HomeMy WebLinkAbout12-4768FLED-OFFICCE
C'I THE PROTHONOTAR)
2012 JUL 30 PM 1: 20
ROBERT D. KODAK, ESQUIRE CUMBERLAND COUNTY
KODAK & IMBLUM, P.C. PENNSYLVANIA
407 N FRONT STREET, PO BOX 11848
HARRISBURG, PA 17108-1848
(717) 238-7159 Attornev for Plai
PEDIATRIX MEDICAL GROUP, INC.
Plaintiff
LISA M MILLER
v
Defendant(s)
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY,
PENNSYLVANIA
-W
NO. 19,14
CIVIL ACTION - LAW
NOTICE/AVISO
YOU HAVE BEEN SUED IN
COURT. If you wish to defend against the
claim set forth in the following pages, you
must take action within twenty (20) days
after this complaint and notice are served,
by entering a written appearance personally
or by an attorney and filing in writing with the
court your defenses or objections to the
claims set forth against you. You are
warned that if you fail to do so the case may
proceed without you and a judgment may be
entered against you by the court without
further notice for any money claimed in the
complaint or for any other claim or relief
requested by the plaintiff. You may lose
money or property or other rights important
to you.
YOU SHOULD TAKE THIS PAPER
TO YOUR LAWYER AT ONCE. IF YOU
DO NOT HAVE A LAWYER, GO TO OR
TELEPHONE THE OFFICE SET FORTH
BELOW. THIS OFFICE CAN PROVIDE
YOU WITH INFORMATION ABOUT
HIRING A LAWYER.
IF YOU CANNOT AFFORD TO
HIRE A LAWYER, THIS OFFICE MAY BE
ABLE TO PROVIDE YOU WITH
INFORMATION ABOUT AGENCIES THAT
MAY OFFER LEGAL SERVICES TO
ELIGIBLE PERSONS ATA REDUCED FEE
OR NO FEE.
USTED HA SIDO DEMANDADO/A I
CORTE. Si usted desea defenderse de
demandas que se presentan mas adelante
las siguientes paginas, debe tomar acci
dentro de los proximos veinte (20) dias desppu
de la notificacion de esta Demanda y Avi
radicando personalmente o por medio de
abogado una comparencencia escrita
radicando en la Corte por escrito sus defens
de, y objecciones a, las demandas presentad
aqua en contra suya. Se le advierte de que
usted falla de tomar accion como se descri
anteriormente, el caso puede proceder sin ust
y un fallo por cualquier suma de dine
reclamada en la demanda o cualquier of
reclamacion o remedio solicitado por
demandante puede ser dictado en contra su
por la Corte sin mas aviso adicional. Usti
puede perder dinero o propiedad u otr
derechos importantes para usted.
USTED DEBE LLEVAR EST
DOCUMENTO A SU ABOGAD,
INMEDIATAMENTE. SI USTED NO TIENE U
ABOGADO, LLAME O VAYA A LA SIGUIENT
OFICINA. ESTA OFICINA PUED
PROVEERLE INFORMACION A CERCA D
COMO CONSEGUIR UN ABOGADO.
SI LISTED NO PUEDE PAGAR POI
LOS SERVICIOS DE UN ABOGADO, E
POSIBLE QUE ESTA OFICINA LE PLIED,
PROVEER INFORMACION SOBREAGENCIA
QUE OFREZCAN SERVICIOS LEGALES SII
CARGO O BAJO COSTO A PERSONAS QUI
CUALIFICAN. ,.?
a
a? Pc?a -?
CUMBERLAND COUNTY BAR ASSOCIATION
TWO LIBERTY AVENUE
CARLISLE PA 17013
717-249-3166
PEDIATRIX MEDICAL GROUP, INC. IN THE COURT OF COMMON PLEAS
Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA
v NO.
LISA M MILLER
Defendant(s) CIVIL ACTION -LAW
COMPLAINT
The Plaintiff, PEDIATRIX MEDICAL GROUP, INC., by its attorneys, KODAK LAW OFFICI
P.C., brings this action of Assumpsit against the Defendant to recover the sum of ONE HUNDR
NINETEEN THOUSAND EIGHT HUNDRED SIXTY EIGHT DOLLARS ($119,868.00), along v
interest thereon at the statutory rate from August 19, 2009, upon a cause of action of which
following is a statement:
1. The Plaintiff, PEDIATRIX MEDICAL GROUP, INC., is a corporation organized and exis
under the laws of the State of Florida, duly registered and authorized to do business in
Commonwealth of Pennsylvania, having an office and place of business at 111 S. F
Street, Harrisburg, Pennsylvania.
2. The Defendant, LISA M MILLER, is an adult individual residing at 75 DEADEND LAN
SHIPPENSBURG, CUMBERLAND COUNTY, PA 17257-8619.
3. On or about March 23, 2009, Defendant sought out medical services from Plaintiff
evidenced by the signed Consent Form, a true and correct copy of which is attached he
marked Exhibit "A" and made a part hereof.
