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HomeMy WebLinkAbout02-0943COMMONWEALTH OF PENNSYLVANIA COURT OF COMMON PLEAS JUDICIAL DISTRICT 09-1-01 NOTICE OF APPEAL DISTRICT JUSTICE JUDGMENT COMMON PLEAS No. (~ -- 9~/~ NOTICE OF APPEAL Notice is given that the _~,~ lant has filed in the above Court of Common Pleas an appeal from the judgment rendered by the District Justice on the date and in the cose meflfianed belo~ ~.iLliBT ltOtfl[ TBI~RAP~'UT"rcs 09-1-01 C/O i[IIUPP, KODtt~.. & llt2Llll'l, P.C., P.O. BOX 11848~ HARR!SBURG~ PA 17108 1/28/02 M&LNIIT HOIiE THER&PKIITICS T.P~C..qIH.I.TA M.D. ' LT 1S;. ____ ~T ]) £C )~. ESO.-~OX 1T~.JmG~ PA ].7108 This block will be s~gned ONLY when this notafiofl is required under Pc~ R.CJ).JJ~. No. If 81~oell~ wss C, LAIMANT(~*~e'I;~R.C.F).J.P. No. 1008B. - ~.~ This Notice of Appeol, when received by the District Justice, will operate os a 1001 (6)in action before District Justice, ~'MUST SIJPERSEDEAS to the judgmenf for possession in this case FILE A COMPLAINT within twenty (20) days after filing his NOTICE of APPEAL. Signa~e of Prothi~olary or Deputy PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE (This section of fora3 to be used ONLY when appellant was DEFENDANT (see Pa. R.C.P.J.P. No. 1001(7) in action before District Justice. IF NOT USED, de~ach from copy of notice of appeal to be sen/ed upon appellee). PRAECIPE: To Prothonotary Enter rule upon , appellee(s), to file a complaint in this appeal Name of appellee(s) (Common PIfK:is ~ ) within twenty (20) dcp/s ofte~ seevice of rule or suffer entry of judgment of non pro~ RULE: To , =ppoilee(s). Name of (1) You am notified that a rule is hereby efltemd upon you to file a complaint in this appeal within tw~fity (20) days ut;et the date of service of this role upon you by pe~'soe~l service or by certified or registered mail (2) ff you da not file a complaint within this time, a JUDGN~NT OF NON PROS WILL BE ENTERED AGAINST YOU. (3) The date of smvice of this role if ~ervice was by mail is the date of mcnling. Date: , 19 . AOPC312-90 COURT FILE TO BE FILED WITH PROTHONOTARY PROOF OF SERVICE OF NOTICE OF APPEAL AND RULE TO FILE COMPLAINT (This proof of service MUST BE FILED WI THIN TEAl (1 O) DA YS AFTER filing the notice of appeal Check applicable boxes) COMMONWEALTH OF PENNSYLVANIA COUNTY OF ; ss AFFIDAVIT: I hereby Swear or affirm that I served ~ [~ a copy of the Notice of Appeal, Common Peas No, _ upon the District Justice designated therein on (da~e of service) [] by personal service [~] by (certified) (registered) mail, sender's receipt attached hereto~ and upon the appellee, (name) , on , 19 [] by personal service [] by (certified) (registered) mail, sender's receipt attached hereto. [] and further that ~ served the Ru~e t~ Fi~e a C~mpiaint acc~mpanying the ab~ve N~tice ~f Appea~ up~n the appe~~ee(s) t~ wh~m the Rule was addressed on __, 19 . , [~ by personal service [] by (certified) (registered) mail, sender's receipt attached hereto. SWORN (AFFIRMED) AND SUBSCRIBED BEFORE ME THIS DAY OF , 19 Signature of affiant 7 itle of My commission expires COMMONWEALTH OF PENNSYLVANIA COUNTY OF: ~EALAND Mag. Dist. No.: 09-1-01 DJ Name: Hon. CHARLES A. CLEareST, JR. ~ra,,: 400 BRIDGE STREET OLDE TOWNE COMMONS -SUITE 3 NEW CUMBERLAND, PA Ta~pho,a:(717) 774-5989 17070 ATTORNEY FOR PLAINTIFF : KNUPP & KODAK P.C. 407 N. FRONT STREET P.O. BOX 11848 HARRISBURG, PA 17108'1848 NOTICE OF JUDGMENT/'rRANSCRIPT CIVIL CASE PLAINTIFF: NAME and ADDRESS, ~.T,NUT HOME THERAPEUTICS P.O. BOX 11848 C/O ROBERT KODAK, ESQ ~ARRISBURG, PA 17108 VS. DEFENDANT: NAME and ADDRESS FSULLIVAN, M.D., CHARLES C 1053 BRANDT AVE. LEMOYNE, PA 17043 Docket No.: CV-0000705-01 [ ~ Date Filed: 12/10/01 THIS IS TO NOTIFY YOU THAT: Judgment ~-~ Judgment was entered for: (Name) ~ Judgment was entered against: (Name) in the amount of $ _ f~O on: ~-~ Defendants are jointly and severally liable. ~ Damages will be assessed on: ~-~ This case dismissed without prejudice. ~-~ Amount of Judgment Subject to Attachment/Act 5 of 1996 $ F-~ Levy is stayed for days or ~ generally stayed. [--~ Objection to levy has been filed and hearing will be held: FOR DEFENDAN'I' .qTTT,T,T~TA~T: M _ I'~ _: R'CJM'R (Date of Judgment) (Date & Time) Amount of Judgment $ o 0O Judgment Costs $ .00 Interest on Judgment $ .00 Attorney Fees $ . OO Total $ .00 Post Judgment Credits $ Post Judgment Costs $ Certified Judgment Total Date: Time: Place: 'i ~ ,%. ~ ANY PARTY HAS THE RIGHT TO APPEAL WITHIN 30 DAYS AFTER THE ENTRY OF jUDGMENT B~ FILING A NOTICE OF APPEAL WITH THE PROTHONOTARY/CLERK OF THE COURT OF COMMON pLEAs, CIVIL DIVISION. YOU MUST INCLUDE A COPY OF THIS NOTICE OF JUDGMENT/TRA~NSCRJiPT FORM WITM YOUR NOTICE OF APPEAL. JAN 2 8 200~)ate ·. * ' ,District Justice I certify that this is a true and correct copy of the record of the proceedings containing the judgment. Date , District Justice My commission expires first Monday of January, AOPC 315-99 2008 SEAL PROOF OF SERVICE OF NOTICE OF APPEAL AND RULE TO FILE COMPLAINT (This proof of service MUST BE FILED WITHIN TEN (10) DAYS AFTER filing the notice of appeal, Check applicable baxea) COMMONWEALTH OF PENNSYLVANIA COUNTY OF___. DAUt~I.J~[~ ; ss AFFIDAVIT: i hereby swear or affirm that ! served C~[ ~ copy of the Notice of Appeal, Common Pleas No, ~, upon the Distdct Justice designated therein on (date of service) [~-I]'~Y 28_. 2002 _ , [] by personal service ]~ by (certified) (~t"[fftt~Jt~t~mail, sender's receipt attached hereto, and upon the appellee, (name) ~"~AUT~"e ~ e~T~T?~A~a U ~ , on [~'~'Y 28,~1.e~002 [] by personal service~ by (certified) (r(~l~0[mail, sender's receipt attached hereto. F-i and further that t served the Rule to File a Complaint accompanying the above Notice of Appeal upon the appellee(s) to whom the Rule was addressed on mail, sendeds receipt attached hereto, SWORN (AFFIRMED) AND SUBSCRIBED BEFORE ME ~iTHiS 2~-"~'~..~ - DAY OF .~, ~ 07 / QTJ_2,QO3. ..... 19 .... Notadal Seal Bonnie Jo Hull, Notary Public M ..Hards~u.rg, D_auphln County y uomrmss~on ~xp~res July 7, 2003 Member, Penr~sy,~ania Asscciation of Notafles ' , 19 . [] by persona~vice [] by (certified) (registered) Signature of affiant 0 Return Receipt Fee --'---Ul~r~rk ...3 -~:$ ;~7 ~ ~t~-~.}'37-' ' ' - -~ -,~- ........................................................ ........................................ WALNUT HOME THERAPEUTICS Plaintiff CHARLES C. SULLIVAN, M.D. Defendant : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : : NO. 02-943 CIVIL : : CIVIL DIVISION - LAW NOTICE 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 1N 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 CLA1MED 1N 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 OR CANNOT AFFORD ONE. GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 (717) 249-3166 or (800) 990-9108 WALNUT HOME THERAPEUTICS Plaintiff CHARLES C. SULLIVAN, M.D. Defendant : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 02-943 C1VIL : CIVIL DIVISION - LAW COMPLA~INT The Plaintiff, WALNUT HOME THERAPEUTICS, by its attorneys, KNUPP, KODAK & IMBLUM, P.C., brings this action of Assumpsit against the Defendant to recover the sum of FIVE THOUSAND, FOUR HUNDRED FORTY-EIGHT DOLLARS AND SEVEN CENTS ($5,448.07), along with interest thereon from October 6, 2000, upon a cause of action of which the following is a statement: 1. The Plaintiff, WALNUT HOME THERAPEUTICS, is a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, having its principal office and place of business at Baldwin Tower, 1510 Chester Pike, Suite 170, Eddystone, Pennsylvania 19022. 2. The Defendant, Charles C. Sullivan, M.D., is an adult individual residing at 1053 Brandt Avenue, Lemoyne, Cumberland County, Pennsylvania 17043. 3. On or about June 16, 2002, Defendant did enter into an agreement with Plaintiff for the provision of services by Plaintiff to Defendant. A tree and correct copy of said document is attached hereto, marked as Exhibit "A" and made a part hereof. 4. On the dates, in the amounts, and for the prices set forth in a tree and correct copy of the Plaintiffs Health Insurance Claim Form hereto attached, marked as Exhibit "B" and made a part hereof, Plaintiff performed labor and provided services of the kind and description set forth on said Exhibit to the total amount of Five Thousand, Three Hundred Forty-Seven Dollars and Seven Cents ($5,437.07). 5. The prices charged for said labor performed and 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 Plaintiff therefor. F:\U SER\BONNIEJO\COMP\WORK\27573 COM.WPD:07Mar02 6. On or about September 6, 2000, Defendant did receive the sum of Five Thousand, Three Hundred Forty-Seven Dollars and Seven Cents ($5,347.07) as payment in full for Plaintifl~s services from his insurance carrier. 7. Defendant refused, despite repeated notices from Plaintiff, to forward the monies paid by his insurance carrier to him for payment of Plaintiffs services. Tree and correct copies of a portion of those notices are attached hereto, collectively marked as Exhibit "C" and made a part hereof. 8. Due to Defendant's default in payment of said mount due and owing as aforesaid, Plaintiff was forced to seek remedy in the lower Court, thereby incurring costs in the amount of One Hundred One ($101.00) Dollars, for which Defendant is further liable. 9. The balance due and owing by Defendant to Plaintiff is the sum of Five Thousand, Four Hundred Forty-Eight Dollars and Seven Cents ($5,448.07). 10. Plaintiff has frequently demanded payment from Defendant of said amount due and owing as aforesaid, but Defendant has refused and neglected and still refuses and neglects to pay said amount of any part thereof. WHEREFORE, Plaintiffbrings this suit to recover from Defendant the sam of FIVE THOUSAND, FOUR HUNDRED FORTY- EIGHT DOLLARS AND SEVEN CENTS ($5,448.07), together with interest thereon from October 6, 2000. Respectfully subm~..~ Robert D. Kodak 407 North Front Street Post Office Box #11848 Harrisburg, PA 17108-1848 (717) 238-7151 Attorney ID No. 18041 Attorney for Plaintiff F:\USER\BONNIEJO\COMP\WORK\27573 COM.WPD:25Feb02 In consideration of the .~..~n~.[~ to bc provided by thc Agency, it is a _gteect__ as follows: i vo umriiy consent to actively par cipa in such se ices as ents, .. ser~ces at my request;/~/queat//f phymaan and/or deas~on of the Agency. - . 2. I~F..!.F. ASE OF INFORMATION: I authorize the Agency to fur~ish ' .u~nmation from my records._~_..tl!kd party comp//iies/nd to alI'0t[///r i~nc/. '=, mstitul~ons, or indivkh,~!s l.,,ov~'~.. ~ heal~ or ~ .se~ces. i ,~as. [~l' . e,.addreas, and telephone correct..I. ~ ~ l~a~.t of the author.., benefits from my mam~mce_~e 4. BH I- OF RIGIt'I~3/RESPONSIBILIT~S: I hereby aclmowledge receiPt and understand the Client's Bill' °f Rights and Responsibilities as a statement of my rights as a client of the AEency. $. HOMEBOUND STATUS: I hereby acknowledge receipt and understand the Homehound Status information provided by the asency. 6. ADVANCE ~ICAL DIREr-tlr'ES: I acknowledEe that I received a copy of.the Agency's pamphlet "It's Up To You" and a copy of the Agency's Client Self-Determination Policy. I acknowledge that the AEency, as required by federal law, has asked me if I have an Advance Directive. CH~.CK ONE BELOW: [] I have provided a copy of my current Advance Directives upon admi~ion. [] I will give my current Advance Directive to the AEency. I understand that since I am not able to provide my Advance Directive to the A~ency, the A~cncy will not be able to honor its contents until I provide it to the AEency. [] I choose not to provide a copy of my current Advance Directive. I undcrstand that since I am no~?roviding my Advance Directive, the Agency will not be able to honor its contents. [] My current Advance Directive is on file from a previous home care srlmi~ion. (Yrofesslonal staff to request a copy m Medical Records) not have a currant Advance Directive, but the Agency has pi~v'ided me with information about Advrmce Direaives. ent is a minor. Advance Directives do not apply. If you desire legal assistance with this pwcess, you may call IUDICARE at (215) 2384/943 (provides ~gal counsel to low- income older adults.) or t,~2dsw~r Refcren~j;~te ,r~ces at (215) 238-1701 for referral to a lawye, I/- - Reason client did ~t si~l~s~d "X~: -- Physically Unable Mentally Unable Minor RELATIONSHIP: DATE: DATE: RESPONSIBLE PARTY: STAFF SIGNATURE i 'l'fl iF.: CLIENT CONSENT FORM PLEASE DO NOT AREA MPCA HEALTH INEUKANg;h-. ~l.,AIIVl I",JK~Vl P~CAJ 1 MEDICARE MEDiCAiD CHAMPLIS CHAMPVA GROUP FECA 0THEF la. ~NSURED'S ID. NUMBER (FOR PROGRAM IN ITEM ed,care ¢) ~(Medlcaid #) ~rSpon$or's SSN)~ ~ (SSN or lD) (SSN; (ID) ~ACiS548~507 2 PATIENT'S NAME (Last Name, First Name. Middle Initial) 3.MMPATIENT'SDDBIRTHyyDATE~ M~ SEX F [] 4. INSURED'S NAME (Las~ Name, First Name, Middle initial) ~'95 "Fzlv~;'~' ',~F TRAIL. Self spouse Child Other ¢'+b'5 ,IMGER~'"4~ TRAIL CITY t~TATE 8. PATIENT STATUS [] []CITY STATE WEST CHESTEF: A SlnGeE~ Married Other WEST ]WESTE:: i 9Ld ~ .