HomeMy WebLinkAbout09-30-11IN THE COND CoUNTOY, PENNSYLVANIA
OF CUMBERLA
ORPHANS' COURT DIVISION
IN RE: ,
No.21-2011-982
CAROLYN M. WIRTH
PROOF OF CLAIM
1. Continuum Care Holdings d/b/a Spring Creek Rehabilitation and Health Care Center,
zi & Associates, P.C., Attn: Andrew R. Eisemann, Esquire, 2933 North Front Street, Harrisburg,
c/o Capoz
makes this claim as a nursing facility against the Estate of the Carolyn M. Wirth, Decedent, in
PA 17110,
the amount of $63,369.00.
This claim should be paid as a priority claim under 20 Pa.C.S.A. §3392(3) (Classification and
2.
ment for Decedent's last six months of costs of medical and nursing services. The Decedent
Order of Pay )
S rin Creek Rehabilitation and Health Care Center, 1205 South 28`" Street, Harrisburg, PA
resided at p g
17111 and died on September 12, 2011. An account summary is attached hereto as Exhibit A.
3. Claimant delivered notice of this Claim by first-class mail to:
Charlotte Berges
5721 Kensington Terrace, Apt. 8
Lancaster, PA 17603
Claimant's Address: Spring Creek Rehabilitation and Health Care Center
c/o Capozzi & Associates, P.C.
Attn: Andrew R. Eisemann, Esquire
2933 North Front Street
Harrisburg, PA 17110
Respectfully submitted,
CAPOZZI & A TES, P.C.
J/
Q ~,
Date: / °` ~ rew emann, Esquire
~.j-- -- ~ Attorney D. o.: 87441
~~ r; ,
. ; _ ~ =- ~ = ___ 2933 North Front Street
Harrisburg, PA 17110
`" `~- - (717) 233-4101
`~ ~` =-' ~ Attorney for Claimant
~~,
;___
-- -
.. ~-
_. c.~~ .ri
~~_---
r~-_
~`_
SPRING CREEK REHAB
1205 SOUTH 2BTF3 ST
HARRISBURG
& HEALTH CARE CENTER
pA 17111
CHARLOTTE BERGES
5"11 KENSINGTON TERRACE
AP'I' $
LANCASTER, PA 17603
TELEPHONE: 717 565 7000
DATE: 09/21/2011
CAROLYN 43IRTH
BILL FOR:
_________
________-
RESIDENT NO 3266_ __^________
_____ ___________ ____ __________
___ _
_s-_==__ __________ CURRENT
UNITS PRICE CHARGES/ BALANCE
DE6CRIPTIOI~I REE'ERENCE PAXMENT DUE
=
=
DATE ==_____ ______ _____am,== a_.--___.-.._. -
_===,s
-
____°___ -
=-==.~,~®m=ma
-~ a,e== .00
PREVIOUS BALANCE
_ .-.--
00
246
2214.00
2214.0.0
11/22/10
11/30'/10..Ii1L7RSI1.3G CARE
CARE 010-1
024-2 g
31 .
246.00
7626.00
00
5658 9840.00
15498.00
12/01/10 12/31/10 NURSING
NURSING CARE
024-2 23 24b.00
246.00 .
1968.00 17466.00
01/01/11 01/23/11
1/31/11 NURSING CARE
0 $
7 246.00 1722.00 19158.00
00
01/24/11
1 0
02/07/11 NURSING CARE 28_9
-1
9
246.00
2214.00
21402.
00
4354
02/01/1
02/08/11 02/16/11 NURSING CARE
CARE 022 12 246.00 2952.00
00
7905 .
2
32259.00
02/17/11 02/28/31 NURSING
NURSING CARE 023-2 31 255.00
00
255 .
7b50.00
39909.00
03/01!11 03/31/11
NURSING CARE 023-2 30 ,
00
255 7905.00 47814.00
04/01/17- 04/30/11
05/31/11 NURSING CARE
023-2 31
30 -
255.00 7650.00 55464.00
00
05/01/11
6/01/11 06/30/11 NURSING CARE 023-2
3-'?
02 14 255.00 3570.00
00 59034.
62b04.0
0
07/O1/il G7/14/~'-1 NURSING CARE
NURSYNG CARE .
023
2 14 255.00
00
255 3570.
765.00 63369.00
p7/15/11 07/28/11
07/31/11 NURSYNG CARE - 3 . 0
07/29/11 63369.0
BALANCE DUE
S
00tPa~nX
10 days from the
a~8e' payable to Spring
~, garb x 7023.
Paymen 7
0
t is due
us at (717) 565 7
B o
changed
E to
Creek. Contact
not prompt income WILY=
Yi income payments are
to Spring CreeK.
come d irectly
Exhibit A