HomeMy WebLinkAbout04-5437
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER
I.D.lf60267
22nd F1.,1845 Wa1put Street
Phila. PA 19103
(215) 569-:5050-
PlalntifJ(s)
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. Box 853
Hershey, PA 17033
ATTORNEY FOR Plaintiff
vs
Defimdants(sj
DOUGLAS S. BAIR
28 Towne Mills
Shippensburg, PA 17257
COURTOFCOMMON PLEAS
DIVISION
CUMBERLAND COUNTY
TERM.
>
No. 6Lf--- ~Y)l ~
NOTICE
COMPLAINT - CIVIL ACTION
AVllIO
You have been sued J n court. If you wi sh to
defend against the claims '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
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 reL ief 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. I F 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 AT A REDUCED FEE OR NO FEE.
CUMBERLAND COUNTY BAR ASSOCIATION
2 LIBERTY AVENUE
CARLISLE, PA 17013
(717)249-3166 (800)990-9108
Le han demandado a usted en La corte. Si
usted qui ere defenderse de estas demandas expuestas
en Las paginas siguientes, usted tiene veinte (20)
dies de pLazo al partir de La fecha de La demandanda
y La notHicacion. Hace fal ta asentar una
comparencia escrita 0 en persona 0 con un abogado y
entregar a La corte en for escrita sus defensas 0 sus
objeciones a Las demandas en contra de su persona.
Sea avisado que si usted no se defiende, La corte
tomara medidas y puede continuar La demandanda en
contra suya sin previo aviso 0 notificacion. Ademas,
la corte puede decidir a favor deL demandante y
requiere que usted cumpLa con todas Las provisiones
de esta demanda. Usted puede perder dinero 0 sus
propiedades u atras derechos importantes para usted.
LLEVE ESTA DEMANDA A UN ABOGADO
INMEDIATAMENTE. SI USTED NO TIENE ABOGADO, VAYA
PERSDNALMENTE D LLAME POR TELEFONO A LA DFICINA
MENCIONADA A CONTINUACION. ESTA OFICINA LE PUEDE
PROVEER LA INFORMACION NECESARIA PARA CONTRATAR A UN
ABOGADD.
SI USTED CARECE DE LOS MEDIOS NECESARIDS PARA
CONTRATAR A UN ABOGADO, DICHA OFICINA LE PUEDE
SUMINISTRAR LA INFORMACION NECESARIA ACERCA DE
AQUELLAS AGENCIAS QUE OFRECEN SERVICIOS LEGALES A LAS
PERSONAS QUE TIENEN DERECHO A RECIBIR TAL AYUDA
GRATIS 0 A UNA CUOTA REDUCIDA.
CUMBERLAND COUNTY BAR ASSOCIATION
2 LIBERTY AVENUE
CARLISLE, PA 17013
(717)249-3166 (800)990-9108
COMPLAINT - CIVIL ACTION
THE MILTON S. HERSHEY MEDICAL CENTER
VS. DOUGLAS S. BAIR
1. Plaintiff is a non-profit corporation located at the
address indicated in the caption hereof.
2. Defendant is an individual who resides at the address
indicated in the caption hereof.
3. As the result of a certain medical condition, defendant
was treated by the plaintiff on Oct. 25, 2003 thru December 3,
2003.
4. The amounts, quantities and nature of said medical care,
the dates on which said medical care was rendered, and the
charges therefore are set forth in Exhibit "A" which is incor-
porated herein as if set forth at length.
5. Said medical care was commensurate with the condition of
defendant and was necessary for the health and welfare of
defendant.
6. At or about the time of defendant's treatment by plain-
tiff, implied, constructive and oral contracts arose
between defendant and plaintiff by the terms of which defendant
became obligated to pay plaintiff the charges for the medical
care rendered by plaintiff to defendant.
7. Defendant refuses to pay the balance due although
plaintiff has made demand that defendant do so.
THIS DOCUMENT IS BEING USED IN CONNECTION WITH THE COLLECTION OF
A DEBT; ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE.
8. As a result of the foregoing, there is due and owing
from defendant to plaintiff the sum indicated in Exhibit "A".