%: (~z.) Emp °yed ~--I Full Time [~Par~'T~me [] ' ~ ') O~ -- 1 ~2'' ~ Student 19382 ( ) N,A. OO2144005 ¥ss []No ME} MMoB,, I ME~ sex PEri [],ss ~om ~YES ~NO CAPITAL ?.LUE CROSS d, INSURANCE PLAN NAME OR P.OG.AM NAME ~0d, RESERVED FOR LOCAL USE ~ IS THERE ANOTHER HEALTH BENEFIT 21. DIAGNOSIS OR NATURE OF ILLNESS OR ImURY. (RE~TE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) m CODE ORIGINAL REF. NO. 2. CZ)~S . ~ ! 4. m :: J~% CrFTRI~XONE m :}6162000 1)62720Cx} ! 2 NDC~ 5086~033~0~ } ~ . ~ 12 ! [ 50 m m , m SDD~ CSLORI[~E 5 mm mm ~ :tj6~~.. .. HEP~RINGLk,e~" UNITS : , , , =~-~ .~=,<-,,-* ~ , CON:'. , : ' CO~t ~- -6c ..... 444.7~-01 !674 ~YES ~NO ~LDWIN TOWER t5!0 CHESTER PIKE SUITE !70 PLEASE DO NOT STAPLE IN THIS AREA CAPZTAL BLLiE CROSS !~AJOR MEDICAL DEPT DEPT. ??~995 HARRISBURG. PA ~?i77 . D[CARE MEDICAID CHAMPUS CHAMPVA GROUP FECA 0THEF 1~ ~NSURED'S ID. NUMBER (FOR PROGRAM IN iTEM 1) ~ *~'.~r,~ .. ........ ~ ~UL, L!VAN~ DR. CITY ~TATE . PATIENT STATUS O[~· S~ WEST CHESTER 'A Single~ Married~ Other~ [4EST CHESTER ... ~YSS ~NO CAF'!TAL BLUE CROSS I I 24 A B ICl ! I m mm i [ JT?~ }6168000 )6~7~OOO [~ a4B¢l EXT~_T (PiCu) l.~ 69'30 9 BALDWIN TOWER 15!0 CHESTER P!EE SUITE !70 APPRO\ .D OMB 0938 0008 FORM HCFA-15QO (12-90), FORM RRB-1500 APPROv'ED OMB 1215 0055 FORM OWCP 1500 APPROVED OMB-0720-0001 fCHAMPUS) PLEASE STAPLE IN THIS AREA 1 ~[~ME p[cA 1'I1:/,~1,, I I'~ I I~i ;~ t,,,111 A I'~ ~,,,,: DICARE MEDICAID CNAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S ID NUMBER (FOR PROGRAM IN ITEM 1) 2 PATIENT'S NAME (Last Name, First Name, Middle initial) 3 PATIENT'S BIRTH CATE SEX F 4. INSURED'S NAME (Last Name, First Name, Middle Initial) MM DD ] 1 S~ LIUAN. DR. CHARLES C 1C'~t2 SULLIVAN. ~'. CHARLES. C. 5 PATIENT'S ADDRESS (No. Street) 6 PATIENT RE~TIONSHIP TO INSURED 7. INSURED'S ADDRESS (No, Street) CITY ~ ~:ATE . PATIE~ STATUS 01~ Zl" CODE TELEPHONE (include Area Code) ZIP CODE TELEPHONB (iNCLUDE AR~ CODE~ Full Time Pad-Time .,9 -~ =:= ( 610) ~SS~ (S~(:))sg*--!?~ Emp°yed~studen, ~StuOen, ~ t ..... 9 OTHER INSURED'S NAME (Laet N~me, First Name Middle Initial) 10, IS PATIENT'S CONDITION RE~TED TO; 11 INSURED'S POLICY GROUP OR FECA NUMBER ~YES ~NO ¢~' 'mT. BLLE ~F ~ . ~L CF:DSS d. INSURANCE P~N NAME OR PROGRAM NAME ,0d. RESERVED FOR LOCAL USE d ,S THERE ANOTHER HEALTH BENEFIT PLAN, DYES ~NO Ifyes. retumtoandcompleteitemgad , I PREGNANCY (LMP) , , FROM I : TO : II MM DD YY MM OD YY R:a~ ko , Le,:.r. mOM 21. DIAGNOSIS OR NATURE OF ~LLNESS OR I~URY (RE~TE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE) ~ ¢55. ?9 a L--~ I z ~}8S. E',I 4. L~ DISC m m ' m ANNdLA4 m m 0616~0Cx} )625200C) t2 A4~8! TOURNIQUET !. 2 0 ~ 00 ! m , m m m , , , , , , , , ~4~ D~if{ TOW PLEAS- PRI& T Ok TYPE APPROVED OMB-0938-0335 FORM HCFA-1503 /12-9D) FORM RRB-1502, A~PRD~ED OME-:215-0355 F©RM ©V, CF 1503 A~PROVBD OMB-0?2D020~ ~SHAM, PUS) PLEASE ~,d~jF}R' MEDIC:AL CE:F:'T I DO NOT ...... - .._= . ,~ STAPLE u~ IN THIS . . R ....... , ~ ~ AREA ~ HEALTH INSURANCE CLAIM FOR|C[ P,CA~r- 1 MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA ETHER la INSURED'S iD, NUMBER fFOR PROGRAM IN ITEM 1) · 495 Tt~IBERLiNE '" ,"T Se"E]S"°u'eE]Chi"~'~ O""C] ~' TIMBERLINE TRAT' [4EST CHESTER'. ' 19¢8~ ( )399- ! 74~ St.de.t Stude.t & , ~Y[s ~so CAPITAL BLUE CROSS ~YES ~NO If yes, retum to and comp~ete item O a.d RAp ~::o. , , 24. A B C D E F G H I J X :}616B000 )6162000 12 ;A4301 PiC CATHETER {~ ~ , ~ , 190 :}6162000 )6272000 12 'a~¢12 RUBBUARD , 1.2 ; 20~= ,, ,~ ~ [ ~ ,' 36232000 )6272000 12 P4SV PROTECTOR ' 1,2 I 1 ~ 34 3 , , , , ; ~ ~ ~ ALCOHOL WIPES ~ ~C, 5 PLEASE PRIf~'T OR TYPE APPROVED OMB-0938-0008 FORM HCFA-!SO0 {12-90), FORM RRB 150C PLEASE "!A-"'QF;' ?!ES -i CAL S"F'~::'=' T DO NOT STAPLE 1N THIS AREA 1 MEDICARE MEDICAID SHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'E 4 ~NSURED'S NAME (Last Name, First Name, Middle initial) 2, PATIENT'S NAME (Last NGme, First Name, Middle ~nitial)3MMPATIENT'SDDBIRTH. yyDATE M ~ SEX F ~ .~____~ ~ ~ 'rV~N~ ~,.r,~' CHARLES ~' !O~ '!957 SULLIVAN~ ~, ~HARLE~ .. Tz:.B ..... N- TR~ZL C]TY ~:~ATE 8. PATIE~STATUS CITY WEST CHESTER' Sing'e~ Married~ Other~ WEST CHESTER' N.A. OO2144OO5 YES NO DAP!TAL ~LuE ,~p:OSS ~. ~.su~*~c~ .~*~ .*ME O~ .~OeR*~ ~*~E ~0~. ~ES~RWU ~O~ ~OC*~ US~ ~, ~S T~ *.OT.~ ~E*~T. ~E~mT I I PREGNANCY (LMP) I I FROM 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RE~T/ITEMS 1,2,3 OR 4 TO ~TEM 24[ BY LINB / CODE ORIGINAL REF, NO, I )6162000 )6272000 !2 A6~O~ 6AUZE PAD EX8 STER!L7 .t . 2 _ '~6 ! 6~'..:: }616200C, 12 ~4987 6LOVES ~TER!LE PER !, 2 2 )6!6E00C "'618-~:']r~ .~ A4~! CONVERTE~ ¢O~N ; ! ,2 10 ;25 1 , apply t0 this bill and ~re made a pad thereof.) ~ i ~U t Home Ther a~eu~ i cs PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA-1500 (12.90) FORM RRBd500, APPROVED OMB-1215-D055 FORM OWCP-t500 APPROVED OMB-0720-0001 (CHAMPUS) PLEASE "'"¢',~" ~'-~':::'? ~_ .,,r ~........,!EAL DEFT , .... '- ~ 77~ 75 STAPLE 'uJ 1 MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la INSURED'S I.D. NUMBER (FOR PROGRAM IN ITEM 1) I 2 PATIENT'S NAME (Last Name, First Name Middle Imfial) kMMPAT]ENT'Si DDBIRTHi ~DATE M~ SEX F ~ 4 INSUR~D'S NAM~ (~st Name, Firs[ Name, Middle ~P' "¢ " 10,1~,!957 SULLIVAN, DR. CHARLES~ SULLIVAN, DRi ~.~AR~_S 5 PATIENT'S ADDRESS (No., Street) 6. PATIENT RE~TIONSHIP TO INSURED 7 INSURED'S ADDRESS (No., Strut) 495 TIMBERLINE TRAIL Self~Spo.se~ChildM Other~ 495 TIMBERLINE TRAIL CITY ~ STATE 8, PATIENT STATUS CITY STATE .... WEST CHESTER'. ~ Full ~me ~Pad-Time ~ 1939E (610)399-!748 *m.oyo~ St,de.t StoOe.t !938S (610) 399-1748 N.A. C6814a}05 Y~S NO 10~ 1~' 1957 - ~AF.TA- BLUE CROSS ,< ~. ~su~c~ PL*~ ~AU~ O~ ~ROGRA~ ~AUE ma. ~ESERW~ FO~ LOCA~ ~SE ~, ~S THE~E A~OTHE~ HEA~TH ~S~; P~? ~YES ~ NO /f yes, r~um m and complete {tern 9 2 088..8! 4.1 ; S!T~ , m ,' ' 0OK mm , , , '",.~1A~¢"¢' -~ }6E5200C) ~ ~ A48B! NrrD~ ~ DISPOSAL BOX; ! , 2 ; ~E .... ~' (L6_,)~ ', m 23-2622006 44472-0! 1674 ~YES ~NO s CONT * * CONT. ~[~!N TO~ER !5!~ 6RE~TER PIEE S~ITE 17~ EDDYSTONE, PA APPROVED OMB-0938~0008 FORM HCFA-1500 (12-90f FORM RRB-1500 APPROVED OMB 1215-0055 FORM OWCP 1500, APPROVED OMB-0720-0001 (CHAMPUS) PLEASE DO NOT DEP-F,, '7..'7C995 STAPLE IN THIS AREA HEALTH INSURANCE CLAIM FORM . 