4. On the dates and for the amounts set forth therein, Plaintiff, at the special insistence
Defendant, provided medical care to Defendant and/or Defendant's newborn child to the tc
amount of One Hundred Nineteen Thousand Eight Hundred Sixty Eight Dollars ($119,868.(
as set forth on Plaintiffs Statement of Account attached hereto, marked Exhibit "B" a
made a part hereof.
F:\USER\Z-MASTER CMP FILES\COMPLAINTS\PEDIATRIX MED GROUP\pediatrix 37054.wpd 2
5. The prices charged for said medical services provided were just and reasonable, were the
legal and market prices therefor and were the prices which the Defendant promised and
agreed to pay to Plaintiff.
6. The balance due and owing by Defendant to Plaintiff is the sum of One Hundred Ninet
Thousand Eight Hundred Sixty Eight Dollars ($119,868.00), as appears by Exhibit
hereto.
7. Plaintiffs Invoices are not attached to this pleading due to the voluminous nature of
and have previously been provided to Defendant.
8. Plaintiff frequently demanded payment from Defendant of said amount due and owing
aforesaid, but Defendant refused and neglected and still refuses and neglects to pay sa
amount or any part thereof.
WHEREFORE, Plaintiff brings this suit to recover from Defendant the sum of One Hunc
Nineteen Thousand Eight Hundred Sixty Eight Dollars ($119,868.00), together with interest as
forth herein.
Respectfully submitted,
KODAK LAW OFFICES, P.C.
UL I - -T tl lzas -?. 39P"l
rRf6#trtJD. Koda , squire
fTVe
40 orth Front Street
Post Office Box #11848
Harrisburg, PA 17108-1848
(717) 238-7159
Attorney ID No. 18041
Attorney for Plaintiff
FAUSERV-MASTER CMP FILES\COMPLAINTS\PEDIATRIX MED GROUP\pediatrix 37054.wpd 4
01-C7-2010 08:43 FROM- ? T-748 P.003/003 F-683
C01SENT FOR TREATMENT- I consent to the rendering of medical care, which may Include diagnostic procedures and such
medical treatment as my attending or consulting physician considers to be necessary. I also understand that, absent erltergencly
c,rc Imstances no invasive or experimental procedure will be performed upon me unless or until i have had an opportunity to irgery, cues
the procedure with my physician and give informed consent to the procedure. I understand that the practice of medicine andis
not 3n oxact sr fence and that diagnosis and treatment may Involve risk of injury or even death- I admowledge that no guaranhas
bee i made to ne regarding any examination or treatment In this hospital.
PRI `-CERTIFICATION REQUIREMENTS - If my insurance company or third party requires pre-certificatlon, then 1 understand ghat it is
my -esponsibJl ty to contact them to obtain such certification. EXCEPTION' Medicare.
ASSIGNMENT OF INSURANCE BENEFITS -- I hereby authorize my Medicare andlor medical insurance benefits payable to m
under the term; of my insurance policies to be paid directly to Pinnacle Health Hospitals- If my attending physician and/or otho
phy iician asso:isted with him or whom he may designate accepts insurance assignment, then I heret)y authorize my Medicare
magical insura ice benefits to be paid directly to those physicians. I assign any alit all legal rights that i have to collect nonefits
Pinnacle Healt i Hospitals. I understand that I am financially responsible for non-covered services, as well os any deductibles,
aolr surance or amounts In excess of insurance benefits. I permit a copy of this consent to no used in place of the original.
GRIEVANCE l.PPEAL CONSENT - I hereby authorize Pinnacle Health Hospitals to act on my behalf in requesting a reconside
of a medical dr:lerminalien made by my managed care plan or utilization review entity regarding my medical care.
ADVANCE DINECTiVES-INPATIENTS ONLY - I understand that Pinnacle Health Hospitals will provide me with written informa
reg:lyding my r ght to make health Caro treatment decisions In compliance with the Patient Self Daterminatlon Act of 1990,
Yhir information will be provided in the Patient Handbook.
ME-)ICARE Ih PATIENTS ONLY - t certify that the information given by me in applying for payment under Title XVII of the
Social Socur% Act Is correct i acknowledge that I have received a copy of -An Important Message from Medicated. My stgnatu
ack iowledges my receipt of this message from Pinnacle Health and does not waive any of my rights to request a review or make me
flab e for any p ayment. I realize that lifetime reserve days are a once lifetime maximum of 80 days. If I should use all of my full days
arto co, in pr,ce days, I agree to use my lifetime reserve days for any remaining days.
NOTICE - I acknowledge that I have received a copy of Pinnacle Health System's Privacy Notice.
(in PER: ONAL VALUABLES -- Pinnacle Health Hospitals is not responsible for personal items brought to the hospital. As fe
. s } is available for valuables such as cash, Important documents, credit cards and Jewelry that can not be sent horns. AIJ
personal items retained at the bedside are the sole responsibility of the patient.
TELE PHONE AND TELEVISION - I understand that there Js a minimal daily charge per day charge for the availability of
(In L? telepl one (IoM calls only) and television servioe as these services are not covered by Insurance. This amount will be
charged to my home telephone bill of which I am authorized to accept charges and allow the release of only information 'o the
telephone company that is necessary to bill for those services.