WHEREFORE, plaintiff demands judgment against defendant for
the sum of $25,083.30 plus six percent (6%) interest per annum
from the date of discharge to the date of judgment, record costs
and non-record costs.
TABAS & ROSEN, P.C.
~ &dFER~iRE
Attorney for Plaintiff
THIS DOCUMENT IS BEING USED IN CONNECTION WITH THE COLLECTION OF
A DEBT; ANY INFORMATION OBTAINED MAY BE USED FOR THAT PURPOSE.
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 03/25/04 at 03:39 PM
Guarantor: BAIR DOUGLAS S
28 TOWNE MILLS
SHIPPENSBURG, PA 17257-0000
Date
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
110/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
110/25/03
I Svc Code I
102018
102019
102100
102104
102105
102118
102147
102189
102215
102303
104020
104042
104065
104398
105067
105657
121125
245208
246162
246400
246705
246708
247786
250577 '
272199
272661
272905
272987
310505
310704
398186
410032
410051
410060
422004
464593
502000
503129
621264
621274
622024
622026
Description
BETA LACTAMASE
GRAM STAIN
CULTURE, BACTERIAL
CULTURE, ANAEROBES ON
CULTURE, BLOOD
SMEAR, FLUOR/ACID FAS
HOMOGENIZATION, TISSU
ID DEFIN AEROB ISOL E
CULTURE TYPE IMM/ANTI
CULTURE, FUNGUS OTHER
C REACTIVE PROTEIN QU
CREATININE, BLOOD
UREA NITROGEN (BUN),
ELECTROLYTES
SEDIMENTATION RATE (E
CBC W/PLT/DIFF AUTO
37 PRIVATE BED 3S0 RE
LIDOCAINE 1 ML
FENTANYL CITRATE 5 ML
PROMETHAZINE 25 MG/ML
MORPHINE SULFATE 4 MG
MEPERIDINE HCL 25 MG
MORPHINE SULFATE 10 M
PROPOFOL 20ML
ONDANSETRON 2MG/ML 2M
ROCURONIUM BROMIDE 10
MEPERIDINE 2500MG/250
CEFAZOLIN 1 GM PRE-MI
CT UPPER EXT ENHANCED
OMNIPAQUE 300MG/ML 15
PACK MINOR ORTHO NLTX
O.R. TIME @ 15MIN INC
BASIC SET-UP, ROUTINE
ELECTROCAUTERY
1/2 TO 1 HOUR-RECOVER
SURGILAV SET MULTI-OR
ANESTHESIA TIME-HOSP
BAIR HUGGER LOWER BOD
I V DEXTROSE 5% LACT
I V DEXTROSE 5%-0.9 S
IRRIGATION SOD CHL O.
IRRIGATION NACL 0.9%
- Continue -
f1 ~ I
PAGE:
1
,
Patient: BAIR DOUGLAS S
Visit #: 3871935
I Units I
1
3
3
3
1
2
1
1
2
2
1
1
1
1
1
1
1
1
6
1
2
3
3
1
4
1
1
2
1
1
1
9
1
1
1
1
9
1
1
1
1
3
Debits
Credits
13.00
69.00
171.00
150.00
75.00
60.00
30.00
35.00
48.00
68.00
43.00
11,00
10.00
27.00
18.00
32.00
1015.00
5.60 I
4.20
3.30
4.70
6.30
7.50
28.75
53.76
61.45
12.85
17.10
976.00
70.00
63.00
2025.00
692,00
28.00
308.00
103,00
622.00
36.00
7.00
6.00
6.00
102.00
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 03/25/04 at 03:39 PM
Guarantor: BAIR DOUGLAS S
28 TOWNE MILLS
SHIPPENSBURG, PA 17257-0000
Date
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/25/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/26/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/21/03
10/27/03
10/27/03
10/27/03
I Svc Code I