1 MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la. INSURED'S ID. NUMBER (FOR PROGRAM IN ITEM ~ ;~.~ ~ 12 !957 SULLIVAN, D... CHm, RLE=. CITY ~,;ATE 8. PATIENT STATUS CITY S~TE 19382 (61C')399-!7A2 Empoyed Student Student 19S82 (610) =99-1 N.A, 0021~4005 ' YY M~ SEX F~ ~Y~S ~NO ]AF'!TAL BLUE CROSS ~. ~.su.*.c~ .~*~ .*~ o...o~.*~ ~*~ ~Od. ~SS~V~p ~o~ ~OC*~ OS~ d ~S T~.~ *.OT~S..~*~T~ ~.mT ~YES ~ NO ffXe¢, return to and complete ~em 9 s~e~Eo SIGNATURE ON FILE OATEQ5 ~6 BOO':' S~EO SIGNATURE ON FILE , , PREGNANCY (LMP) , , FROM [ [ TO 1 Rap ko. Leon ~,o~ '. ] TO : FrO~ATE(S) TO of P~/~POS/ MODIFIEm UNrTS ~pply to this bill and are made a pad thereof ) ~a]~ Home EDD¥STONE. P~ PLEASE PR/k'T OR TYPE APPROVED OMS-0938-0008 FORM HCFA-1500 (12-90), FERN' RRB 1500 APPROVED OMB 1215-0055 FORM OWCP-1500 APPROVED OMB-0720-0001 {CHAMPUS) STAPLE AREA < 1 MEDICARE MEDICAID CHAMF~US CHAMPVA GROUP FEGA OTHER la INSURED'S ID NUMBER {FOR PROGRAM IN iTEM 1) ](M¢dicare#~[]f'Medicald#) [~($po~$or'$~N) E~(VAFiIe#) [~%ANLo]HzI~N~$L~A~UNG~-I(ID) QAC 185484507 4 ~NSURED'S NAME (Last Name, First Name, Middle Initial) = .... gA .. DR. CHARL-o C 10,1~,!957 SULLiVAN~ DR. CHARLES, A95 ]"ZMBERLZNE TR'.~ZL ,elf~Spouse~Ohild~ DITY ~;TE 8. PATIENT STATUS Cl~ STA: WEST u.-= ~.R ?', .... N. A, .}18'i44005 ~YES ~NO %])~ DD,~i, ~*S* YY M~ SEX F~ ~YES ~NO CAPITAL BLOE CROSS d ~NSURANOE PLAN NAME OR PROGRAM NAME 10d RESERVED FOR LOCAL USE ~. IS THERE ANOTHER HEALTH 8ENEF'T PLAN? ~YES ~T~ ~' SIGNet SIGNED ~ ,.N~TII..P RN ~T( ~ DATE(')A lA ~C)C)C) SIGNED ,~8,cs ~ ~oo~ co~s ~o~*~ )61¢2L)?0 }62~20~}0 [2 [:A428! VACL~A!N~R 8ML I ~2 0',90 3 )6162000 }62520C)C) ._~ A4BSI VACUTAINER TI6ER !, 2 -m ,=.,~ o= 3 .)6!62] ]C D625200C) .~2 !~*~8~ VACUTAINER ~ :3G 1~2 2~'P=-,.,, 3 , }6i6E000 }6252000 2 ~. DRESS!NET (BOX) APPROVED OMS-Og38-O008 FORM HCFA-1500 (t2 gui, FORM RRB-1500, STAPLE '* .... ' '-' ' ' '~ AREA POAr~l-~L. I I'1 II~Ur~/API~..C, t~L/-~llVl rU~lV~ PICA 1 MEDICARE MEDICAID CHAMPUS CHAMPVA GROUP FECA OTHER la INSURED'S LD NUMBER (FOR PROGRAM IN [TEM 1) D(Med/cgre*~(Med, caid*D¢onsor'SSN) ~A*.') HEALTH P~N ELK LUNG 2 PATIENT'S NAME (Last Name, First Name, Middle Initial) 3.MMPAT~ENT'S, BDBIRTH. yyDATE M ~ SEX F ~ 4. INSURED'S NAME (Last Name, First Name, M~ddle Initial) ~ ~ T'¢~ ~ 10~ "!957 SULLIVAN, DR. CHARLES~ C. ..... l.,N~ DR. CHARLES C 18~ 5. PATIENT'S AOD~ESS (No. S~reet) 6. PATIENT RE~TIONSHIP TO INSURED 7 INSURED'S ADDRESS (No, Street) CITY ~BTATE 8 PATIENT STATUS CI~ WEST CHESTER'A Single~ Barried~Other~ WEST CHESTER Z~P CODE TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (INCLUDE AREA CODE) ~ Full Time ~Pa~-Time ~ ' 9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial) 10 ~S PATIENT'S CONDITtON RE~TED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER N. P. 00~!GG005 a OTHER INSURED'S POLICY OR GROUP NUMBER a. EMPLOYME~? (CURRE~ OR PREVIOUS) a. INSURED'S DATE OF BIRTH ~ '~ ]m~ !957 b. OTHER INSURED'S DATE OF BIRTH b. AUTO AOCJDEN~ P~CE (~)b. EMPLOYER'S NAME OR SCHOOL NAME c EMPLOYER'S NAME OR SCHOOL NAME c, OTHER ACCIDEN~ c. INSURANCE P~N NAME OR PROGRAM NAME ~YES~NO CAPITALBLUE CROSS d INSURANCE P~N NAME OR PROGRAM NAME 1Od. RESERVED FOR LOCAL USE d. IS THERE ANOTHER HEALTH BENEFit P~N? ~YES ~ NO ~ye~ return to and compile [tern 9 READ BACK OF FORM BEFORE COMPLETING & SI~NING THIS FORM. 13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE ~ authorize ~2 PATIENT'S OR AUTHORI~D PER~N'S SIGNATURE J ~uthorize the rele~ of any m~i~ or ~her information n~w payment of m~ical benef~s to the unders~gaed physician or supplier for to proc~s this Cairn, I ¢~ r~uest payment of ~ernment ~n¢~s eider to m~elf or to the ~ w~o ac~pts ~slgnment se~ic~ des~i~d ~low below. SIGNED SIGNATURE Ot%~ FILE DA~(')~ 1 ('){3(3 SIGNED ~T(I~;~ ~h~ ~ 14. DATE OF CURRENT: ~ I~NESS (First symptom) OR 15. IF PATIENT HAS HAD SAME OR SIMI~R iLLNESS. 16 DATES PATIENT UNAB~ TO WORK IN CURRENT OCCUPATION MM ~ DB I YY~ INJURY (~cident) OR GIVE ¢IRST DATE MM I DD I YY MM DD YY MM DD YY I I PREGNANCY (LMP) I , FROM ', : TO ', 17. NAME Of REFERRING PHYSICIAN OR OTHER SOURCE 17a. I.D. NUMBER OF REFERRING PHYSICIAN 18 HOSP~TAL[~TION DATES RE~TED TO CURRENT SERVICES MM I DD I YY MM I DD I YY 24, A B C D E F G H r J K .... 0',00.. . :)6162000 :)6B52C)00 ~12 A~8~! M~C. P~TIENT NEED5 ~ ~ 0 ~ (')(') ,, , , , , , , , ,, ,. ~: , '616~-)-) :-)A!6~000 l~ BuU~FAN~ CAP 1 ~ 1 00 ' I ~ (For go~ ciai ..... back) B~LD~H~ TOWER !5!0 CHESTER PiKE SUITE 170 EDDYSTONE, PA !90~8 fAPPROVEE) By AMA COUNCIL ON MEDICAL SERVLCE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM HCFA 1500 (12-93i FORM RRB-1500, APPROVED OMB 1215-0055 FOR~ OWCP-150O APPROVED OMB-0720-0001 fCHAMPUSI PLEASE DO NOT STAPLE IN THIS AREA MAJOR MEE ]]CAL T£,EF:'T' ii i~,~cA ~,-~.l n II~.J~"~J~,l~lf~.~= f~.~L.~ll¥1 I-~.,/I'~IVI P]OA I I ~ MEDICARE MEDICAID CHAMPUS CHAMPVA GROU~ FECA OTHER la. INSURED'S I.D. NUMBER (FOR P~OG~AM IN ITEM SULLIVAN, DR. CHARLES C lO,l~,~.u ;ULLIVAN, DR. CHARLES, .¢ ~zh!~.L~NE TRAIL ~95 TIMBERLINE TRAIL Of TY ~TATE . PA~ENT STATUS S,~ WEST CHESTER A Single~ Married~ Othe,~ *EST CHESTER z 9¢~,~ (6!0)399-1748 Furl Time Pam~me L. ~. :}02 i 44005 YES NO !C)~ 12~ !957 M F ~YES ~NO CAPITAL BLUE CROSS 21. DaGNOSIS OR NATURE OF ~LLNESS OR INJURY. (RB~TE J~MS 1,2,8 OR 4 TO ITEM 24E BY LINE) j ~ ~55. '79 a. ~ .__~ I ~ (For go~ clai .... back) B~LDWIN TOWER !5!0 CHESTER PIKE SUITE i70 EDDYSTONE, PA 190BB (APPROVED By A~4A COUNCIL ON MEDICAL SERVICE 8/88) PLEASE PRINT OR TYPE APPROVED OMB-0938-0008 FORM RCFA-1500 (12-90), FORM BRB*1500 APPROVED OMB-1215-0055 FORM OWCP-1500, APPROVED OMB-0720~0001 (CHAMPUS) Walnut Home Therapeutics BALDWIN TOWER 1510 C~ESTER PIKE SUITE 170 EDDYSTONE, PA 19022 January 15, 2001 TO: Dr. Charles C. Sullivan 495 Timberline Trail West Chester, PA 19382 Patient Name: Dr. Charles C. Sullivan Account No: 011674 Dear Dr. Charles C. Sullivan, Walnut Home Therapeutics has billed your insurance company for services/supplies sent to Dr. Charles C. Sullivan. The balance due is for services/supplies that your insurance cgrrier has determined to be your responsibility. A copy of your carrler's explanation of benefits is attached for your records. Prompt payment would be appreciated. I have enclosed a self addressed envelope for your remittance. ( ) Check ( ) Money Order ( ) Charge Card; ( ) ( ) ( ) Amount of Payment $ Visa Mastercard Cardholder Name: Account # : Expiration Date: Signature : PAYMENT IN FULL IS DUE WITHIN,~ DAYS. SERVICE INVOICE INVOICE AMOUNT DATE NUMBER AMOI/NT PAID 06/16/00 44472 5347.07 0.00 BALANCE DUE 5347.07 TOTAL AMOUNT DUE $ If you should have other insurance or any questions, please do not hesitate to call me directly at the Reimbursement. Department, (215)955-2834. 