HomeMy WebLinkAbout05-0574TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER
I.D.#60267
22nd F1.,1845 Walnut Street
Phila. PA 19103
(215) X69-5050.°
ATTORNEYFOR Plaintiff
Plaintiff(s)
THE MILTON S. HERSHEY MEDICAL CENTER
P.O. Box 853
Hershey, PA 17033
Dejendanls(s)
Vs
COURT OF COMMON PLEAS
DIVISION
CUMBERLAND COUNTY
TERM,
No. ®S- S?yv (21'0 ILv?1
ALBERT BOMGARDNER &
ROBIN BOMGARDNER, h/w
702 Barbara Street
New CUmberland, PA 17070
COMPLAINT - CIVIL ACTION
NOTICE AVISO
You have been sued in court. If you wish 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 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 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 an to corte. Si
usted quiere defenderse de estas demandas expuestas
en Las paginas siguientes, usted tiene veinte (20)
dias de plazo at partir de la fecha de Is demandanda
y Is notificacion. Hace falta asentar una
comparencia escrita o en persona o con un abogado y
entregar a to corte en for escrita sus defenses o sus
objeciones a [as demandas en contra de su persona.
Sea avisado que si usted no se defiende, to corte
tomara medidas y puede continuer Is demandanda en
contra suya sin previo aviso o notificacion. Ademas,
to corte puede decidir a favor del demandante y
requiere que usted cumpla con todas Las provisioner
de esta demands. Usted puede perder dinero o sus
propiedades u otros derechos importantes para usted.
LLEVE ESTA DEMANDA A UN ABOGADO
INMEDIATAMENTE. SI LISTED NO TIENE ABOGADO, VAYA
PERSONALMENTE 0 LLAME POR TELEFONO A LA OFICINA
MENCIONADA A CONTINUACION. ESTA OFICINA LE PUEDE
PROVEER LA INFORMAC16N NECESARIA PARA CONTRATAR A UN
ABOGADO.
SI USTED CARECE DE LOS MEDIOS NECESARIOS PARA
CONTRATAR A UN ABOGADO, DICHA OFICINA LE PUEDE
SUMINISTRAR LA INFORMACION NECESARIA ACERCA DE
AOUELLAS AGENCIAS OUE OFRECEN SERVICIOS LEGALES A LAS
PERSONAS OUE 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
COUNT I
THE MILTON S. HERSHEY MEDICAL CENTER
V. ROBIN BOMGARDNER
1. Plaintiff is a non-profit corporation located at the
address indicated in the caption hereof.
2. Count I defendant is an individual who resides at the
address indicated in the caption hereof.
3. As the result of a certain medical condition, Count I
defendant was treated at the plaintiff hospital on March 24,
2000 thru May 2, 2000, April 5, 2000 thru May 4, 2000, Feb.
20, 2001 thru Jan. 31, 2003, May 12, 2001, Aug. 7, 2002 thru
April 15, 2003, Aug. 19, 2003, and April 27, 2004 thru Sept. 27,
2004.
4. The amounts, quantities and nature of the medical care
rendered, the date on which said medical care was rendered, and
the charges therefore are set forth in Exhibit "A", which is
incorporated herein as if set forth at length.
5. Said medical care was commensurate with the condition
of Count I defendant and was necessary for the health and welfare
of Count I defendant.
6. At or about the time of Count I defendant's treatment
at the plaintiff hospital, implied, constructive and oral con-
tracts arose between Count I defendant and plaintiff by the terms
of which Count I defendant became obligated to pay plaintiff the
charges incurred for the medical care rendered by plaintiff to
Count I defendant.
THIS DOCUMENT IS BEING USED IN CONNECTION WITH THE COLLECTION OF
A DEBT; ANY INFORMATION OBTAINED MAY BE USED FOR THAT PURPOSE.
7. Count I defendant refuses to pay the balance due
although plaintiff has made demand that Count I defendant do so.
8. As a result of the foregoing, there is due and owing
from Count I defendant to plaintiff the sum indicated in Exhibit
"A,
WHEREFORE, plaintiff demands judgment against Count I
defendant for the sum of $13,844.03 plus six percent (6%)
interest per annum from the date of discharge to the date of
judgment, record costs and non-record costs.
COUNT II
THE MILTON S. HERSHEY MEDICAL CENTER V. ALBERT BOMGARDNER
9. The foregoing paragraphs are incorporated herein as if
set forth at length.
10. Count II defendant is an individual who resides at the
address indicated in the caption hereof.
11. Count II defendant is the spouse of Count I defendant.
12. Defendant's spouse was treated at the plaintiff hospi-
tal on March 24, 2000 thru May 2 2000, April 5, 2000 thru May
4, 2000, Feb. 20, 2001 thru Jan. 31, 2003, May 12, 2001,
Aug. 7, 2002 thru April 15, 2003, Aug. 19, 2003, and April 27,
2004 thru Sept. 27, 2004.
13. Said medical care was commensurate with the condition
of defendant's spouse and was necessary for the health and
welfare of defendant's spouse.
14. Count I defendant is indigent.
15. Count II defendant is financially able to pay for the
medical care of Count I defendant.