627070
640322
669206
669208
669209
670334
104020
104433
105657
121125
245475
245483
246703
246705
246708
250092
250899
272176
272 98 7
273686
621034
621054
627086
630831
670727
102019
102100
102104
104585
121125
245208
245257
245431
246708
249820
250092
251127
272199
272988
273686
398186
410032
Description
IV EXT SET 90" W/FLAS
CONTAINER,ANAEROBIC S
VAC DRESSING LG FOR V
VAC DRESSING SML FOR
CANISTER FOR VAC UNIT
IV INFUSION SET, UNIV
C REACTIVE PROTEIN QU
BASIC METABOLIC PANEL
CBC W/PLT/DIFF AUTO
37 PRIVATE BED 3S0 RE
GENTAMICIN 40MG/ML
DEXTROSE 5% 50ML
LORAZEPAM 2 MG
MORPHINE SULFATE 4 MG
MEPERIDINE HCL 25 MG
OXYCODONE APAP ITAB
HYDROMORPHONE 30MG/60
ZOLIPIDEM 5MG TAB
CEFAZOLIN 1 GM PRE-MI
PENICILLIN GK 2MU PRE
I V DEXTROSE 5%-.45 S
I V LACTATED RINGERS
TUBING APll PCA PUMP
FOLEY CATH 16 FR W/BA
PCA SET, ANTI-REFLUX
GRAM STAIN
CULTURE, BACTERIAL
CULTURE, ANAEROBES ON
GENTAMICIN LEVEL
37 PRIVATE BED 3S0 RE
LIDOCAINE 1 ML
LORAZEPAM 1 MG
METOCLOPRAMIDE 5 MG/M
MEPERIDINE HCL 25 MG
CIPROFLOXACIN 750MG
OXYCODONE APAP ITAB
CLINDAMYCIN 900MG
ONDANSETRON 2MG/ML 2M
CEFTRIAXONE 1 GM PRE-
PENICILLIN GK 2MU PRE
PACK MINOR ORTHO NLTX
O.R. TIME @ 15MIN INC
PAGE:
2
I Units I
1
2
2
1
1
1
1
1
1
1
5
5
1
1
2
4
1
1
1
7
1
1
1
1
1
2
2
2
1
1
1
1
1
4
1
5
3
4
2
1
1
7
,
Patient: BAIR DOUGLAS S
Visit #: 3871935
Debits
Credits
17.00
18.00
150.00
49,00
60,00
8.00
43.00
36,00
32.00
1015.00
10.50
13 .25
8.70
2.35
4.20
8.40
19.30
11.80
8,55
45,85
6.00
6.00
87.00
11.00
10.00
46.00
114.00
100.00
76.00
1015.00
2.10
2.10
2.25
8.40
12.30
10,50
32.04
53,76
148.00
6.55
63.00
1575.00
--~-----------------------------_._----~-----------------------------------------
- Continue -
Ft-~
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 03/25/04 at 03:39 PM
Guarantor: BAIR DOUGLAS S
28 TOWNE MILLS
SHIPPENSBURG, PA 17257-0000
Date
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27/03
10/27 /03
10/28/03
10/28/03
10/28/03
10/28/03
10/28/03
10/28/03
10/28/03
10/28/03
10/28/03
10/28/03
10/28/03
10/28/03
10/29/03
10/29/03
10/29/03
10/29/03
10/29/03
10/29/03
'10/29/03
10/29/03
10/29/03
10/29/03
10/29/03
10/30/03
110/30/03
10/30/03
I Svc Code I
410051
410060
422005
464593
502000
503129
503141
621034
621054
622024
622026
627086
634801
640322
670334
670727
121125
245257
246162
246708
247786
249820
250577
251127
272425
273401
600004
621043
713
765
13 54 0
121125
245257
246400
246708
249820
250092
273401
273788
121125
245257
245690
Description
BASIC SET-UP, ROUTINE
ELECTROCAUTERY
1-1 1/2 HOURS-RECOVER
SURGILAV SET MULTI-OR
ANESTHESIA TIME-HOSP
BAIR HUGGER LOWER BOD
LARYNGEAL MASKS
I V DEXTROSE 5%-.45 S
I V LACTATED RINGERS
IRRIGATION SOD CHL O.
