action - Law
PRAECIPE TO ENTER DEFAULT JUDGMENT
TO THE PROTHONOTARY/CLERK OF SAID COURT:
Pursuant to Pa.R.Civ. P. No. 1037(b), enter judgment in favor of Plaintiff, U.S. Renal
Care, Inc. f/k/a Dialysis Corporation of America d/b/a DCA of Chesapeake, and against
Defendant, Linda Reyes, 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:
Principal Amount Due: $14,523.91
Attorney Fees: $ 1,054.50
Cost of Court: $ 213.75
TOTAL: $15,792.16
* Plus post-judgment interest at the legal rate of 6% per annum, and costs of
collection.
Fees: $ 1054.50
Disb: $213.75
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:
ate *LL to fA Q
1. The last known address for Defendant is as follows:
Linda J. Reyes,
5126 Brookwood Road
Brooklyn Park, MD 21225
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: 11-22-11
B
Y•
Philip C. W holic, Esquire
Attorney I.D o.: 86341
2933 North Front Street
Harrisburg, PA 17110
(717) 233-4101
Attorney for Plaintiff
2
U.S. RENAL CARE, INC F!K/A DIALYSIS CORPORATION OF AMERICA 0/B/A
DCA OF CHESAPEAKE
Plaintiff
VS.
LINDA J REYES
Defendant
Person to be served (Name and Address):
LINDA J REYES
5126 BROOKWOOD RD
BROOKLYN PARK MD 21225
By serving: LINDA J REYES
Attorney: PHILIP C WARHOLIC, ESQ
Papers Served: NOTICE TO DEFEND, COMPLAINT, EXHIBITS
Service Data: xServed Successfully (] Not Served
Date/Time: U L? 0 `? ( Qt (0 jtpf"Y-)
( ) Delivered a copy to him/her personally
><Left a copy with a competent household member over 14 years of age residing
therein (indicate name 8 relationship at right)
( ] Left a copy with a person authorized to accept service, e.g. managing agent, Name of Person Served and reladonship/title:
registered agent, etc. (indicate name 8 official title at right) C l SC ?t_L=,
5c ?? -7--
Description of Person Accepting Service: G
SEX: AGE: HEIGHT: ? i WEIGHT: SKIN: I 1 ?1 HAIR: (3a C ? OTHER:
Unserved:
[ J 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
[ j Defendant is evading service
(j No response on: Date/Time:
Date/Time:
DatefTime:
Other:
Served Data:
Subscribed and Sworn to me this
7 day of 0C trh' J' .20 Notary Signature: ai? /tw(iL-
6T-r t EdLCC1.rr 1 eery: naq-1 I oi "Z(1l
Name of Notary Commissi Expiration
NO i ARY
` PUBLIC
LIRE C
(`' un1t??.7C?Jt?G?il??court of ?on'Y)1cr1 V?Q??S
venue
Docket Number: 11 7199
AFFIDAVIT OF SERVICE
(For Use by Private Service)
Cost of Service pursuant to R. 4:4-3(c)
Attempts: Dale/Time:
Oste/Time:
Oale/Time:
was at the time of service a competent adult, over
the age of 18 and not having a direct interest in the
litigation. I declare under penalty of pedury that the
fore, going is true and correct.
`4?? 1r `„em s I! /-'()/ 21i
Signature of Process Server Date
Exhibit A
U.S. RENAL CARE, INC. f/k/a
DIALYSIS CORPORATION OF AMERICA
d/b/a DCA OF CHESAPEAKE,
Plaintiff
V.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
: Docket No.: 11-7199
LINDA J. REYES,
Defendant
: Civil Action - Law
NOTICE OF INTENTION TO ENTER JUDGMENT BY DEFAULT
TO: Linda J. Reyes,
5126 Brookwood Road
Brooklyn Park, MD 21225
DATED: November 9, 2011
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
U.S. RENAL CARE, INC. f/k/a IN THE COURT OF COMMON PLEAS OF
DIALYSIS CORPORATION OF AMERICA CUMBERLAND COUNTY, PENNSYLVANIA
d/b/a DCA OF CHESAPEAKE,
Plaintiff
V. : Docket No.: 11-7199
LINDA J. REYES,
Defendant : Civil Action - Law
NOTICIA IMPORTANTE
TO: Linda J. Reyes,
5126 Brookwood Road
Brooklyn Park, MD 21225
DATED: November 9, 2011
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 _
Exhibit B
Capozzi & Associates, P.C.
2933 N. Front Street
Harrisburg, PA 17110
(717) 233-4101
U.S. RENAL CARE, INC. f/k/a
DIALYSIS CORPORATION OF AMERICA
d/b/a DCA OF CHESAPEAKE,
Plaintiff
V.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
Docket No.: 11-7199
LINDA J. REYES,
Defendant
: Civil Action - Law
CERTIFICATE OF SERVICE
I hereby certify that I have this date caused a copy of the foregoing Praecipe to Enter
Default Judgment to be served by regular first class U.S. Mail addressed to the following:
Linda J. Reyes,
5126 Brookwood Road
Brooklyn Park, MD 21225
Date: 11-22-11
Philip C. 'flarholic, Esquire
Attorney I . No.: 86341
Capozzi & Associates, P.C.
2933 North Front Street
Harrisburg, PA 17110
(717) 233-4101
Attorney for Plaintiff
U.S. RENAL CARE, INC. f/k/a
DIALYSIS CORPORATION OF AMERICA
d/b/a DCA OF CHESAPEAKE,
Plaintiff
V.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
: Docket No.: 11-7199
LINDA J. REYES,
Defendant
: Civil Action - Law
RULE 236 NOTICE OF ENTRY OF JUDGMENT BY DEFAULT
NOTICE OF DEBTOR'S RIGHTS
TO: Linda Reyes, Defendant
You are hereby notified that on 2011, judgment was
entered against you in the sum of Fifteen Thousand, Seven Hundred Ninety-Two Dollars and
16/100 ($15,792.16), ulusuo_st judgment interest at the leeal rate of 6% Der annum and cost
of collection, for failure to appear or file an Answer to the C
action despite Notice of Intent served on November 9, 2011.
Date: ll 1 a I
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OF 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
I hereby certify that the following is the address of the Defendant stated in the certificate of
residence: Linda J. Reyes, 5126 Brookwood Road, Brooklyn Park, MD 21225
w +rj l
/ p.
Date: +J
Jarholic, Esquire
D. No.: 86341
Capozzi & Associates, P.C.
2933 North Front Street
Harrisburg, PA 17110
(717) 233-4101
Attorney for Plaintiff
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