THIS DOCUMENT IS BEING USED IN CONNECTION WITH THE COLLECTION OF
A DEBT; ANY INFORMATION OBTAINED MAY BE USED FOR THAT PURPOSE.
16. By virtue of the marital relationship, the Act of 1937,
June 24, P.L. 2045, Sec. 3, as amended, 62 Pa. Cons. Stat. Ann.
Sec. 1973 and Article 1, Sec. 28 of the Pennsylvania Constitution
and all other applicable statutes, laws and ordinances, Count II
defendant has a duty to support Count I defendant.
17. Count II defendant has been unjustly enriched by plain-
tiff's discharge of Count II defendant's duty to support Count I
defendant, which duty Count II defendant failed to perform.
18. Count II defendant refuses to pay the balance due,
although plaintiff has made demand that Count II defendant do so.
19. As a result of the foregoing, there is due and owing
from Count II defendant to plaintiff the sum indicated in
Exhibit "A"
WHEREFORE, plaintiff demands judgment against Count II
defendant for the sum of $13,844.03 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.
LEW S C. TRAUFFER, ESQUIRE
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.
fq )73/
ACCOUNT #
1018572
STATEMENT
DATE: 031"
LAST STATE
DATE: 0311
!vim +r rw+ vvca..vna. r?r++a? wn.n+r.. M.IAM{+ rNI IGPII !`11YN1'141NL .7C1[YIl+C3 ftU :AA lU # Z5155TU35
DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR
CODE CODE ADJUSTMEN T BALANCE
>>> PATIENT: ROBIN BOMGARDNER 1018572
653283
PERFORMED BYs DIV OF NEURO SURGERY
PLACE OF SVCs SATELLITE CLINIC
03/14/W 99245 723.1 OFFICE CONSULTATION 228.00
04/08/00 NOT A COVERED SERVICE 0.00 228s90
664880
PERFORMED BY.- PENN STATE FAMILY HEALTH
PLACE OF SVCs SATELLITE CLINIC
03/29/00 NRNG/CO 739.1 KEYSTONE OMT S-LVL 3 58.00
04/15/00 NOT A COVERED SERVICE 0.00 58.00
04t/05/DO 90801 296.33
05/06/00
04/11/00 90853 296.33
05/13/00
04/11100 90862 296.33
04/20/00
04/29/00
04/18/00 90853 296.33
05/20/00
04/25(00 90853 296.33
05/20/00
04/25/00 90862 296.33
05/05/00
05/13/00
05/4YL00 90853 296.33
05/27/00
3131637
PERFORMED BY: PENN STATE FAMILY HEALTH
- PLACE OF SVC: SATELLITE CLINIC
-
677345
PERFORMED BYs DIV GMT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INITIAL COMP DIAGNSTIC-OP 159.00
NOT A COVERED SERVICE
GROUP PSYCHOTHERAPYAWPT 57.00
NOT A COVERED SERVICE
PHARMACOLOGIC MANAGMENT 62.00
BLUE SHIELD PAYMENT*
NOT A COVERED SERVICE
GROUP PSYCHOTHERAPY-OUTPT 57.00
HOT A COVERED SERVICE
GROUP PSYCHOTHERAPY-OUTPT 57.00
NOT A COVERED SERVICE
PHARMACOLOGIC MANAGMENT 62.00
BLUE SHIELD PAYMENT*
NOT A COVERED SERVICE
GROUP PSYCHOTHERAPY-OUTPT 57.00
NOT A COVERED SERVICE 9
?.a
0.00 159.00
0.00 57.00
0.00
0.00 62.00
0.00 57.00
0.00 57.00
0.00
0.00 62.00
0.00 57.00
A
MS HERSHEY MEDICAL CENTER PAGE: 1
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 04/21/04 at 03:35 PM
Guarantor: BOMGARDNER ROBIN M
702 BARBARA STREET
NEW CUMBERLAN, PA 17070-0000
Patient: BOMGARDNER ROBIN M
Visit #: 677345
-------------------------------------------------------------------------
Date Svc Code Description Units Debits Credits
04/05/00 6700 GROUP THERAPY 1 55.00
04/05/00 6703 ACTIVITY THERAPY 1 38.00
04/05/00 6704 FAMILY THERAPY W/PATI 1 81.00
04/05/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/05/00 6709 INDIV THERAPY 45-50 M 1 65.00
04/06/00 6700 GROUP THERAPY 1 55.00
04/06/00 6703 ACTIVITY THERAPY 1 38.00
04/06/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/07/00 6700 GROUP THERAPY 1 55.00
04/07/00 6703 ACTIVITY THERAPY 1 38.00
04/07/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/07/00 6709 INDIV THERAPY 45-50 M 1 65.00
04/10/00 6700 GROUP THERAPY 1 55.00
04/10/00 6703 ACTIVITY THERAPY 1 38.00
04/10/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/10/00 6709 INDIV THERAPY 45-50 M 1 65.00
04/11/00 6700 GROUP THERAPY 1 55.00
04/11/00 6703 ACTIVITY THERAPY 1 38.00
04/11/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/12/00 6700 GROUP THERAPY 1 55.00
04/12/00 6703 ACTIVITY THERAPY 1 38.00
04/12/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/12/00 6709 INDIV THERAPY 45-50 M 1 65.00