5347.07 Sincerely, REIMBURSEMENT DEPARTMENT Your Insurance Carrier has told us that you received a check from them in the amount of $5347.07 for the service date on this statement. Please endorse the Insurance check, mark it for Deposit Only, and send it to us in the enclosed envelope. If you have cashed the Insurance Check, please send us your personal check. It is important to include the Insurance carrier's Explanation of Benefits with the check. This will ensure that the payment is applied correctly. Until we receive the payment, ~ sent to you, we must continue to bill you for the full amount of these services. This Claim is P~*s~: I~ue. Please Remit $5:~47.07 Thank you. Walnut Home Therapeutic~ BALDWIN TOWER 1510 CHESTER PIKE SUITE 170 EDDYSTONE, PA 19022 January 24, 2001 TO: Dr. Charles C. Sullivan 495 Timberline Trail West Chester, PA 19382 Patient Name: Dr. Charles C. Sullivan Account No: 011674 Dear Dr. Charles C. Sullivan, Walnut Home Therapeutics has billed your insurance company for services/supplies sent to Dr. Charles C. Sullivan. The balance due is for services/s~p~lies that your insurance carrier has determined to be your responsibility. A copy of your carrier's explanation of benefits is attached for your records. Prompt payment would be appreciated. I have enclosed a self addressed envelope for your remittance. ( ) Check ( ) Money Order ( ) Charge Card; ( ) ( ) ( ) Amount of Payment $ Visa Mastercard Cardholder Name: Account # : Expiration Date: Signature : PAYMENT IN FuhL IS DUE WITHIN J0 DAYS. SERVICE INVOICE INVOICE AMOUNT DATE NUbIBER AMOUNT PAID 06/16/00 44472 5347.07 0.00 BALANCE DUE 5347.07 TOTAL AMOUNT DUE $ If you should have ot~er insurance or any questions, please do not hesitate to call me directly at the Reimbursement. Department, (215)955-2834. 5347.07 Sincerely, REIMBURSEMENT DEPARTMENT Your Insurance Carrier has told us that you received a check from them for the service date on this statement. Please endorse the Insurance cheek, mark it for Deposit Only, and send it to us in the enclosed envelope. If you have cashed the Insurance Check, please send us your personal check. If this claim is not paid in 10 days, we will refer the claim to our collection attorneys Freeman & Mintz ~ 34 Tanner SWeet, Haddonfield, NJ 08033. We regret having to collect this debt in this manner. Please avoid this action bv sendin~ the amount due above today. Walnut Home Therapeutics BALDWIN TOWER 1510 CHESTER PIKE SUITE 170 EDDYSTONE, PA 19022 November 21, 2000 TO: Charles C. Sullivan 495 Timberline Trail W. Chester, PA 19382 Patient Name: Charles C. Sullivan Account No: 011674 Dear Charles C. Sullivan, Walnut Rome Therapeutics has billed your insurance company for services/supplies sent to Charles C. Sullivan. The balance due is for services/supplies that your insurance carrier has determined to be.you~ responsibility. A copy of your carrier's explanation of benefits xs attached for your records. Prompt payment would be appreciated. I have enclosed a self addressed envelope for your remittance. ( ) Check ( ) Money Order ( ) Charge Card; ( ) ( ) ( ) Amount of Payment $ Visa Mastercard Cardholder Name: Account # : Expiration Date: Signature : PAYMENT IN FULL IS DUE WITHIN~ DAYS. SERVICE INVOICE INVOICE AMOUNT BALANCE DATE NUMBER AMOUNT PAID DUE 06/16/00 44472 5347.07 0.00 5347.07 TOTAL AMOUNT DUE $ 5347.07 If you should have other insurance or any questions, please do not hesitate to call me directly at the Reimbursement Department, (215)955-2834. YourInsuranceCarrierhastoldusthatyoureceivedacheck ~om Sincerely, REIMBURSEMENT DEPARTMENT them for the service date on this statement. Please endorse the Insurance check, mark it for Deposit Only, and send it to us in the enclosed envelope. If you have cashed the Insurance Check, please send us your personal check. It is important to include the Insurance carrier's Explanation of Benefits with the check. This will ensure that the payment is applied correctly and to determine your responsibiliW, if any. Until we receive the payment, ~ sent to you, we must continue to bill you for the full amount of these services. This Claim is [~lSt [~l~. Please Remit $5,347.07. Thank you. Walnut Home Therapeutics BALDWIN TOWER 1510 CHESTER PIKE SUITE 170 EDDYSTONE, PA 19022 October 26, 2000 TO: Charles C. Sullivan 495 Timberline Trail W. Chester, PA 19382 Patient Name: Charles C. Sullivan Account No: 011674 Dear Charles C. Sullivan, Walnut Home Therapeutics has billed your insurance company for services/supplies sent to Charles C. Sullivan. The balance due is for services/supplies that your insurance carrier has determined to be.you~ responsibility. A copy of your carrier's explanation of benefits ~s attached for your records. Prompt payment would be appreciated. I have enclosed a self addressed envelope for your remittance. ( ) Check ( ) Money Order ( ) Charge Card; ( ) ( ) ( ) Amount of Payment Visa Mastercard Cardholder Name: Account # : Expiration Date: Signature : PAYMENT IN FULL IS DUE WITHIN 30 DAYS. SERVICE INVOICE INVOICE AMOUNT DATE NUMBER AMOUNT PAID 06/16/00 44472 5347.07 0.00 BALANCE DUE 5347.07 TOTAL AMOUNT DUE $ If you should have other insurance or 9ny question~, please do not hesitate to call me directly at the Remmbursement Department, (215)955-2834. Sincerely, REIMBURSEMENT DEPARTMENT 5347.07 Your Insurance Carrier has told us that you received a check from them in the amount of ~ for the service date on this statement. Please endorse the Insurance check, mark it for Deposit Only, and send it to us in the enclosed envelope. If you have cashed the Insurance Check, please send us your personal cheek. It is important to include the Insurance carrier's Explanation of Benefits with the check. This will ensure that the payment is applied correctly and determine your responsibility if any. Until we receive the payment, and the EOB sent to you, we must continue to bill you for the full amount of these services. Thank you. I, WA~ T. WILSON, Rc, imbtmmnent I~ of WALNUT HONI~ THEIt. APEU~CS, v~ ~nat ~e ~a~mn~ mad~ i~ thc aforc~o~n~ docummt ~e ~e and c~r~c~. 