PL T1ENT ANONYMITY (Facirfly Director Opt Out for Patients in the Emergency Department and Those Asaisned loan in-House Boo) - Ira uest
Pil naclo Heatti, Hospitals to control the knowledge of my Identity and presence during this course of care only. ,l acknowledge that the Pinnacle
Health Hospita s Patient Anonymity Policy has been expiained to me am that I have been provided with the guidelines.
- I
ignature of .1aH t or Legal Representative Date Signed
` CONSENT MUST 8E SIGNFD BY THE PATIENT'S LEGAL REPRESENTATIVE IN THE
` C PAM OR HEnN THE PATIENT IS PHYSICALLY OR MENTALLY t CAPACITATED.
Sigr atuTa of Pat ant or Legal Represontativo Dote Signed
Pair tad Name of Legal Reprasentative and
Pat -rrt is unable- to sign because:_.4
Habpital Raprasantative
4v:? PINNACLEHFALTH
Hospitals
s
CONSENT FOR TREATMENT
11111111111111111111111 11il1111IGN111I
ADICO
;o INV W90 [WE 7] MR (rol)l
MR: *'*102367 CASE: 290277575
i MILLER .BUY f
PATE; ? M
Ph#: 717-423-5120 AGE.
DR:DONAHLIFMARGARET
?z_
PEDIATRIX MEDICAL GROUP (PVA) ACCOUNT INQUIRY RUN DATE 01/06/10 PAGE 3
4624201 998 AkjW Y49 99468 INITIAL INPA 209Q/IO 3560.00 04/27/09
02504 77089 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER 209Q/10 TO 209Q/PO 3560
00
4624201 *TOTAL* DUE FROM 209Q/PO .
3560.00 AGE= 171
4624202 998 Y49 99465 /25 DELIVERY/BIR 209Q/IO 756.00 04/27/09
02501 77089 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER 209Q/IO TO 209Q/PO 756
00
4624202 *TOTAL* DUE FROM 209Q/PO .
756.00 AGE= 171
4624216 9984NOMW Y49 99469 SUBSEQUENT I 209Q/TO 2262.00 04/28/09
02504 77089 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER BAL 0.00 0"7119109
TFER 209Q/IO TO 209Q/P0 2262
00
4624216 *TOTAL- DUE FROM 209Q/PO .
2262.00 AGE= 171
4624231 998mVpM W96 99469 SUBSEQUENT I 209Q/10 2262.00 04/29/09
02504 77089 1 CAPITAL BL 3*
*ADJ*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER* 209Q/I0 TO 209Q/PO 2262
00
4624231 *TOTAL* DUE FROM 209Q/PO .
2262.00 AGE= 171
4624253 998 Jf 86C 99469 SUBSEQUENT I 209Q/ID 2262.00 04/30/09
02504 77089 1 CAPITAL BL 3*
*ADJ*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER* 209Q/I0 TO 209Q/PO 2262
00
4624253 *TOTAL- DUE FROM 209Q/P0 .
2262.00 AGE= 1.71
4624260 998 M 351 99469 SUBSEQUENT I 209Q/10 2262.00 05/01/09
02504 7704 1 CAPITAL BL 3*
*ADJ*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER* 209Q/IO TO 209Q/PO 2262
00
4624260 *TOTAL* DUE FROM 209Q/PO .
2262.00 AGE= 171
4624271 998 4W 349 99469 SUBSEQUENT I 209Q/IO 2262.00 05/02/09
02504 "+704 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER 209Q/ID TO 209Q/PO 2262.00
4624271 *TOTAL* DUE FROM 209Q/PO 2262.00 AGE= 171
4624289 998 NW W96 99469 SUBSEQUENT I 209Q/10 2262.00 05/03/09
02504 7704 CAPITAL BL 3*
*ADJ*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER* 209Q/IO TO 209Q,/PO 2262
00
4624289 *TOTAL* DUE FROM 209Q/PO .
2262.00 AGE:= 171
4624312 998 WOW 86C: 99469 SUBSEQUENT I 209Q/IO 2262.00 05/04/09
02504 7704 1 CAPITAL BL 3 *
*ADJ*
*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER 209Q/IO TO 209Q/PO 2262
00
4624312 *TOTAL- DUE FROM 209Q/PO .
2262.00 AGE= 171
4624340 998 WW K04 99469 SUBSEQUENT I 209Q/IO 2262.00 05/05/09
02504 7704 1 CAPITAL BL 3 *
*ADJ*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER* 209Q/IO TO 209Q/PO 2262
00
4624340 * TOTAL* DUE FROM 209Q/PO .
2262.00 AGE= 171
4624365 998 Awwp? 349 99469 SUBSEQUENT I 209Q/10 2262.00 05/06/09
02504 7?089 1 CAPITAL BL 3*
*ADJ*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER* 209Q/IO TO 209Q/PO 2262
00
4624365 - TOTAL* DUE FROM 209,)/PO .