04/13/00 6700 GROUP THERAPY 1 55.00
04/13/00 6703 ACTIVITY THERAPY 1 38.00
04/13/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/14/00 6700 GROUP THERAPY 1 55.00
04/14/00 6703 ACTIVITY THERAPY 1 38.00
04/14/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/14/00 6708 INDIV THERAPY 20-30 M 1 43.00
04/17/00 6700 GROUP THERAPY 1 55.00
04/17/00 6703 ACTIVITY THERAPY 1 38.00
04/17/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/17/00 6708 INDIV THERAPY 20-30 M 1 43.00
04/18/00 6700 GROUP THERAPY 1 55.00
04/18/00 6703 ACTIVITY THERAPY 1 38.00
04/18/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/19/00 6700 GROUP THERAPY 1 55.00
04/19/00 6703 ACTIVITY THERAPY 1 38.00
04/19/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/19/00 6709 INDIV THERAPY 45-50 M 1 65.00
04/20/00 6700 GROUP THERAPY 1 55.00
Continue
.q I
MS HERSHEY MEDICAL CENTER PAGE: 2
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 04/21/04 at 03:35 PM
Guarantor: BOMGARDNER ROBIN M
702 BARBARA STREET
NEW CUMBERLAN, PA 17070-0000
Patient: BOMGARDNER ROBIN M
Visit #: 677345
-------------------------------------------------------------------------
Date I Svc Code I Description Unitsj Debits Credits
04/20/00 6703 ACTIVITY THERAPY 1 38.00
04/20/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/20/00 6708 INDIV THERAPY 20-30 M 1 43.00
04/21/00 6700 GROUP THERAPY 1 55.00
04/21/00 6703 ACTIVITY THERAPY 1 38.00
04/21/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/24/00 6700 GROUP THERAPY 1 55.00
04/24/00 6703 ACTIVITY THERAPY 1 38.00
04/24/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/24/00 6708 INDIV THERAPY 20-30 M 1 43.00
04/25/00 6700 GROUP THERAPY 1 55.00
04/25/00 6703 ACTIVITY THERAPY 1 38.00
04/25/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/26/00 6700 GROUP THERAPY 1 55.00
04/26/00 6703 ACTIVITY THERAPY 1 38.00
04/26/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/26/00 6709 INDIV THERAPY 45-50 M 1 65.00
04/27/00 6700 GROUP THERAPY 1 55.00
04/27/00 6703 ACTIVITY THERAPY 1 38.00
04/27/00 6706 EDUC/TRNG SESSION GRO 2 76.00
04/27/00 6708 INDIV THERAPY 20-30 M 1 43.00
04/28/00 6700 GROUP THERAPY 1 55.00
04/28/00 6703 ACTIVITY THERAPY 1 38.00
04/28/00 6706 EDUC/TRNG SESSION GRO 2 76.00
05/02/00 6700 GROUP THERAPY 1 55.00
05/02/00 6703 ACTIVITY THERAPY 1 38.00
05/02/00 6706 EDUC/TRNG SESSION GRO 2 76.00
05/02/00 6709 INDIV THERAPY 45-50 M 1 65.00
05/04/00 6700 GROUP THERAPY 1 55.00
05/04/00 6703 ACTIVITY THERAPY 1 38.00
05/04/00 6706 EDUC/TRNG SESSION GRO 2 76.00
05/04/00 6709 INDIV THERAPY 45-50 M 1 65.00
05/07/00 920001 BLUE CROSS CONTR ADJ -1 254.00-
06/07/00 902002 BLUE CROSS PAY HOSP -1 3474.00-
07/27/00 902002 BLUE CROSS PAY HOSP -1 386.00-
05/31/02 980090 HOSPITAL BAD DEBT W/O -1 82.00-
05/31/02 980091 HOSPITAL BAD DEBT PLA 1 82.00
* - Not posted Balance: I 82.00
------------------------
P.3
IF ANY Q UESTIONS PLEASE CONTACT MSHMC PATIENT FINANCIAL-SERwrFs F ED TAX ID # 251857035
DATE PROCEDURE DIAL DESCRIPTION
CITY INS CHARGE PAYMENT! GUARANTOR
ADJUSTMENT BALANCE
CODE CODE
»> PATIENT: ROBIN DOMGARDNER 1018572
UN
1326368
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
02/27/01 90806 296.30 INDIV PSYCHO TX I HR 96.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 85.50
03120/01 90806 296.30 INDIV PSYCHO TX 1 HR 98.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 85.50
1330551
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
02/20/01 90853 296.35 GROUP PSYCHOTHERAPY-OVTPT 60.00 47.50
1332771
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
02/20/01 90806 296.30 INDIV PSYCHO TX 1 HR 98.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 85.50
1333363
PERFORMED BY: DIV DUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
02/27/01 90853 296.35 GROUP PSYCHOTHERAPY (MSM) 60.00
11109/01 MAJOR MEDICAL PAYMENT 12.50- 47.50
1356458
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
03/06/01 90853 296.35 GROUP PSYCHOTHERAPY (MSM) 60.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 47.50
CHECK BOX
ON BACK
A?