1 un~k~t~d tl~t fulse stammelm herein rite ma~ ~ to g~e pma~ti~ of 18 ]~. C. $. §4904, ~tstlsqS M ueswcen fahiflc~,~e~ to ~. Wayne T. V~,son - R~imb~us~m~nt l~ps.-mm~ ~;'d Dd )~flOS¢ ~ dc~Fif4~.~ t.~tt:~t ~::'0, ~ ~3..-I gO'd V~O: '[ l: ;~0- Z ~- qe.,-I WALNUT HOME THERAPEUTICS Plaintiff CHARLES C. SULLIVAN, M.C. Defendant : 1N THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : : NO. 02-943 CIVIL CERTIFICATE OF SERVICE I, ROBERT D. KODAK, ESQUIRE, hereby certify that on March 15, 2002, I served a tree and correct copy of the Complaint in the above-captioned matter upon the below listed individual(s) by causing same to be deposited in the United States mail, first class postage prepaid at Harrisburg, Dauphin County, Pennsylvania, addressed as follows: CHARLES C SULLIVAN MC 1053 BRANDT AVENUE LEMOYNE PA 17043 Dated: Robert D. Kodak 407 North Front Street Post Office Box #11848 Harrisburg, PA 17108-1848 (717) 238-7151 Attorney I.D. No. 18041 Attorney for Movant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA WALNUT HOMES THERAPEUTICS, Plaintiff CHARLES C. SULLIVAN, M.D., Defendant NO. 02-943 CIVIL ACTION - LAW PETITION FOR STAY AND REQUEST TO REOPEN JUDGMENT AND NOW, comes the Charles C. Sullivan, M.D., by and through his attorney, Gary L. Kelley, and respectfully petitions this Honorable Court as follows: 1. On or about April 8, 2002, Plaintiff, through counsel, sent to Defendant at 1053 Brandt Avenue, Lemoyne, Pennsylvania 17043, a ten day notice of intention to enter judgment for failure to file a responsive pleading to Plaintiff's complaint. 2. Shortly thereafter, the undersigned contacted counsel for Plaintiff. 3. Counsel informally agreed to an open-ended extension in which to file a response while the parties discussed a possible settlement. 4. The parties continued to negotiate a possible resolution of the above action. 5. Unfortunately, the matter remained unsettled as a result of physical problems Defendant was experiencing and their resultant impact upon his health. 6. On August 30, 2002, the undersigned received notice that a default judgment in the amount of $6,060.97 in favor of the plaintiff and against the Defendant had been entered to the above term and caption. 7. Attached to the notice as Exhibit "A" was a letter dated July 15, 2002 addressed to the Defendant c/o the undersigned's address and Exhibit "B" which was a ten day notice dated the same date. True and correct copies are attached hereto as Exhibits "A" and "B", respectively. 8. Counsel never received copies of these documents and, as a result, never filed a responsive pleading. 9. Counsel's secretap~, Ursula Woodward, is responsible for the intake of the undersigned's daily mail. 10. Ms. Woodward did not receive copies of the aforementioned documents at the undersign's office address. A true and correct copy of her affidavit attesting to the same is attached hereto as Exhibit "C." 11. Defendant did not receive copies of the aforementioned documents, Exhibits "A" and "B" as the copies were addresses to the undersigned. 12. The undersigned had not entered a formal entry of appearance. Therefore, service should have been made upon Defendant at his last known 13. address. 14. It is in the best interest of justice that the judgment in this matter be stayed and reopened pending further Order of Court. WHEREFORE, the Defendant, Charles C. Sullivan, M.D., respectfully requests that this Honorable Court enter an Order staying the judgment in this matter, reopening the judgment, and permitting the Defendant to file an answer to the complaint filed by the Plaintiff in this matter. Respectfully submitted, Harrisburg, PA 17101 (717) 238-1484 ATTORNEY FOR DEFENDANT EXHIBIT "A" Robot L. Kzlupp Robert D. Kodak Gar'~ J. Imblu~n Of Counsel Mark A. Mate~a CHARLES C SULLIVAN MD C/O GARY L KELLEY ESQ 132-134 WALNUT STREET HARRISBURG PA 17101 LAW OF~C~..S OF KNuPP, KODAK & IMBLUM, P.C. C~ERON ~nNS~ON 407 NORTH FRONT STREET POST OFFICE BOX 11848 HARRISBURG, PA 17108-1848 Telephone: 717/238-7159 Facsimile: 717/238-7158 ematl: kki.law~verlzon.net July 15, 2002 Robert H. Maurer (1923-1998) RE: VS: Walnut Home Therapeutics Charles C. Sullivan, MD No. 02-943 Civil Term, Court of Common Pleas Cumberland County, Pennsylvania Our File No. 27573 Greetings: In accordance with Pennsylvania Rules of Civil Procedure 237.1, we are enclosing herewith a Notice of a Praecipe for Entry of Default Judgment. According to the records as they are found in the Office of the Prothonotary of Cumberland County, you have not filed responsive pleadings to the Complaint filed against you to the above term and number, nor has any attorney entered an appearance on your behalf. Accordingly, we are forwarding to you the enclosed Notice which indicates that if you do not take action as set forth in this Notice, we, at the expiration of time indicated therein, will request the Office of the Prothonotary of Cumberland County, Pennsylvania, to enter Judgment against you in the amount as set forth in said Complaint. Very truly yours, KNUPP, KODAK & IMBLUM, P.C. Robert D. Kodak, Esq. THIS LETTER IS AN ATTEMPT TO COLLECT A DEBT AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE RDK/kqb enclosure cc: ROBERT D. MINTZ ESQUIRE #82982 FREE~AAN & MIN'I-Z P A 3~, TANNER STREET HADDONFIELD NJ 08033-2482 EXHIBIT "B" WALNUT HOME THERAPEUTICS Plaintiff CHARLES C. SULLIVAN, M.D. Defendant FILE COPY · CUMBERLAND COUNTY, PENNSYLVAN'IA : : NO. 02-943 CIVIL : : CIVIL DIVISION - LAW IMPORTANT NOTICE TO: CHARLES C. SULLIVAN, M.D., Defendant(s) DATE OF NOTICE: fi_FLY 15, 2002 YOU ARE IN DEFAULT BECAUSE YOU HAVE FAg.ED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY_ ATTORNEY AND FILE 1N WRITING WITH THE COURT YOUR DEFENSES OR OBYECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A ZGDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING, AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP: CUMBERLAND COUNTY BAR ASSOCIATION TWO LIBERTY AVENUE CARLISLE PA 17013 (717) 249-3166 NOTICIA IMPORTANTE A: CHARLES C. SULLIVAN, M.D., Demandado(s) FECHA DE NOTICIA: IULY 15, 2002 USTED NO HA COMPLIDO CON EL AVISO ENTERIOR PORQUE HA FALTADO EN TOMAR lVlEDIDAS REQUERIDS RESPECTO A ESTE CASE. SI USTED NO ACTUA DENTRO DE DItiZ (I0) DIAS DESDE LA FECHA DE ESTA NOTICIA, ES POSIBLE QUE UN FALLO SEIA REGISTRADO CONTRA USTED SIN UNA ALrDIENCIA Y USTED PODRIA PERDER SU PROPIEDAD O OSTROS DERECHOS IMPORTANTES. USTED DEBE LLEVAR ESTA NOTICLA A SU ABOGADO EN SEGUIDA. SI USTED NO TI~2qE ABOGADO O NO TIENE CON QUE PAGAR LOS SERVICIOS DE UN ABOGADO, VAYA O LLAME A LA OFICI2qA ESCRITA ABMO PARA AVERIGUAR A DON-DE USTED PUEDE OBTENER LA AYUDA LEGAC: CUMBERLAND COUNTY BAR ASSOCIATION TWO IJllERTY AVENUE CARL[qLE PA 17013 (717) 249-3166 EXHIBIT "C" IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA WALNUT HOMES THERAPEUTICS, : Plaintiff : _, V. : .. CHARLES C. SULLIVAN, M.D., : Defendant : NO. 02-943 CIVIL ACTION - LAW 1. My name is Ursula Woodward and I have been employed by the law Offices of Gary L. Kelley for approximately two (2) years as a legal secretary. 