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HomeMy WebLinkAbout9-27-12NOTICE OF CLAIM COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF BARBARA A. BROZACK, DECEASED No. 21-12-258 To the Clerk of the Orphans' Court Division: Kindly enter the claim of Claremont Nursing and Rehabilitation Center in the amount of $9,478.85 against the above-captioned Estate. The Decedent, who resided at 914 Wertzville Road, Enola, PA 17025, died on December 29, 2011. This claim is for charges for nursing facility services incurred within 6 months of the date of death, and is a priority claim pursuant to 20 Pa.C.S. §3392(3). Written notice of said claim was given to Keith Brenneman, Esq., counsel for the estate of Barbara A. Brozack, Snelbaker & Brenneman, PC, 44 West Main Street, Mechanicsburg, PA 17055 on September 14, 2012. Claimant: Claremont Nursing and Rehabilitation Center 1000 Claremont Rd. Carlisle, PA 17013 Respectfully Submitted, ~~~~. 9-a~ ~k~lJ ~ O v~ a ~~v -* .. Q _ t....,. 3 1....... r ~ _ t t ~ ~ ~ .__. :.J J . 1 ] N ~ -? ~ y ^,j -1 ~ ~.~y (Y~ t L ~ ~l~ C'~! VU y._ Latsha Davis & McKenna, P.C. Steven M. Montresor Attorney No. 74244 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Phone: (717) 620-2424 Fax: (717) 620-2444 smontresor@ldylaw. com h~ 173732v1 Sep. 25. 2012 12:04PM CLAREMONT BUSINESS OFFICE ~ery1,~ont ~Nur~:i~~ ~~~ Q~ ~P~abzlitation Center ***I NVOI C E*** INVQICE DATE: BARBARA B ROZAC K C/O ROXAN NA KUYKEN PALL 1000 CLAREMONT ROAD CARLISLE, PA 17013 AD]VI17TE D: 08/19!2011 DISCHARGED: 12/29/2011 September 24, 2012 DATE OF SERVICE DAYS RATE PAYMENTS AIVrOUNT DUE 11i27/2o11 - 11/30/2011 4 $ 255.00 $ (34.00} $ 9s6.oo November 2011 Pharmacy - $ - $ 192.35 November 2011 Part B Coin $ 150.00 12/01/2011 -12129/201 ~ 29 $ 255.00 $ 7,395.00 December 2011 Pharmacy - $ - $ 280.50 December 2011 Part BCoin - $ - $ 475.00 GRAND TOTAL DUE' $ 8,475.85 No. 7395 P. 2 1040 Claremont Road Carlisle, PA 17©13,8805 main (717) X43-2031 fax (717) 240-1952 """PLEASE REMIT PAYMENT TO CLAREMONT NURSING & REHABILII-AT30N CENTER'`' ~s~en.^ice a~2r~c~ of Cufnl~ej-lnnd Cot~nt~ G ,; Q ~~ Jr ~ ti~ d s (~ ro R O m ~' ~~ D G J ~~ z~ c'~j x r-i o +•_ ,~" O Q O ~^.. 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CNR CD FA 9 9 _ } j CNR.C DPA ACCGUNT ~ ._.....___._.__-- - ~~ CNRC BILLING QFFICE GRP-CNR.C I 10 0 4 CLAREMt~N'T' RD PAGE 10 ~ i -. Amount Paid ~ ,_. CARLISLE PA ~.7 013 ~ ,_ -_-- ,_ ~ ~ ~ --- ---------------__._._.._.........._,......_...___..~r _ -.._-....---._ ._-._.____--.---~ -------------~-~-..._.~._.._..._..___.____._ _......_.._... PLEASE DETACH AND RE'T'URN TOP PORTION WITH YOUR PAYNtIENT TNC .219 i~IORTH BALTTI~ICRE_ AVE . MT H©LLY SPGS , _ PA 17~ 5 _._._--'2 8 0 5 0 12 .. 6 0 '' LEGEND ~ -; NON'--LEGEND FUR MONTH FaR MONT....-~ + - .342':41_: 49.31-`. FOR ALL: PHARM/~.CY REI~ATCD..INQL)1RES"PLEASE CAE~CAter# Phaimacy $ernces, Inc at_1-80Q-266 995 -'. ,. ,; ; ; :.: Statement Terrninotngy on 3everse - ~" ._......__~~:_ ~~~ ~ A FZPdANCE CHARGE OF 1.50 ~ PER MONTH Q~ OR A PHARMACY SERVT,CE.4 II~C:. {AN ANNUAL PERCENTAGE RATE OF 18 . ~1 ? 1 ~~ Ncn1h B~cltimc~re A~-e MSN~MUM SERVICE CHARGE OF $ ~.. 0 0 WIT.+L EE CHA.RG$D ~'it iiully Srr~iatt~r_ .P:1 t7()Ei~ Kpp-`'(~E> ~3~i4 1',1.7 j ~BCi-Ktip(i ON ALL AMQLII~TS 30 DAYS OR N40RE PAST DUE rv~wr~.a-[ertpl~artnacY.c~m .. _. _._ _ . 11/30/2011 _ _._ ... _._ .. ®~~e _ _ _.. _ _ .. PMT DUE. .12/29 11 ;' CNRCDPA999___ CNRC DPA ACCOUNT ~. ` GRP-CNRC 30 DABS 13:968.75 ~ CNRC BILLING OFFICE _._. , ~ 1000 CLAREMONT RD PAGE 12 a ! Amount Paid I', CARLISLE PA 17013 ) _: __ .:...... lP1LEA3E DETACH Al~T'C1 RETilRi~ To~P P~RTit]9~1 1d~{T~i YCDtyR PAYl~Et~T ALERT PHARMACY SERV . INC . 2 ]. 9 N412TH BAL~SMO~RE MT HOLLY S PGS , PA ~ 0 6~ COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ESTATE OF BARBARA A. BROZACK, DECEASED No. 21-12-258 CERTIFICATE OF SERVICE The undersigned hereby certifies that on this date a true and correct copy of the foregoing Notice of Claim was served via Certified Mail, Return Receipt Requested and First-Class United States mail, postage prepaid, upon the following: Keith Brenneman, Esq. Snelbaker & Brenneman, PC 44 West Main Street Mechanicsburg, PA 17055 o~~ea: ~/~G ~G1 Steven M. Montresor 173732v1