PENNSTATE ROBIN BOMGARDNER 1 of 13
702 BARBARA STREET STATEMENT
The Milton S. Hershey Medical Center NEW CUMBERLAD PA 17070
The College of Median DATE: LAST STATEMENT
ACCOUNT # 1018572 DATE: 02/1$/03
ACCOUNT # 1018572
STATEMENT
DATE: 03114103
LAST STATEMENT
DATE: 02118103
A IF ANY Q UESTIONS, PLEASE CONTACT : MSHM - PATIENT EIMANCIAI SE RVICES FED TAX ID if 251857035
DATE PROCEDURE
CODE DIAG
CODE QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR
ADJUSTMEN T BALANCE
1363260
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
03/06/01 90806 296.30 INDIV PSYCHO TX 1 HR 98.00
11/09/01 MAJOR MEDICAL PAYMENT 12,50- 85.50
1363566
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
03/06/01 90862 296.35 PHARMACOLOGIC MANAGMENT 70.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 57.50
1387942
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
03/20/01 90853 296.35 GROUP PSYCHOTHERAPY (MSM) 60.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 47.50
1395801
PERFORMED BY. DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
03/20/01 90862 296.36 PHARMACOLOGIC MANAGMENT 70.00
03/30/01 BLUE SHIELD PAYMENTS 0.00
04/07/01 NOT A COVERED SERVICE 0.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 57.50
1408241
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
03/27/01 90853 296.35 GROUP PSYCHOTHERAPY (MSW) 60.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 47.50
03/27/01 90806 296.30 INDIV PSYCHO TX 1 HR 98.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 85.50
1423602
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
04/03/01 90853 296.35 GROUP PSYCHOTHERAPY (MSW) 60.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 47.50
1427307
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
04/03/01 90806 296.30 INDIV PSYCHO TX 1 HR 98.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 85.50
1443639
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
04/10/01 90806 296.30 INDIV PSYCHO TX 1 HR / 98.00
11/09/01 MAJOR MEDICAL PAYMENT n
1 `l 12.50- 85.5D
AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
PENNSTATE ROBIN BOMGARDNER 3 of 13
SUM"
The Milton 702 BARBARA STREET
S. Hershey Medical Center NEW CUMBERLAD PA 17070
STATEMENT
® The College of Median DATE: 03114103
LAST STATEMENT
ACCOUNT # 1018572 DATE: 02/18/03
'.? IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251 8 5703 5
DATE PROCEDURE
CODE DIAG QTY DESCRIPTION
CODE INS CHARGE PAYMENT/ GUARANTOR
ADJUSTMEN T BALANCE
1454424
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
04/17/01 90853 296135 GROUP PSYCHOTHERAPY (MSH) 60.00
05/12/01 NOT A COVERED SERVICE 0.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 47.50
1459609
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
04/17/01 90806 296.30 INDIV PSYCHO TX 1 HR 98.00
05/04/01 BLUE SHIELD PAYMENTS 0.00
05112/01 NOT A COVERED SERVICE 0.00 98.00
1473788
PERFORMED BY. DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
04/24/01 90853 296.35 GROUP PSYCHOTHERAPY (MSM) 60.00 60.00
1475628
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
04/24/01 90808 296.30 INDIV PSYCHO 1 1/2 HR 125.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 112.50
1475967
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
04/24/01 9DO62 296.36 PHARMACOLOGIC MANAGMENT 70.00
11/09/01 MAJOR MEDICAL PAYMENT 12.50- 57.50
1485884
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
05/01/01 90853 296.35 GROUP PSYCHOTHERAPY (MSN) 60.00 60.00
1491798
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
05/01/01 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 96.00
1500267
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
05/08/01 90853 296.35 GROUP PSYCHOTHERAPY (MSM) 60.00 60.00
1507855
PERFORMED BY: DIV GUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
05105101
05/12/01 90806 296.20 INDIV PSYCHO TX 1 NR
BLUE SHIELD PAYMENT* -L2 98.00
0.00
ACCOUNT ## 1018572
STATEMENT
DATE: 03/14/03
LAST STATEMENT
DATE: 02118103
IF ANY WUL*IIWNS PLCNUE CWI
DATE PROCEDURE DIAG
CODE CODE
05/19/01
05/15/01 90853
05/15/01 90806
05/22/01 90853
05/22/01 90806
05/25/01
06/08/01
05/29/01 90853
02/25/02
05/29/01 90806
06/05/01 90853
06/05/01 90806
06/08/01
06/08/01
06/08/01
06/21/01
296.36
296.30
296.36
296.30
296.36
296.30
296.36
296.30
CHECK
CITY DESCRIPTION
NOT A COVERED SERVICE
1521637
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
GROUP PSYCHOTHERAPY (MSW)
1524220
PERFORMED BY. DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
1532776
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
GROUP PSYCHOTHERAPY (MSW)
1539813
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
BLUE SHIELD PAYMENT*
NOT A COVERED SERVICE
1550668
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
GROUP PSYCHOTHERAPY (MSW)
NO PAYMENT FROM INS CO*
1552536
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
1564210
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
GROUP PSYCHOTHERAPY (MSW)
1568847
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIY PSYCHO TX 1 HR
BLUE SHIELD PAYMENT*
BLUE SHIELD PAYMENT*
BLUE SHIELD PAYMENT*
NOT A COVERED SERVICE
1569178 n
ADDRESS OR
mm?
