HomeMy WebLinkAbout01-17-121
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.Air Methods PBS Office
621 Carnegie Dr. Ste. 210 ,
San Bernardino, CA 92408 =_ ~ ~
(909) 915-2364 --
In pro per ':' ~~
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~' In the Probate Court of Cumberland County -State of Pennsylvania °
Estate of Paul Mattus,
Case No.: 21-2011-0949
CREDITORS CLAIM
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Decedent,
SEE ATTACHED EXHIBIT "1"
The undersigned, Esmeralda Contreras being first duly sworn on oath states that the
creditor named below is the owner of the claim against Paul Mattus, deceased, which is hereto
attached, and which is made a part hereof by reference the same as if it were fully set-out herein;
that said claim is lawful and justly due; that the undersigned has personal knowledge of the said
claim, or is the credit manager of the claimant and is the custodian of claimant's books and
records of account upon which said claim is based: that there is now due and unpaid on the said
claim the sum of $47,417.59 and that all claims, credits, set-offs and adjustments have been
given. Further Affiant saith not. ~-..,
Dated this -~ ,Z~:~_ day of ~ ~ -v,w.n,. 201~~
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State of California
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Countyo __~'~~~ ~ti i1r'~.~C~,~t.~:
Esmeralda Contreras
Air Methods PBS Office
621 Carnegie Dr. Ste. 210
San Bernardino CA 92408
Run# 11-85100 & 11-85190
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Subscribed and sworn to E~-- ~~) before me on this ~ ~~~ day of ~~~ux(t~01~. by
t`.-~~ 1' ~~'~(~. (~i ~.~"1'~~~~'-i~(,~ti, proved to me on the basis of satisfactory evidence to be the
person who appeared before me.
28 LINDA KOKOSZKA
j~ :~~ Commission # 1888649
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~`~' Notary Public -California v
San Bernardino County
My Comm. Expires May B, 2014
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CREDITORS CLAIM - 1
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PROOF OF SERVICE BY MAIL (1013a, 2015 5, C C P )
STATE OF CALIFORNIA )
ss:
COUNTY OF SAN BERNARDINO)
I, DIANE FIELDS, declare as follows:
I am a resident of the County aforesaid; I am over the age of eighteen years and am
not a party to the within entitled action; my business address is 621 E. Carnegie Dr. #210, San
Bernardino CA 92408
On ~ '3 , 2012, I served the following: CREDITORS CLAIM on the interested
parties in said action by mail, as follows:
Linda Olsen
P.O. BOX 886
Harrisburg, PA 17108
Pamela Mattus
514 Partridge Court
Mechanicsburg, PA 17050
Joseph Metz, Esquire
112 Market Street
Harrisburg, PA 17101
I am "readily familiar" with the firm's practice of collection and processing
correspondence for mailing. Under that practice it would be deposited with the U.S. Postal Service
on that same day with postage thereon fully prepaid, at San Bernardino, California, in the ordinary
course of business. I am aware that on motion of the party served, service is presumed invalid if
postal cancellation date or postage meter date is more than one day after date of deposit for mailing
in affidavit/declaration.
I declare under penalty of perjury and the laws of the State of California that the
foregoing is true and correct.
Executed on 1-3 , 2012, at San Bernardino, California.
DIANE FIELDS
CREDITORS CLAIM - 2
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CREDITORS CLAIM - 3
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EXHIBIT "1"
CREDITORS CLAIM - 4
ROCKY MOUNTAIN HOLDINGS, LLC
PO BOX 713375
CINCINNATI OH 45271-3375
(888)636-4438
Air Ambulance Services provided by Air Methods Corporation
Patient Name: MATTUS, PAUL
Run Number: 11-85190
Date of Call: 8%28/2011
Time of Call: 19:44
Caller:
From: Robert Packer Hospital - Adul[ Lvl
MATTUS, PAUL To: 42°09.590N, 076°53.490`W
514 PARTIDGE CRT
MECHANICSBURG, PA 17050 Primary payor: Bill Patient
Secondary payor:
Payment
Description Check #
Quantity Unit Price Date Amount
Helicopter Rotor Miles 25 $192.39 $4,809J5
Helicopter Rotor Base 1 $18,225.68 $18,225.68
**CMS Rules determine Medicaid/Medicare payments made to providers are conditional where a settlement is pending. In
the event a settlement is garnered, Medicaid/Medicare will be refunded by the provider and the provider is thereby entitled
to full payment from the settlement for total balances to include contractual and/or bad debt write-offs**
BALANCE:
-----------------
DETACH ALONG LME AND RETURN STLB WITH YOUR PAYMENT. THANK YOU.
Patient Name: MATTUS, PAUL
Run Number: 1.1-85190
Current Date: 12/29/2011
Incident Number: 604046
AMOU\T
ENCLOSED:
X23,035.43
D
RtrM~T To: ROCKY MOUNTAIN HOLDINGS, LLC
PO BOX 713375
CINCINNATI OH 45271-3375
ROCKY MOUNTAIN HOLDINGS, LLC
PO BOX 713375
CINCINNATI OH 45271-3375
(888)636-4438
Air Ambulance Services provided by Air Methods Corporation
Patient Name: MATTUS, PAUL
Run Number: 11-85100
Date of Call: 8;28/2011
MATTUS, PAUL,
514 PARTIDGE CRT
MECHANICSBURG, PA 17050
Description Check #
Time of Call: 15:43
Caller:
From: Corning Hospital
To: Robert Packer Hospital -Adult Lvl 2
Primary payor: Bill Patient
Secondary payor:
Payment
Quantity Unit Price Date Amount
Helicopter Rotor Miles 32 $192.39
Helicopter Rotor Base 1 $18,225.68
$6,156.48
$18,225.68
**CMS Rules determine Medicaid/Medicare payments made to providers are conditional where a settlement is pending. In
the event a settlement is garnered, Medicaid/Medicare will be refunded by the provider and the provider is thereby entitled
to full payment from the settlement for total balances to include contractual and/or bad debt write-offs**
BALANCE: $24,382.16
DETACH ALONG LEVE AND RETURN STUB WITH YOUR PAYY(ENT THANK YOU.
Patient Name: MATTUS, PAUL
Run Number: ll-85100
Current Date: 12/29/2011
Incident Number: 603956
A1901 N"I' $
ENCLOSED:
REMrr T~o: ROCKY MOUNTAIN HOLDINGS, LLC
PO BOX 713375
CINCINNATI OH 45271-3375