IRRIGATION NACL 0.9%
TUBING AP11 PCA PUMP
DRAIN, CLOSED WND SUC
CONTAINER,ANAEROBIC S
IV INFUSION SET, UNIV
PCA SET, ANTI-REFLUX
37 PRIVATE BED 3S0 RE
LORAZEPAM 1 MG
FENTANYL CITRATE 5 ML
MEPERIDINE HCL 25 MG
MORPHINE SULFATE 10 M
CIPROFLOXACIN 750MG
PROPOFOL 20ML
CLINDAMYCIN 900MG
MIDAZOLAM 1MG/ML 2ML
ZOSYN 3.75GM BAG
RTL VAC WOUND CLOSURE
I V SODIUM CHLORIDE 0
INITIAL EVALUATION-OT
SPLINTING MATERIALS
ORTH FABRIC/FIT/TRN 1
37 PRIVATE BED 3S0 RE
LORAZEPAM 1 MG
PROMETHAZINE 25 MG/ML
MEPERIDINE HCL 25 MG
CIPROFLOXACIN 750MG
OXYCODONE APAP ITAB
ZOSYN 3. 75GM BAG
HYDROCODONE & APAP 5/
37 PRIVATE BED 380 RE
LORAZEPAM 1 MG
CLONIDINE HCL 0.1 MG
- Continue -
(tJ
PAGE:
3
,
Patient: BAIR DOUGLAS S
Visit #: 3871935
I Units I
1
1
1
1
7
1
1
1
1
1
2
2
1
2
1
1
1
1
3
9
1
2
1
3
1
4
4
1
1
3
1
1
1
1
4
2
4
4
2
1
3
1
Debits
Credits
692.00
28.00
357.00
103.00
502.00
36.00
42.00
6.00
6.00
6.00
68.00
174,00
30,00
18.00
8.00
10.00
1015.00
2.10
2,10
18.90
2.50
24.60
28.75
32.04
2.10
187.80
412.00
6.00
13 7.00
51.00
46.00
1015.00
2.10
3.30
8.40
24.60
8.40
187,80
4.20
1015.00
6.30
2.10
MS HERSHEY MEDICAL CENTER
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 03/25/04 at 03:39 PM
Guarantor: BAIR DOUGLAS S
28 TOWNE MILLS
SHIPPENSBURG, PA 17257-0000
Date
I Svc Code I
10/30/03
10/30/03
10/30/03
10/30/03
10/30/03
10/30/03
10/30/03
10/31/03
10/31/03
10/31/03
10/31/03
10/31/03
10/31/03
10/31/03
10/31/03
10/31/03
10/31/03
10/31/03
10/31/03
10/31/03
10/31/03
.10/31/03
11/01/03
11/01/03
11/01/03
11/01/03
246400
248234
249820
250092
273401
273788
621044
104042
104065
104129
105657
121125
245690
248234
249820
250092
273401
307101
621043
703322
712011
712075
245690
248234
249820
250092
* - Not posted
Description
PROMETHAZINE 25 MG/ML
METHADONE 10MG
CIPROFLOXACIN 750MG
OXYCODONE APAP 1TAB
ZOSYN 3.75GM BAG
HYDROCODONE & APAP 5/
I V SODIUM CHLORIDE 0
CREATININE, BLOOD
UREA NITROGEN (BUN),
PHOSPHORUS, BLOOD
CBC W/PLT/DIFF AUTO
37 PRIVATE BED 3S0 RE
CLONIDINE HCL 0.1 MG
METHADONE 10MG
CIPROFLOXACIN 750MG
OXYCODONE APAP 1TAB
ZOSYN 3.75GM BAG
CHEST 1 VIEW
I V SODIUM CHLORIDE 0
IP NUTR, 15 MIN,ORL/TB
CV CATH PLACE,PERC,>
CATHETER INSERTION KI
CLONIDINE HCL 0.1 MG
METHADONE 10MG
CIPROFLOXACIN 750MG
OXYCODONE APAP ITAB
Pr .~
PAGE:
4
,
Patient: BAIR DOUGLAS S
Visit #: 3871935
I unitsl
2
2
2'
1
4
3
1
1
1
1
1
1
2
3
2
4
4
1
1
1
1
1
2
2
1
2
Debits
Credits
6.60
4.20
24,60
2.10
187.80
6.30
6.00
11.00
10.00
11.00
32.00
1015.00
4.20
6.30
24.60
8.40
187.80
104.00
6.00
68,00
407.00
57.00
4.20
4.20
12.30
4.20
Balance:
20618.30 I
DOUGLAS S BAIR
28 TOWNE MILLS
SHIPPENSBURG PA 17257
1 .r 2