INS CHARGE PAYMENT/ GUARANTO
ADJUSTMENT BALANCE
0.00 98.00
60.00 60.00
98.00 98.00
60.00 60.00
98.00
0.00
0.00 98.00
60.00
60.00
98.00 98.00
60.00 60.00
98.00
0.00
0.00
0.00
0.00 98.00
ON BACK
PENNSTATE ROBIN BOMGARDNER
702 BARBARA STREET
The Milton S. Hershey Medical Center NEW CUMBERLAO PA 17070
The College of Medicine
ACCOUNT ## 1018572
STATEMENT
DATE. 03/14103
LAST STATEMENT
DATE: 02/18103
5of13
JS It ANY WhNIIONS. PLEASE CONTACT : MSHMC PATIENT FINANCIAL SE RVICES F ED TAX BD ft 2 51857035
DATE PROCEDURE DIAG
CODE QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR
ADJUSTMENT BALANCE
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
06/05/01 90862 300.01 PHARMACOLOGIC MANAGMENT 70.00
06/08/01 BLUE SHIELD PAYMENT* 0100
06/08/01 BLUE SHIELD PAYMENT* 0100
06/08/01 BLUE SHIELD PAYMENT* 0.00
06/21/01 NOT A COVERED SERVICE 0.00 70.00
1SM462
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: DP PHYSICIAN
06/12/01 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 98.00
1595536
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
06/19/01 90853 296.36 GROUP PSYCHOTHERAPY (MSM) 60.00 60.00
07/10/01 90806 963.0 INDIV PSYCHO TX 1 HR 98.00
07/14/01 BLUE SHIELD PAYMENT* 0.00
01/22/02 BLUE SHIELD PAYMENT 0.00 98.00
1600102
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
06/19/01 90806 296.30 INDIV PSYCHO TX 1 HR 9B.00 98.00
1637911
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
07/10/01 90853 296.36 GROUP PSYCHOTHERAPY (MS14) 60.00 60.00
1657323
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
07/17/01 90806 296.31 INDIV PSYCHO TX 1 HR 98.00 98.00
1687722
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: DP PHYSICIAN
07/31/01 90806 2%.30 INDIV PSYCHO TX 1 HR 98.00 98.00
1693652
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
08/02/01 90862 296.36 PHARMACOLOGIC MANAGMENT 70.00
08/10/01 BLUE SHIELD PAYMENTS 0.00 70.00
1732691
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
08/21/01 90806 296.30 INDIV PSYCHO TX 1 NR ?? 98.00 98.00
PENNSTATE ROBIN BOMGARDNER 6 of 13
702 BARBARA STREET
The Milton S. Hershey Medical Center NEW CUMBERLAD PA 17070 STATEMENT
® The College of Median DATE: 03114103
LAST STATEMENT
ACCOUNT # 1018572 DATE: 02116103
t1 IF ANY QUESTIONS PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035
DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR
CODE CODE ADJUSTMENT BALANCE
1747983
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
08/28/01 90606 2%.30 INDIV PSYCHO TX 1 HR 98.00 98.00
1760799
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
09104/01 90806 296.30 INDIV PSYCHO TX 1 HR
1761204
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
09/04/01 90862 2%.36 PHARMACOLOGIC MANAGMENT
09/11/01 90806 296.30
09/18/01 90806 296.30
09/21/01
09125/01 90806 296.30
10/02/01 90806 296.30
10/04/01 90862 300.01
10/09/01 90806 296.30
10/16/01 90806
296.30
1886145
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
1901756
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
NOT COVERED BY INSURANCE
1917735
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
1933404
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
1939791
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
PHARMACOLOGIC MANAGMENT
1949006
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC! DP PHYSICIAN
INDIV PSYCHO TX 1 HR
1964950
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC% OP PHYSICIAN
INDIV PSYCHO TX 1 HR
98.00
70.00
98.00
98.00
98.00
98.00
70.00
98.00
98.00
98.00
70.00
96.00
0.00 98.00
98.00
98.00
70.00
48.00
98.00
PENNSTATE ROBIN BOMGARDNER
702 BARBARA STREET
The Milton S. Hershey Medical Center NEW CUMBERLAD PA 17070
® The College of Medicine
ACCOUNT # 1018572 PAGE
7 of 13
STATEMENT
DATE: 03114103
LAST STATEMENT
DATE: 02118103
] IF ANY QUESTIONS PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 2518ST035
DATE PROCEDURE
CODE DIAG QTY DESCRIPTION
CODE INS CHARGE PAYMENT/ GUARANTOR
ADJUSTMENT BALANCE
1981216
PERFORMED BY: DIY OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
10/23/01 90806 296.39 INDIV PSYCHO TX 1 HR 98.00 98.00
1997560
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
10/30/01 90806 296.30 INDIV PSYCHO TX 1 MR 98.00 98.00
2040214
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
11/16/01 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 98.00
2047995
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
11/20/01 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 98.00
2076584
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC. OP PHYSICIAN
12/04/01 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 98.00
2093722
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
12/11/01 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 98.00
2111049
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
12/18/01 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 98.00
2127014
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
12/27/01 90862 300.01 PHARMACOLOGIC MANAGMENT 70.00 70.00
2149268
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
01108/02 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 98.00
2184282
PERFORMED BY: DIV GMT PSYCH ADULT
PLACE OF SYC: OP PHYSICIAN
01/22/02 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 98.00
2203233 4 -m
PENNSTATE ROBIN BOMGARDNER 8 of 13
702 BARBARA STREET
The Milton S. Hershey Medical Center NEW CUMBERLAD PA 17070 STATEMENT