2262.00 AGE,= 171
4624402 998 NW 349 99469 SUBSEQUENT I 209Q/10 2262.00 05/07/09
02504 7704 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER BAL 0.00 07/1
9/09
TFER 209Q/10 TO 209Q/PO .
2262
00
4624402 * TOTAL* DUE FROM 209Q/PO .
2262.00 AGE=- 171
4624432 998 flWD 349 99469 SUBSEQUENT I 209Q/IO 2262.00 05/CB/09
02504 7704 1 CAPITAL BL 3*
*ADJ* 8001
* TBTA TRANSFER BAL 0.00 07/19/09
TFER* 209Q/10 TO 209Q/PO 2262
00
4624432 -TOTAL* DUE FROM 209Q/PO .
2262.00 AGE= 171
4624451 998 NMIiT1 K04 99469 SUBSEQUENT I 209Q/IO 2262.00 05/09/09
02504 7 704 1 CAPITAL BL
3*
*ADJ* 5001 TBTA TRANSFER BAL 0.00 07/19/09
I 1q)s(ov
b O
PEDIATRIX. MEDICAL GROUP (PVA) ACCOUNT INQUIRY RUN DATE 01/06/10 PAGE 4
*TFER* 209Q/I0 TO 209Q/110 2262.00
4624451 *TOTAL* DUE FROM 209Q/PO 2262.00 AGE= 171
4624470 998 10646- 86C 99469 SUBSEQUENT I 209Q/10 2262.00 05/10/09
02504 7704 1 CAPITAL BL 3*
*ADJ* 8001 TBTA TRANSFER BAD 0.00 0.7119109
*TFER* 209Q/IO TO 209Q/P0 2262.00
4624470 *TOTAL* DUE FROM 209Q/PO 2262.00 AGE= 171
4624489 998 NEPP ? W96 99469 SUBSEQUENT I 209Q/IO 2262.00 01_5/11/09
02504 7704 1 CAPITAL BL 3*
*ADJ* 8001 TBTA TRANSFER BAL 0.00 07/19/09
*TFER* 209Q/IO TO 209Q/PO 2262.00
4624489 *TOTAL* DUE FROM 209Q/PO 2262.00 AGE= 177.
4624515 998"1 Y49 99469 SUBSEQUENT I 209Q/IO 2262.00 05/12/09
02504 7704 1 CAPITAL BL 3*
*ADJ* 8001 TBTA TRANSFER BAD 0.00 07/19/09
*TFER* 209Q/IO TO 209Q/PO 2262.00
4624515 *TOTAL* DUE FROM 209Q/PO 2262.00 AGE= 171
4624537 998 aMMM W96 99469 SUBSEQUENT I 209Q/10 2262.00 05/13/09
02504 7704 1 CAPITAL BL 3*
*ADJ* 8001 TBTA TRANSFER BAL 0.00 07/19/09
*TFER* 209Q/IO TO 209Q/P0 2262.00
4624537 *TOTAL* DUE FROM 2C9Q/PO 2262.00 AGE= 171
4624563 998"W"1r W96 99469 SUBSEQUENT I 209Q/IO 2262.00 05/14/09
02504 7704 1 CAPITAL BL 3*
*ADJ* 8001 TBTA TRANSFER BAL 0.00 07/19/09
*TFER* 209Q/I0 TO 209Q/PO 2262.00
4624563 *TOTAL* DUE FROM 209Q/PO 2262.00 AGE= 171
4624578 998 IMP Y49 99469 SUBSEQUENT I 209Q/10 2262.00 05/15/09
02504 '7704 1 CAPITAL BL 3*
*ADJ* 8001 TBTA TRANSFER BAD 0.00 07/19/09
*TFER* 209Q/IO TO 209Q/PO 2262.00
4624578 -TOTAL* DUE FROM 209Q/PO 2262.00 AGE= 171
4624596 998 qNVW' 86C 99469 SUBSEQUENT I 209Q/IO 2262.00 05/16/09
02504 7704 L CAPITAL BL 3*
*ADJ* 8001 TBTA TRANSFER BAL 0.00 07/19/09
*TFER.* 209Q/IO TO 209Q/PO 2262.00
4624596 *TOTAL* DUE FROM 209Q/PO 2262.00 AGE= 171
4624630 998 W 349 99469 SUBSEQUENT I 209Q/10 2262.00 05/17/09
02504 7704 1. CAPITAL BL 3 *
*ADJ* 800'_ TBTA TRANSFER BAL 0.00 07/19/09
*TFER* 209Q/10 TO 209Q/,Po 2262.00
4624630 *TOTAL* DUE FROM 209Q/PO 2262.00 AGE.= 171
4624661 998 iNNWV¦ K04 99469 SUBSEQUENT I 209Q/10 2262.00 05/18/09
02504 7704 1 CAPITAL BL 3 *
*ADJ* 8001 TBTA TRANSFER BAL 0.00 07/19/09
*TFER* 209Q/I0 TO 209Q/PO 2262.00
4624661 *TOTAL* DUE FROM 209Q/PO 2262.00 AGE= 171
4624705 998 WOMP 351 99469 SUBSEQUENT I 209Q/IO 2262.00 05/19/09
02504 7704 1 CAPITAL BL 3 *
*ADJ* 8001 TBTA TRANSFER BAL 0.00 07/19/09