2. My duties include the responsibility for the daily intake of incoming mail. 3. I have reviewed the attached Exhibits, "A" and "B", respectively, which were dated July 15, 2002. 4. I was working during the week of July 15, 2002 and at no time did this office receive Exhibits "A" and "B". 5. Consequently, this office was not placed on notice of Plaintiff's intention to request a default judgment. 6. This office first received copies of Exhibits "A" and "B" on August 30, 2002 when we received a copy of the judgment entered against Defendant with said Exhibits attached. I hereby verify that the statements contained herein are true and correct. I understand that false statements made herein are subject to the penalties of 18 Pa.C.S. Section 4904 relating to unsworn falsification to authorities. l~sula W~0-dward,-~.l ~cretary to Gary L. Kelley VERIFICATION I hereby verify that the statements contained herein are tree and correct. I understand that false statements made herein are subject to the penalties of 18 Pa.C.S. Section 4904 relating to unswom falsification to authorities. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA WALNUT HOMES THERAPEUTICS, : Plaintiff : ; V. : ; CHARLES C. SULLIVAN, M.D., : Defendant : NO. 02-943 CIVIL ACTION - LAW CERTIFICATE OF SERVICE I, GARY L. KELLEY, Esquire, attorney for Defendant in the above-captioned matter, do hereby certify that I served a true and correct copy of Defendant's Petition For Stay AND Request To Reopen Judgment on counsel for Plaintiff by depositing same in the U.S. Mail, first class, postage prepaid, on the 10TH day of September, 2002, addressed as follows: Robert D. Kodak, Esq. 407 North Front Street PO Box 11848 Harrisburg, PA 17108-1848 Harrisburg, PA 17101 (717) 238-1484 Attorney for Defendant WALNUT HOME THERAPEUTICS Plaintiff CHARLES C. SULLIVAN, M.D. Defendant 1N THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA : NO. 02-943 CIVIL : CIVIL DIVISION - LAW TO: PROTHONOTARY, COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA PRAECH-E FOR DEFAULT JUDGMENT Enter judgment in favor of Plaimiffand against Defendant(s), CHARLES C. SULLIVAN, M.D., named fo~ failure to fde within the required time an Answer to the Complaint in the above-captioned case and assess the Plaintiffs damages as follows: Amount claimed in Plaintiffs Complaint Interest from October 6, 2000 at the legal rate of 6% per annum Total $5,448.07 $ 612.90 $6,060.97 It is hereby certified that a written notice of intention to file this Praecipe was mailed to the Defendant(s) and his attorney of record, al~er the default occurred and at least ten (10) days prior to the date of the filing of this Praecipe. See Exhibits A & B attached. DATED: KNU~uM, P.C. 0~/~10~..~ Robert D. Kodak, Attorney for Plaintiff Judgment entered and damages assessed as above. Prothonotary Robert L. Knupp Robert D. Kodak Gary J. Imblum Of Counsel Mark A. Mateya CHARLES C SULLIVAN MD C/O GARY L KELLEY ESQ 132-134 WALNUT STREET HARRISBURG PA 17101 LAW OFFICES OF KNUPP, KODAK & IMBLUM, P.C. CAMERON MANSION 407 NORTH FRONT STREET POST OFFICE BOX 11848 HARRISBURG, PA 17108-1848 Telephone: 717/238-7159 Facsimile: 717/238-7158 entail: kki. law~verizon.net July 15, 2002 Robert H. Maurer (1923-1998) RE: VS: Walnut Home Therapeutics Charles C. Sullivan, MD No. 02-943 Civil Term, Court of Common Pleas Cumberland County, Pennsylvania Our File No. 27573 Greetings: In accordance with Pennsylvania Rules of Civil Procedure 237.1, we are enclosing herewith a Notice of a Praecipe for Entry of Default Judgment. According to the records as they are found in the Office of the Prothonotary of Cumberland County, you have not filed responsive pleadings to the Complaint filed against you to the above term and number, nor has any attorney entered an appearance on your behalf. Accordingly, we are forwarding to you the enclosed Notice which indicates that if you do not take action as set forth in this Notice, we, at the expiration of time indicated therein, will request the Office of the Prothonotary of Cumberland County, Pennsylvania, to enter Judgment against you in the amount as set forth in said Complaint. Very truly yours, KNUPP, KODAK & IMBLUM, P.C. RDK/kqb enclosure CC: Robert D. Kodak, Esq. THIS LEI'rER IS AN ATTEMPT TO COLLECT A DEBT AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE ROBERT D. MINTZ ESQUIRE FREEMAN & MINTZ P A 34 TANNER STREET HADDONFIELD NJ 08033-2482 #82982 WALNUT HOME THERAPEUTICS Plaintiff FILE COPY tN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 02-943 CIVIL CHARLES C. SULLIVAN, M.D. Defendant : CIVIL DIVISION - LAW IMPORTANT NOTICE TO: CHARLES C. SULLIVAN, M.D., Defendant(s) DATE OF NOTICE: JULY 15, 2002 YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF TI-frS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING, AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FfND OUT WHERE YOU CAN GET LEGAL HELP: CTtSMBERLAND COUNTY BAR ASSOCIATION TWO LlBERTY AVENUE CARLISLE PA 17013 (717) 249-3166 NOTICIA IMPORTANTE A: CHARLES C. SULLIVAN, M.D., Demandado(s) FECHA DE NOTICIA: JULY 15, 2002 USTED NO HA COMPLIDO CON EL AVISO ENTERIOR PORQUE HA FALTADO EN TOMAR MEDIDAS REQUERIDS RESPECTO A ESTE CASE. SI USTED NO ACTUA DENTRO DE DIEZ (I0) DIAS DESDE LA FECHA DE ESTA NOTICIA, ES POSIBLE QUE UN FALLO SEIA REGISTRADO CONTRA USTED SIN UNA AUDIENCIA y USTED PODRIA PERDER SU PROPIEDAD O OSTROS DERECHOS IMPORTANTES. USTED DEBE LLEVAR ESTA NOTICIA A SU