® The College of Medicine DATE: 03114103
LAST STATEMENT
ACCOUNT # 1018572 DATE: 02118103
MY IF ANY QUESTIONS PLEASE CONTACT : MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035
DATE PROCEDURE
CODE DIAG
CODE QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR
ADJUSTMENT BALANCE
PERFORMED BY: DIV 0UTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
01/30/02 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 98.00
2237432
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
02/12/02 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 98.00
2273366
PERFORMED BY: DIV OUIPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
02/26/02 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 98.00
2306430
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
03/12/02 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 98.00
2330584
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: DP PHYSICIAN
03/21/02 90862 296.36 PHARMACOLOGIC MANAGMENT 70.00 70.00
2440511
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
05/02/02 90862 296.36 PHARMACOLOGIC MANAGMENT 70.00 12.50
2451628
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
05/07/02 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 12.50
2488663
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC% OP PHYSICIAN
05/21/02 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 12.50
2536741
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
06/11/02 90806 296.30 INDIV PSYCHO TX 1 HR 98.00 12.50
2616951
PERFDRMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
07/12/02 90806 296.30 INDIV PSYCHO TX 1 HR 130.00 12.50
2685090 A
BOX AND ENTER ANY ADDRESS OR INSURANCE
!Hi IF ANY QUESTIONS, PLEASE CONTACT : MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035
DATE PROCEDURE
CODE D1AG
CODE QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR
ADJUSTMENT BALANCE
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
08107102 90806 296.30 INDIV PSYCHO TX 1 HR CST 130.00
09/06/02 BLUE SHIELD PAYMENTS 0.00
2706294
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
08115/02 90862 300,01 PHAR14ACOLOGIC MANAGMENT 95.00 12.50
2717616
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
08/20/02 90806 296.30 INDIV PSYCHO TX 1 HR 130.00 12.50
U ?` J PERFORMED BY. DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
0960/02 90806 296.30 INDIV PSYCHO TX 1 HR CBT 130.00
2785300
PERFORMED $Y: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
09/17/02 90862 296.36 PHARMACOLOOIC MANAGMENT CBT 95.00
2858928
PERFORMED BYi DIV GMT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
10/15/02 90806 296.30 INDIV PSYCHO TX 1 HR CST 130.00
2876508
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
10/22/02 90806 296.30 INDIV PSYCHO TX 1 HR CBT 130.00
2894495
PERFORMED BY: DIV DUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
.10/29/02 90806 296.30 INDIV PSYCHO TX 1 HR CDT 130.00
2914305
PERFORMED BY. DIV O1TPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
11105102 90862 2%.35 PHARMACOLOGIC MANAGMENT CBT 95.00
2934982
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
11/12/02 90806 2%.30 INDIV PSYCHO TX 1 HR CST 130.00
2471674 A • o-
PENNSTATE ROBIN BOMGARDNER 9 of 13
702 BARBARA STREET
IV The Milton S. Hershey Medical Center NEW CUMBERLAD PA 17070 STATEMENT
The College of Median DATE: 03114103
LAST STATEMENT
ACCOUNT # 1018572 DATE: 02118103
ACCOUNT # 1018572
STATEMENT
DATE: 03114103
LAST STATEMENT
DATE: 02/19/03
'A) IF ANY Q UESTIONS. PLEASE CONTACT : MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 2 51 8 5703 5
DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR
CODE CODE ADJUSTMENT BALANCE
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SYC: OP PHYSICIAN
11/26/02 90806 296.30 INDIV PSYCHO TX 1 HR CST 130.00
2975954
PERFORMED BY: DIV DUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
11/27/02 90862 296.36 PHARMACOLOGIC MANAGMENT CST 95.00
3002721
PERFORMED BY: DIV GMT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
12/10/02 90806 296.30 INDIV PSYCHO TX 1 HR CST 130.00
12/31/02 90862 296.36
01/07/03 90806 296.30
01/28/03 90806 296.30
¦ 02/11/03 90806 296.30
¦ 02/25/03 90806 296.30
3048954
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
PHARMACOLOGIC MANAGMENT
3063972
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
3120972
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
3159509
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SYC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
3197385
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
CST 95.00
CBT 130.00
CST 130.00
CST 130.00
CST 130.00
* 03/10/03 90862 296.36
3232281
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
PHARMACOLOGIC MANAGMENT
10185729422
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
90806 INSIGHT ORIEN 45-50 MIN
90853 GROUP PSYCHOTHERAPY-OUTPT
90806 INSIGHT ORIEN 45-50 MIN
90853 GROUP PSYCHOTHERAPY-OUTPT A-1
CST 95.00
90.00
57.00
90.00
57.00
90.00
57.00
90.00
57.00
CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
PENNSTATE ROBIN BOMGARDNER
702 BARBARA STREET
® The Milton S. Hershey Medical Center NEW CUMBERLAD PA 17070
The College of Medicine
ACCOUNT # 1016572
PAGE
STATEMENT
DATE: 03114/03
LAST STATEMENT
DATE: 02/18103
11 of 13
DATE PROCEDURE DIAG QTY DESCRIPTION
CODE CODE INS CHARGE '..""""' " "^"'?