*TFER* 209Q/I0 TO 209Q/PO 2262.00
4624705 *TOTAL* DUE FROM 209Q/PO 2262.00 AGE= 171
4624776 998 1O1• W96 99469 SUBSEQUENT I 209Q/IO 2262.00 05/20/09
02504 7704 1 CAPITAL BL 3 *
*ADJ* 8001 TBTA TRANSFER BAD 0.00 07/19/09
*TFER* 209Q/IO TO 209Q/PO 2262.00
4624776 * TOTAL* DUE FROM 209Q/PO 2262.00 AGE== 171
4624835 998 ?NOW Y49 99469 SUBSEQUENT I 209Q/IO 2262.00 05/21/09
02504 7704 1 CAPITAL BL 3*
*ADJ* 8001 TBTA TRANSFER BAL 0.00 07/19/09
*TFER* 209Q/I0 TO 209Q/PO 2262.00
4624835 * TOTAL* DUE FROM 209Q/PO 2262.00 AGE== 171
4624863 998 NOW Y49 99469 SUBSEQUENT I 209Q/IO 2262.00 05/22/09
02504 7704 1 CAPITAL BL 3*
*ADJ* 8001 TBTA TRANSFER BAL 0.00 07/19/09
*TFER* 209Q/IO TO 209Q/PO 2262.00
4624863 ' TOTAL* DUE FROM 209Q/PO 2262.00 AGE= 171
PEDIATRIX MEDICAL GROUP ;PVA% ACCOUNT INQUIRY RUN DATE 01/06/10 PAGE 5
4624908 998 NOW 351 99469 SUBSEQUENT I 209Q/10 2262.00 05/23/09
02504 7704 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER SAL 0.00 07/19/09
TFER 209Q/IO TO 209Q/PO 2262.00
4624908 *TOTAL* DUE FROM n9Q/PO 2262.00 AGE= 171
4624954 998 NOWN. 86C 99469 SUBSEQUENT I 2.09Q/IO 2262.00 05/24/09
02504 7704 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER SAL 0.00 07/19/09
TFER 209Q/IO TO 209Q/PO 2262.00
4624954 *TOTAL* DUE FROM 209Q/PO 2262.00 AGE= 171
4624985 998 1fWW 86C 99472 SUBSEQUENT I 209Q/IO 2290.00 05/25/09
02504 7704 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER SAL 0.00 07/19/09
TFER 209Q/IO TO 209Q/PO 2290
00
4624985 *TOTAL* DUE FROM 209Q/PO .
2290.00 AGE= 171
4625020 998 »- 351 99472 SUBSEQUENT I 209Q/10 2290.00 05/26/09
02504 7704 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER SAL 0.00 07/19/09
TFER 209Q/I0 TO 209Q/PO 2290
00
4625020 *TOTAL* DUE FROM 209Q/PO .
2290.00 AGE= 171
4625063 998 AWd& 351 99472 SUBSEQUENT I 209Q/IO 2290.00 05/27/09
02504 7704 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER SAL 0.00 07/19/09
TFER 209Q/I0 TO 209Q/PO 2290
00
4625063 -TOTAL* DUE FROM 209Q/PO .
2290.00 AGE= 171
4625125 998 400=0'- 351 99472 SUBSEQUENT I 209Q/10 2290.00 05/28/09
02504 7704 1 CAPITAL BL 3*
*ADJ*
*
* 8001. TBTA TRANSFER SAL 0.00 07/19/09
TFER 209Q/I0 TO 209Q/PO 2290
00
4625125 *TOTAL* DUE FROM 209Q/PO .
2290.00 AGE= 171
4625172 998 d=W 86C 99472
" SUBSEQUENT I 209Q/10 2290.00 05/29/09
02°_04
1704 1 CAPITAL BL 3*
*ADJ*
* 8001 TBTA TRANSFER SAL 0.00 07/19/09
TFER* 209Q/IO TO 209Q/PO 2290
00
4625172 *TOTAL* DUE FROM 209Q/PO .
2290.00 AGE- 171
4625203 998 IWWW 351 99472 SUBSEQUENT I 209Q/TO 2290.00 05/30/09
02504 7704 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER SAL 0.00 07/19/09
TFER 209Q/IO TO 209Q/PO 2290
00
4625203 *TOTAL- DUE FROM 209Q/PO .
2290.00 AGE= 171
4625246 998 )WW Y49 99472 SUBSEQUENT I 209Q/IO 2290.00 05/31/09
02504 7704 1 CAPITAL BL 3 *
*ADJ*
*
* 8001 TBTA TRANSFER SAL 0.00 07/19/09
TFER 209Q/IO TO 209Q/PO 2290
00
4625246 *TOTAL* DUE FROM 209Q/PO .