PENN STATE
I!!iI The Milton S. Hershey Medical Center
.., The College of Medicme
ACCOUNT #
1359459
STATEMENT
DATE: 03/19/04
LAST STATEMENT
DATE: 03/04/04
FED TAX 10 # 251857035
INS '<;HARGE PAYMENT' GUARANTOR
ADJUSTMENT BALANCE
IiII 'I' ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES
- DATE PRacEDURE DIAG QTY DESCRIPTION
CODE CODE
>>> PATIE~T: DllWLAS S BAIR 1359459
10/25/03 11044 998.59
10/25/03 11044 998,59
10/25/03 7320126 719,03
10/2.7/03 11044,58 998.59
10/27/03 11044 998.59
10/27/03 992.53 729,1
10/29/03 99232 129.l
10/30103 992.32. 129.1
10/30/113 99253 719,42
10/31103 99231 729.1
10/31/03 7101026 V5B.81
W03l03 99Z1l
682..3
3871935
PERFORMED BY' ORTHOPAEDICS DIVISION
PLACE OF SYC, INPATIENT
DEBR SKI~ TIS MUS BO
PERFO~D BY, DIY Of ANESTHESIA
12. DEBRIDEHT,SKN,TISS,HUS,BN
PERFORMED BY: DIY Of OIAG RADIOLOGY
CT UPPER EXTREMITY EIffAN
PERFORMED BY' ORTHOPAEDICS DIVISIoN
DEBR SKIN TIS MUS BO
PERFORMEO BY I DIY OF ANESTHESIA
11 DEBRIOEMT,SKH,TISS,MUS,BN
PERfORMED BY I DIY. OF INfECT DIS l EPIOM
INITIAL INPT CONSULTATION
HOSPYISIT INTER CC
HOSP VISIT INTER CC
pERfOflHEO BYrPAIN.1IGMT IPALUATlYECAIIE
INITIAL INPTCONSULTATION
PERf ORHEDBY, DIY OFINfECTOIS l EPION
HaSP YISIT BRXEfCC
PERFORl1EDilYi DIY Of OIAGRADIOLOGY
CHEST 1 VIEIl
730.00 730.00
960. DO "0,00
32.6.00 32.6.00
730. DO 730,00
880.00 880.00
ZlZ.00 ZlZ,Oo
124.00 12.4,00
12.4.00 WI,OO
212..00 212.00
74.00 74.00
51.00 51.00
3964383
PERFORMED 8Y I ORTHOPAEDICS DIVISION
PLACE OF SVC, OP PHYSICIAN
OUTP ArIENT YISITEST
BALANCE, DOUGLAS S8AIR $4465,00
42.00
42.,00
IF YOU HAVE ANY lWESTIONS ABOUT THE AHOlM' YllJR INSUIlANCE
COMPANY PAID, CONTACT THEMOIRECTLY. fOR ANY OTHER QUESTIONS
REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMENT
HAS BEEN.MADE. THANK YOU AND DISREGARD THIS BILL,
RJKO
THANK YOU FOR USING MSHHC PHYSICIANS GROUP fOR YOUR PHYSICIAN
SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE
CONTACT us AT 717-531-5069 OR 800-2.54-Z619, BETWEEN 8,00AM AND
5,30PM MONDAY THROUGH HEDNESDAY OR BETWEEN 8,OOAM AND 4,30PM
THURSDAY AND fRIDAY.
o CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
PENN STATE
S The Milton S. Hershe:y Medical Center
. The College of Medicme
DOUGLAS S BAIR
28 TOWNE MILLS
SHIPPENSBURG PA 17257
pjl8!
2 or 2
ACCOUNT #
1359459
STATEMENT
DATE: 03/19/04
lAST STATeMENT
DATE: 03/04/04
FED TAX 10 # 251857035
>CHARGE PAYMENTI GUARANTOR
. ADJUSTMENT BALANCE
_1'1 IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES
DATE PROCEDURE DIAG QTY DESCRIPTION
CODE CODE
INS
BALANCE SUlttARY
RESPbNSISLE PARTY
""" GUARANTOR RESI'\lNSI8IlITY
POLICY .