ADJUSTMENT BALANCE
05/25/00 90853 GROUP PSYCHOTHERAPY-OUTPT 57.00 57.00
05/30/00 90862 PHARMACOLOGIC MANAGMENT 62.00 62.00
06/01/00 90806 INSIGHT ORIEN 45-50 MIN 90.00 90.00
06/01/00 90853 GROUP PSYCHOTHERAPY-OUTPT 57.00 57.00
06/06/00 90806 INSIGHT ORIEN 45-50 MIN 90.00 90.00
06/08/00 90853 GROUP PSYCHOTHERAPY-OUTPT 57.00 57.00
06/13/00 90862 PHARMACOLOGIC MANAGMENT 62.00 62.00
06/15/00 90853 GROUP PSYCHOTHERAPY-OUTPT 57.00 57.00
06/20/00 90806 INSIGHT ORIEN 45-50 MIN 90.00 90.00
06/21/00 90862 PHARMACOLOGIC MANAGMENT 62.00 62.00
06/22/00 90853 GROUP PSYCHOTHERAPY-Ot1TPT 57.00 57.00
06/27/00 90862 PHARMACOLOGIC MANAGMENT 62.00 62.00
06/27/00 90806 INSIGHT ORIEN 45-50 MIN 90.00 90.00
06/29/00 90853 GROUP PSYCHOTHERAPY-OUTPT 57.00 57.00
07/05/00 90806 INSIGHT ORIEN 45-50 MIN 98.00 98.00
07/06/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 60.00
07/11/00 90806 INSIGHT ORIEN 45-50 MIN 98.00 98.00
07/12/00 90862 PHARMACOLOGIC MANAGMENT 70.00 70.00
07/13/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 60.00
07/18/00 90806 INSIGHT ORIEN 45-50 MIN 98.00 98.00
07/20/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 60.00
07/27/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 60.00
08/01/00 90806 INSIGHT ORIEN 45-50 MIN 98.00 98.00
08/03/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 60.00
08/03/00 90862 PHARMACOLOGIC MANAGMENT 70.00 70.00
08/08/00 90806 INSIGHT ORIEN 45-50 MIN 98.00 98.00
08/10/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 60.00
08/17/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 60.00
08/22/00 90806 INSIGHT ORIEN 45-50 MIN 98.00 98.00
08/22/00 90862 PHARMACOLOGIC MANAGMENT 70.00 70.00
08/24/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 60.00
09/05/00 90806 INSIGHT ORIEH 45-50 MIN 98.00 85.50
09/07/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 47.50
09/19/00 90806 INSIGHT ORIEN 45-50 MIN 98.00 85.50
09/19/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 47.50
09/26/00 90862 PHARMACOLOGIC MANAGMENT 70.00 57.50
09/26/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 47.50
10/03/00 90806 INSIGHT ORIEN 45-50 MIN 98.00 85.50
10/03/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 47.50
10/10/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 47.50
10/17/00 90806 INSIGHT ORIEN 45-50 MIN 98.00 85.50
10/17/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 47.50
10/26/00 90862 PHARMACOLOGIC MANAGMENT 70.00 57.50
10/31/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 47.50
11/21/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 47.50
11/28/00 90806 INSIGHT ORIEN 45-50 MIN 98.00 85.50
11/28/00 90862 PHARMACOLOGIC MANAGMENT 70.00 57.50
11/28/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 47.50
12/05/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 47.50
12/05/00 90862 PHARMACOLOGIC MANAGMENT 70.00 57.50
12/05/00 90806 INSIGHT ORIEN 45-50 MIN d -Ili 98.00 85.50
DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTO
CODE CODE ADJUSTMENT BALANCE
12/12/00 90853 GROUP PSYCHOTHERAPY-DUTPT 60.00 47.50
12/12/00 90806 INSIGHT BRIEN 45-50 MIN 98.00 85.50
12/19/00 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 47.50
01/04101 90806 INSIGHT BRIEN 45-50 MIN 98.00 98.00
01/09/01 90806 INSIGHT BRIEN 45-50 MIN 98.00 98.00
01/09/01 90862 PHARMACOLOGIC MANAGMENT 70.00 70.00
01/09/01 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 60.00
01/16/01 90806 INSIGHT BRIEN 45-50 MIN 98.00 98.00
01/16/01 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 60.00
01/23/01 90806 INSIGHT BRIEN 45-50 MIN 98.00 98.00
01/23101 90862 PHARMACOLOGIC MANAGMENT 70.00 70.00
01/23/01 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 60.00
01/30/01 90806 INSIGHT BRIEN 45-50 MIN 98.00 98.00
01/30/01 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 60.00
02/06/01 90806 INSIGHT BRIEN 45-50 MIN 98.00 98.00
02/06/01 90862 PHARMACOLOGIC MANAGMENT 70.00 70.00
02/06101 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 60.00
02/09/01 90806 INSIGHT BRIEN 45-50 MIN 98.00 98.00
02/13/01 90806 INSIGHT BRIEN 45-50 MIN 98.00 98.00
02/13/01 90853 GROUP PSYCHOTHERAPY-OUTPT 60.00 47.50
BALANCE: ROBIN BOMGARONER 111368.50
¦ INDICATES NEW FINANCIAL ACTIVITY SINCE LAST BILL.