2290.00 AGE=- 171
4625310 998 41 351 99472 SUBSEQUENT I 209Q/IO 2290.00 06/01/09
02504 7704 1 CAPITAL BL 3 *
*ADJ*
*
* 8001 TBTA TRANSFER SAL 0.00 07/19/09
TFER 209Q/IO TO 209Q/PO 2290
00
4625310 * TOTAL* DUE FROM 209Q/PO .
2290.00 AGE== 171
4625386 djjW 351 99472 SUBSEQUENT I 209Q/10 2290.00 06/02/09
02504 7704 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER SAL 0.00 07/1
9/09
TFER 209Q/IO TO 209Q/PO .
2290
00
4625386 * TOTAL- DUE FROM 209Q/P0 .
2290.00 AGE= 171
4625478 998 NOR 351 99472 SUBSEQUENT I 209Q/10 2290.00 06/03/09
02504 7704 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER SAL 0.00 07/19/09
TFER 209Q/I0 TO 209Q/PO 2290
00
4625478 -TOTAL. DUE FROM 209Q/PO .
2290.00 AGE= 171
4625552 998 Nd? K04 99472 SUBSEQUENT I 209Q/10 2290.00 06/04/09
02504 7704 1 CAPITAL BL 3*
*ADJ* 8001 TBTA
* TRANSFER SAL 0.00 07/19/09
TFER* 209Q/IO TO 209Q/PO 2290
00
4625552 *TOTAL* DUE FROM 209Q/PO .
2290.00 AGE= 171
4625611 998 86C 99472 SUBSEQUENT I 209Q/IO 2290.00 06/05/09
0 7704 1 CAPITAL BL 3*
*ADJ* 8
*TFER* 001 TBTA TRANSFER BAL 0.00 07/19/09
209Q/I0 TO 209Q/PO 2290.00
PEDIATRI) MEDIAL GROUP (PVA)
ACCOUNT INQUIRY RUN DATE i
01/06/10
PAGE 6
4625611 -TOTAL* DUE FROM 209Q/PO 2290.00 AGE= 171
4625685 998 41=5 86C 99472 SUBSEQUENT I 209Q/IO 2290.00 06/06/09
0250 4 7704 1 CAPITAL BL 3*
*ADJ* 8001 TBTA TRANSFER BAL 0.00 0"7/19/09
*TFER* 209Q/IO TO 209Q/PO 2290.00
4625685 -TOTAL* DUE FROM 209Q/PO 2290.00 AGE= 171
4625777 998' W96 99472 SUBSEQUENT I 209Q/IO 2290.00 06/07/09
02504 7704 1 CAPITAL BL 3*
*ADJ* 8001 TBTA TRANSFER BAL 0.00 07/19/09
*TFER* 209Q/IO TO 209Q/PO 2290.00
4625777 *TOTAL* DUE FROM 209Q/PO 2290.00 AGE= 171
4625852 998 M11M Y49 99472 SUBSEQUENT I 209Q/10 2290.00 06/08/09
02504 7704 1 CAPITAL BL 3*
*ADJ*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER* 209Q/IO TO 209Q/PO 2290.00
4625852 -TOTAL* DUE FROM 209Q/PO 2290.00 AGE= 171
4625944 998 42f W96 99479 SUBSEQUENT 1209Q/IO 843.00 06/09/09
02504 76503 1 CAPITAL BE, 3*
*ADJ* 8001 TBTA TRANSFER BAL 0.00 07/19/09
*TFER* 209Q/10 TO 209Q/PO 843.00
4625944 *TOTAL* DUE FROM 2C9Q/PO 843.00 AGE= 171
4626054 998 1= 86C 99479
' SUBSEQUENT I 209Q/IO 843.00 06/10/09
02504 76503 1 CAPITAL BL 3*
*ADJ*
* 8001 TBTA TRANSFER BAT, 0.00 07/19/09
TFER* 209Q/IO TO 209Q/PO 843.00
4626054 *TOTAL* DUE FROM 209Q/PO 843.00 AGE= 171
4626129 998 4OW K04 99479 SUBSEQUENT I 209Q/10 843.00 06/11/09
02504 76503 L CAPITAL BE, 3 *
*ADJ*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER* 209Q/I0 TO 209Q/PO 843.00
4626129 *TOTAL* DUE FROM 209Q/PO 843.00 AGE= 171
4626230 9984? W96 99479 SUBSEQUENT I 209Q/10 843.00 06/12/09
02504 76503 1. CAPITAL BL 3 *
*ADJ*
* 8001. TBTA TRANSFER BAL 0.00 07/19/09
TFER* 209Q/I0 TO 209Q/PO 843.00
4626230 *TOTAL* DUE FROM 209Q/PO 843.00 AGE= 171
4626330 998 45W Y49 99479 SUBSEQUENT I 209Q/IO 843.00 06/13/09
02504 76503 1 CAPITAL BL 3*
*ADJ*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER* 209Q/IO TO 209Q/PO 843.00
4626330 *TOTAL* DUE FROM 209Q/PO 843.00 AGE= 171
4626412 998 NNVN- 86C 99479 SUBSEQUENT I 209Q/IO 843.00 06/14/09
02504 76503 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER 209Q/IO TO 209Q/PO 843
00
4626412 *TOTAL* DUE FROM 209Q/PO .