TOTAL
$ 444;.00
. _ _"______________.______._.__1.ltr!E.Q!1Wit'-f-''-..~'LRm!tfL'"NP_f!.{rYJ!N_~p.rlJ1M.f_qtn:LQ.1!.Pf..J_t41ft.N1I.IYHllJ:iU!'-~lLf.'"U1.../!LJ'__,.________..__..______._.__.
STATEMENT D.A.'TE:GlIARANTOft. RUF-ONSIB/lITY: MINIMUM' PAYM,N1
03/19/04 $ 4465.00 $ 4465.00
BF6
MSHMC PHYSICIANS GROUP
BILLING SERVICES
POBOX 854
HERSHEY PA 11033.0854
00001359459 UP 0000000000446500031904
1,.,11,1.1...1,1.11"./"1..11,,.11..,.11..11.,.,11,,11,1.,1.1
Md MSHMC PHYSICIANS GROUP
To;
PO BOX 643313
PITTSBURGH PA 15264-3313
DOUGLAS S BAIR
28 TOWNE MILLS
SHIPPENSBURG PA 17257
_M/C
_VISA
IIIIII1 II II I I IIII
CARD NUMBER EXP DATE
JJ;Jg!fJE$!Wi~N~r 1.
1359459
OfFICE USE OUl Y
.; CHECK ONE
FOR CREDIT CARD PAYMENT, PLEASE AlliN lNfo~MATION BELOW
He , F6BO
TVP, DMND
CARDHOLDER NAME (PRINT)
$ 4465.00
~
04/09/04
CREDIT CARD SIGNATURE
MSHMC PHYSICIANS GROUP
CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
{+,(O
BAIR, DOUGLAS S.
111359459
$20,618.30
4,465.00
(Hasp)
(Phys)
VERIFICATION
LINDA SCHLADER hereby states that she is the Super-
visor of Financial Counselors and Collection of Milton S. Hershey
Medical Center, The Pennsylvania State University and verifies
that the statements made in the foregoing pleading are true and
correct to the best of her knowledge, information and belief.
The undersigned understands that the statements therein
are made subject to the penalties of 18 Pa. C.S. ~4904 relating
to unsworn falsification to authorities.
,;fL.~
{r)IDt SCHLADER
DATE:
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SHERIFF'S RETURN - NOT FOUND
CASE NO: 2004-05437 P
COMMONTWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
MILTON S HERSHEY MEDICAL CTR
VS
BAIR DOUGLAS S
R. Thomas Kline
,Sheriff or Deputy Sheriff, who being
duly sworn according to law, says, that he made a diligent search and
inquiry for the within named DEFENDANT
BAIR DOUGLAS S
but was
unable to locate Him in his bailiwick. He therefore returns the
COMPLAINT & NOTICE
, NOT FOUND , as to
the within named DEFENDANT
, BAIR DOUGLAS S
28 TOWN MILLS
SHIPPENSBURG, PA 17257
DEFENDANT MOVED AND LEFT NO FORWARDING ADDRESS.
Sheriff's Costs:
Docketing
Service
Not Found
Surcharge
18.00
14.80
5.00
10.00
.00
47.80
So answers~ -
_ _...: .--:::-;>r- ~/ _
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,- - 7~- -_.--:-.----
-- R ~ Thomas Kl ine -"
Sheriff of Cumberland County
./
TABAS & ROSEN
11/08/2004
Sworn and subscribed to before me
this ,1~' day ofc;1~
A'"V{ A.D.
~L(llut~oop'J ~'
Pro h notary , .
~ABAS & ROSEN, P.C.
SY: LEWIS C. TRAUFFER
I.D. No. 60267
22nd Fl.,1845 Walnut Street
Fhiladelphia, PA 19103
(215)569-5050
Attorney for plaintiff
!
THE MILTON S. HERSHEY MEDICAL CENTER
COURT OF COMMON PLEAS
CUMBERLAND COUNTY
VS
I
~OUGLAS S. BAIR
NO. 04-5437 Civil
P RAE C I P E
i
~O THE PROTHONOTARY:
please withdraw the above matter without prejudice.
L~~ER' E~
Attorney for Plaintiff
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