ABOGADO EN SEGUIDA. SI USTED NO TIENE ABOGADO O NO TIENE CON QUE PAGAR LOS SERVICIOS DE UN ABOGADO, VAYA O LLAME A LA OFICINA ESCRITA ABAJO PARA AVERIGUAR A DONDE USTED PUEDE OBTENER LA AYUDA LEGAC: CUMBERLAND COUNTY BAR ASSOCIATION TWO l JRERTY AVENUE CARLISLE PA 17013 (717) 249-3166 Robert L. Knupp Robert D. Kodak Gary J. Imblum Of Coun~l Mark A. Mateya LAW OFFICES OF KNUPP, KODAK & IMBLUM, P.C. CAMERON MANSION 407 NORTH FRONT STREET POST OFFICE BOX 11848 HARRISBURG, PA 17108-1848 Telephone: 717/238-7151 Facsimile: 717/238-7158 email: kki.law~vertzon.net April 8, 2002 FILE Robert H. Maurer (1923-1998) CHARLES C SULLIVAN MD 1053 BRANDT AVE LEMOYNE PA 17043 RE: VS: Walnut Home Therapeutics Charles C. Sullivan, M.D. No. 02-943 Civil Term, Court of Common Pleas Cumberland County, Pennsylvania Our File No. 27573 Dear Dr. Sullivan: In accordance with Pennsylvania Rules of Civil Procedure 237.1, we are enclosing herewith a Notice of a Praecipe for Entry of Default Judgment. According to the records as they are found in the Office of the Prothonotary of Cumberland County, you have not filed responsive pleadings to the Complaint filed against you to the above term and number, nor has any attomey entered an appearance on your behalf. Accordingly, we are forwarding to you the enclosed Notice which indicates that if you do not take action as set forth in this Notice, we, at the expiration of time indicated therein, will request the Office of the Prothonotary of Cumberland County, Pennsylvania, to enter Judgment against you in the amount as set forth in said Complaint. Very truly yours, KNUPP, KODAK & IMBLUM, P.C. RDK/kqb enclosure CC: Robert D. Kodak, Esq. robert, kodak@verizon.net THIS LETTER IS AN ATTEMPT TO COLLECT A DEBT AND ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE ROBERT D MINTZ ESQUIRE FREEMAN & MINTZ P A 34 TANNER STREET HADDONFIELD NJ 08033-2482 #82982 FILE COPY' WALNUT HOME THERAPEUTICS Plaintiff CHARLES C. SULLWAN, M.D. Defendant : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 02-943 CIVIL : : CIVIL DMSION - LAW IMPORTANT NOTICE TO: CHARLES C. SULLIVAN. M.D., Defendant(s) DATE OF NOTICE: YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH TId~E COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A I-IEARRqG, AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE TI-IIS NOTICE ,TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP: CUMBERLAND COUNTY BAR ASSOCIATION TWO LIBERTY AVENUE CARLISLE PA 17013 (717) 249-3166 T T A: CHARLES C. SULLIVAN. M.D., Demandado(s) FECHA DE NOTICIA:~ USTED NO HA COMPLIDO CON EL AVISO ENTERIOR PORQUE HA FALTADO EN TOMAR MEDIDAS REQUERIDS RESPECTO A ESTE CASE. SI USTED NO ACTUA DENTRO DE DIEZ (10) DIAS DESDE LA FECHA DE ESTA NOTICIA, ES POSIBLE QUE UN FALLO SEIA REGISTRADO CONTRA USTED SIN UNA AUDIENCIA y USTED PODRIA PERDER SU PROPIEDAD O OSTROS DERECHOS IMPORTANTES. USTED DEBE LLEVAR ESTA NOTICIA A SU ABOGADO EN SEGUIDA. SI USTED NO TIENE ABOGADO O NO TIENE CON QUE PAGAR LOS SERVICIOS DE UN ABOGADO, VAYA O LLAME A LA OFICINA ESCRITA ABA JO PARA AVERIGUAR A DONDE USTED PUEDE OBTENER LA AYUDA LEGAC: CUMBERLAND COUNTY BAR ASSOCIATION TWO LIBERTY AVENUE CARLISLE PA 17013 (717) 249-3166 F:~US E R\KATHY~10DAYLTR\10-DAY.NOT:Apdl 8, WALNUT HOME THERAPEUTICS Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CHARLES C. SULLIVAN, M.D. Defendant : NO. 02-943 CIVIL : CIVIL DIVISION - LAW To CHARLES C. SULLIVAN, M.D., Defendant(s) You are hereby notified that on (Judgment) has been entered against you in the above-captioned case. the following Judgment entered in the amount of $6,060.97. DATE: Prothonotary I hereby certify that the name and address of the proper person(s) to receive this notice is: CHARLES C. SULLIVAN M.D. 1053 BRANDT AVE LEMOYNE PA 17043 CHARLES C. SULLIVAN M.D. C/O GARY L KELLEY ESQ 132-134 WALNUT STREET HARRISBURG PA 17101 A/CHARLES C. SULLIVAN M D Defendido ·., /a Defen&dos/as Por este medio se le esta notificando que el de del 20 , el/la siguiente(Fallo) ha sido anotado en contra suya en el caso mencionado en el epigrafe. -- FECHA: Protonotario Certificao que la siguiente direccion es la del defendido/a segun indicada en el cetificado de residencia: CHARLES C. SULLIVAN M.D. 1053 BRANDT AVE LEMOYNE PA 17043 CHARLES C. SULLIVAN M.D. C/O GARY L KELLEY ESQ 132-134 WALNUT STREET HARRISBURG PA 17101 Abogado del Demandante IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYLVANIA WALNUT HOMES THERAPEUTICS, Plaintiff CHARLES C. SULLIVAN, M.D., Defendant NO. 02-943 CIVIL ACTION - LAW AND NOW, this day of September, 2002, upon consideration of Defendant's Petition For Stay And Request To Reopen Judgment, it is hereby ORDER_ED and DECREED that WALNUT HOME THERApEuTICS Plaintiff V. CHARLES C. SULLIVAN, M.D. Defendant In the C:ourt of COMMON PLEAS of CUMBERLAND County, Pennsylvania NO. 02-943 CIVIL DIVISION - LAW PRAECIPE TO THE PROTHONOTARY: Please mark the above-captioned matter as satisfied and discontinued with prejudice. TO CUMBERLAND County Prothonotary Dated: March 13, 2003 Robert D. Kodak Attorney for P'~ai~ Attorney I.D. No. 18041 F \FILES\DATAFILE\DickinsonCollege7619\ColIections\Current\38 pra3 Created 12/29/O4 2:33PM Revised. 12/29/04 2:52PM 79619C 38 David R. Galloway, Esquire MARTSON DEARDORFF WILLIAMS & OTTO Ten East High Street Carlisle, PA 17013-3093 (717) 243-3341 Attomeys for Plaintiff DICKINSON COLLEGE, Plaintiff Vo DIANE M. CARR, A/K/A DIANE M. GRADY, Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 03-943 CIVIL TERM CIVIL ACTION-LAW JURY TRIAL OF TWELVE DEMANDED PRAECIPE TO THE PROTHONOTARY OF CUMBERLAND COUNTY: Please mark the judgment in the above-captioned case: satisfied and issue a certificate reflecting the same. MARTSON Df. CktLDORFF WILLIAMS & OTTO BYDavid R. Galloway;"Esqqire I.D. Number 872;26 ] Ten East High Street I Carlisle, PA 17013-3093' (717) 243-3341 Attorneys for Plaintiff Date: December 29, 2004 CERTIFICATE OF SERVICE I, Jean Taylor, an authorized agent for Martson Deardorff Williams & Otto, hereby certify that a copy of the foregoing Praecipe was served this date by depositing same in the Post Office at Carlisle, PA, first class mail, postage prepaid, addressed as follows: Ms. Diane Carr 21883 Blossom Hill Terrace #303 Ashbum, VA 20147 MARTSON DEAKDORFF WILLIAMS & OTTO B Jean Taylor_ Ten ~pst High Street CarlYle, PA 17013 (717) 243-3341 Dated: December 29, 2004