843.00 AGE== 171
4626499 998 d"f 351 99479 SUBSEQUENT I 209Q/IO 843.00 06/15/09
025C4 76503 1 CAPITAL BL 3*
*ADJ*
* 81001 TBTA TRANSFER BAL 0.00 07/1
9/09
TFER* 209Q/10 TO 209Q/PO 843.00 .
4626,199 * TOTAL* DUE FROM 209Q/PO 843.00 AGE=: 171
4626812 998 V? 349 99479 SUBSEQUENT I 2090/10 843.00 06/16/09
02504 76503 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
TFER 209Q/I0 TO 209Q/PO 843
00
4626812 * TOTAL* DUE FROM 209Q/PO .
843.00 AGE= 171
4630441 998 40W W96 99479 SUBSEQUENT I 209Q/10 843.00 06/17/09
02504 76503 1 CAPITAL BL 3*
*ADJ*
* 8001 TBTA TRANSFER BAL 0.00 0 7/19/09
TFER* 209Q/IO TO 209Q/PO 843
00
4630441 * TOTAL* DUE FROM 209Q/PO .
843.00 AGE= 171
4630808 998 NSW Y49 99479 SUBSEQUENT I 209Q/IO 843.00 0 6/1,3/09
02504 76503 1 CAPITAL BL 3*
*ADJ* 8001
*' TBTA TRANSFER BAL
0.00 0
7/19/09
TFER* 209Q/IO TO 209Q/PO 843
00
4630808 *T OTAL* DUE FROM 209Q/PO .
843 .00 AGE= 171
- T
PEDIATRIX MEDICAL GROUP (PVA) ACCOUNT INQUIRY RUN DATE 01/06/10 PAGE 7
4631223 998JOEM K04 99479 SUBSEQUENT I 209Q/IO 843.00 06/19/09
02504 76503 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER DAL 0.00 07/19/09
TFER 209Q/IO TO 209Q/PO 843
00
4631223 *TOTAL* DUE FROM 209Q/PO .
843.00 AGE= 171
4638784 -NMNN? K04 99479 SUBSEQUENT I 209Q/IO 843.00 06/20/09
02504 76503 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER DAL 0.00 0"7119109
TFER 209Q/IO TO 209Q/PO 843
00
4638784 *TOTAL* DUE FROM 209Q/PO .
843.00 AGE= 171
4639211. 998 JEW 349 99479 SUBSEQUENT I 209Q/IO 843.00 06/21/09
02504 76503 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER BAD 0.00 07/19/09
TFER 209Q/I0 TO 209Q/PO 843.00
4639211 -TOTAL* DUE FROM 209Q/PO 843.00 AGE= 171
4644091 998 JWW Y49 99479 SUBSEQUENT I 209Q/IO 843.00 06/22/09
02504 76503 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER BAD 0.00 07/19/09
TFER 209Q/IO TO 209Q/PO 843
00
4644091 *TOTAL* DUE FROM 209Q/PO .
843.00 AGE= 171
4648856 998 VOW 351 99479 SUBSEQUENT I 2C9Q/IO 843.00 06/23/09
02504 76503 1 CAPITAL BL 3*
*ADJ*
*
* 8001 TBTA TRANSFER BAD 0.00 07/19/09
TFER 209Q/IO TO 209Q/PO 843
00
4648856 *TOTAL* DUE FROM 209Q/PO .
843.00 AGE= 171
4651971 998 ANOW 86C 99479
- SUBSEQUENT I 209Q/10 843.00 06/24/09
02504
76503 1 CAPITAL BL 3 *
**AD
* 8001 TBTA TRANSFER DAL 0.00 07/19/09
J 2090/10 TO 209Q/PO 843
00
4651971 *TOTAL- DUE FROM 209Q/PO .
843.00 AGE= 171
4652379 998 40W 351 99479 SUBSEQUENT I 209Q/10 843.00 06/25/09
02504 76503 .. CAPITAL BL 3 *
*ADJ*
*
* 8001 TBTA TRANSFER DAL 0.00 07/19/09
TFER 209Q/IO TO 209Q/PO 843
00
4652379 *TOTAL* DUE FROM 209Q/PO .
843.00 AGE= 171
4652725 998 NMMW- 349 99479 SUBSEQUENT I 209Q/IO 843.00 06/26/09
02504 76503 1 CAPITAL BL 3 *
*ADJ*
*
* 8001 TBTA TRANSFER DAL 0.00 07/19/09
TFER 209Q/I0 TO 209Q/PO 843
00
4652725 *TOTAL* DUE FROM 205,Q/PO .
843.00 AGE= 171
4656852 998 = 349 99479 SUBSEQUENT I 209Q/10 843.00 06/27/09
02504 76503 1 CAPITAL BL 3*
**AD
J*
* 8001 TBTA TRANSFER BAD 0.00 07/19/09
R 209Q/IO TO 209Q/PO 843
00
4656852 *TOTAL* DUE FROM 209Q/PO .
843.00 AGE= 171
4662400 998 JMPW 349 99479 SUBSEQUENT I 209Q/10 843.00 06/28/09
02504 76503 1 CAPITAL BL 3*
*ADJ*
*TF
* 8001 TBTA TRANSFER BAL 0.00 07/19/09
ER 209Q/I0 TO 209Q/PO 843
00
4662400 * TOTAL* DUE FROM 209Q/P0 .
843.00 AGE=: 171
4667153 998 AVOW Y49 99479 SUBSEQUENT I 209Q/I0 843.00 06/29/09
02504 76503 1 CAPITAL BL 3*
*ADJ*
*T
* 8001 TBTA TRANSFER BAD 0.00 07/19/09
FER 209Q/IO TO 209Q/P0 843
00
4667153 * TOTAL* DUE FROM 209Q/PO .
843.00 AGE= 171
4670446 998 NdW Y49 99479 SUBSEQUENT I 209Q/10 843.00 06/30/09
02504 76503 1 CAPITAL BL 3*
*ADJ*
*TF
* SCO1 TBTA TRANSFER DAL 0.00 0.7/19/09
ER 209Q/IO TO 209Q/PO 843
00
4670446 * TOTAL* DUE FROM 209Q/PO .
843.00 AGE= 171
4674298 998 35
1 92586
50 HEARING SCRE 209Q/IO 226.00 06/30/09
,
4 76503 1 CAPITAL BL 3*
*ADJ* 8001 TBTA
*TFER* TRANSFER BAL 0.00 07/19/09
4674298 *T
OTAL* 209Q/I0 TO 209Q/PO 226.00
DUE FROM 209Q/PO 226.00 AGE= 171
46?7483 998 qM*f' 86C 99479 SUBSEQUENT I 209Q/IO 843.00 07/0:
/09
* 02504 76503 1 CAPITAL BL 3* .
ADJ* 8
*TFER* 001 TBTA TRANSFER DAL 0.00 07/19/09
209Q/I0 TO 209Q/PO 843.00
_-.
r-
PEDIATRIX MEDICAL CROUP (PVA) ACCOUNT INQUIRY RUN DATE 01/06/1 0 PAGE 8
4677483 *TOTAL* DUE FROM 209Q/PO 843. 00 AGE= 171
4676157 998 "NNIZ- 86C 99239 HOSPITAL DIS 209Q/IO 513. 00 07/02/09
02504 7707 1 CAPITAL BL 3*
*ADJ*
* 8001 TBTA TRANSFER BAL 0. 00 07/19/09
TFER* 209Q/IO TO 2 09Q/PO 513 00
4678157
--------- *TOTAL*
-------- ------------- DUE FROM
------------------- 209Q/PO
--------- .
513.
------- 00
-- AGE= 171
---------
07/23/2012 13:19
07/1812012 14:55
JUL-17-2012 1l:d1
8042530416
KODAK AND IMBLUM P.C.
PEDIATRIX
TAX)
PAGE 05/05
P.005
712 238 7168 P,06
V>rRLFICAT 10N
i, VIAL gJ14I? 1 t?i'et.?jQ? i?'t 7uT C .ay? S
One") ?U
of PUDIATRIX MEDICAL. GROUP, INC,, verity that the, statements made in the aforagoirng
document are true and correct I understand that false statements hereln are made subject to the
penalties of I8 Pa. C. S. §4904, relating to unswem fatsificaftn to autbl)dties,
PED IX MEDIC ROUP, INC,
BY:
We;
+- ttc mt--Ie n
Dated:,
37054/&wu i 4
MILLER
TOTAL, P,06
Ronny R Anderson
Sheriff
Jody S Smith
Chief Deputy
Richard W Stewart
Solicitor
SHERIFF'S OFFICE OF CUMBERLAND COUNTY ',
i~~~~~i~+-t=~1''-
~®t~~+,t~ of ~u~brr,~~6
~ ~~~.~: ~J,~ AEG 17 AM ~ f !
Pediatrix Medical Group, Inc.
vs.
Lisa M. Miller
Case Number
2012-4768
SHERIFF'S RETURN OF SERVICE
08/06/2012 04:55 PM -Timothy Black, Deputy Sheriff, who being duly sworn according to law, states that on Augu
6, 2012 at 1655 hours, he served a true copy of the within Complaint and Notice, upon the within name
defendant, to wit: Lisa M. Miller, by making known unto herself personally, at 75 Deadend Lane,
Shippensburg, Cumberland County, Pennsylvania 17257 its contents and at the same timie handing to
personally the said true and correct copy of the same.
TIM
SHERIFF COST: $48.45
August 09, 2012
SO ANSWERS,
RON R ANDERSON, SHERIFF
(cl CeuntySuite Sheriff, Teleosoft, Inc.