PAYMENTS OF 87.50 APPLIED TO YOUR CHARGES NOT INCLUDED ON THIS BILL.
IF YOU HAVE ANY QUESTIONS ABOUT THE AMOUNT YOUR INSURANCE
COMPANY PAID, CONTACT THEM DIRECTLY. FOR ANY OTHER QUESTIONS
REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMENT
HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL.
RSS9
THANK YOU FOR USING MSHMC PHYSICIANS GROUP FOR YOUR PHYSICIAN
SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE
CONTACT US AT 717-531-5069 OR 800-254-26191 BETWEEN $:DOAN AND
5:30PM MONDAY THROUGH WEDNESDAY OR BETWEEN 8:00AM AND 4:30PH
THURSDAY AND FRIDAY.
OR INSURANCE CORRECTIONS ON BACK
DATE PROCEDURE DIAG
CODE CODE
>>> PATIENT: ROBIN BOMGARDNER
01/31/03 99213 466.0
02/27/03
02/27/03
INS CHARGE PAYMENT/ GUARANTO
ADJUSTMENT BALANCE
1018572
3131637
PERFORMED BY: PENN STATE FAMILY HEALTH
PLACE OF SVC: SATELLITE CLINIC
OUTPATIENT VISIT EST
APPLIED TO DEDUCTIBLE
BC PHYS CONTRACTUAL ADJ
60.00
0.00
6.96-
IF YOU HAVE ANY QUESTIONS ABOUT THE AMOUNT YOUR INSURANCE
COMPANY PAID, CONTACT THEM DIRECTLY. FOR ANY OTHER QUESTIONS
REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMENT
HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL.
RSS9
THANK YOU FOR USING MSHMC PHYSICIANS GROUP FOR YOUR PHYSICIAN
SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE
CONTACT US AT 717-531-5069 OR 800-254-26191 BETWEEN B:OOAM AND
5:30PM MONDAY THROUGH WEDNESDAY OR BETWEEN 8:001114 AND 4:30PM
THURSDAY AND FRIDAY.
QTY DESCRIPTION
A '/?
PENNSTATE ROBIN BOMGARDNER 1 or 2
702 BARBARA STREET
® The Milton S. Hershey Medical Center NEW CUMBERLAD PA 17070 STATEMENT
The College of Mediane DATE. 03114/03
LAST STATEMENT
ACCOUNT # 1018572 DATE: 03/07/03
ROBIN BOMGARDNER PAGE 13 of 13
PENNSTATE 702 BARBARA STREET
® The Milton S. Hershey Medical Center NEW CUMBERLAD PA 17070 STATEMENT
mo"aa The College of Medicine DATE: 03114103
LAST STATEMENT
ACCOUNT # 1018572 DATE: 02118103
IF ANY QUESTIONS PLEASE CONTACT, MQHM PATIENT FINANCIAL SERVICES FED TAX ID # 251857035
DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR
CODE CODE ADJUSTMENT BALANCE
BALANCE SUMMARY RESPONSIBLE PARTY POLICY 9 TOTAL
CST CAPITAL BLUE CROSS/CAIC YNA19146099"OE4990000 0 2035.00
*** GUARANTOR RESPONSIBILITY S 11368.50
____________________________I IMPOHi t.-PLEASE DETACH AND RETURN_BOTTOM P9_p' ON_Of STA7EMEN7 WITH YOUB PAYAfENT_j ______________________________
STATEMENT DATE% GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT:
BF6 1018572 03/14/03 $ 11368.50 $ 11368.50
MSHMC PHYSICIANS GROUP
BILLING SERVICES
P O BOX 854
HERSHEY PA 17033.0854 00001018572 56000 0000000001136850031403
Mart DIV OUTPT PSYCH ADULT ROBIN BOMGARDNER
TO. MSHMC PHYSICIANS GROUP 702 BARBARA STREET
P 0 BOX 628611 NEW CUMBERLAD PA 17070
PHILADELPHIA PA 19182-86
FFICE USE ONLY IICHECK ONE FOR CREDIT CARD PAYMENT. PLEASE FILL IN INFORMATION BELOW
I I I I i I I I I I I I I I I I 1 101857
_M/C CARD NUMBER EXP DATE EmmummmERNIffim
-VISA $ 11368.50
{C: F680 CARDHOLDER NAME (PRINT) N I?Iy
TYP I DMND
0
CREDIT CARD SIGNATURE MSHMC PHYSICIANS
CORRECTIONS
Ammwmmm?
MS HERSHEY MEDICAL CENTER PAGE: 1
500 UNIVERSITY DRIVE
HERSHEY, PA 17033
Statement on: 03/19/03 at 04:19 PM
Guarantor: BOMGARDNER ROBIN
702 BARBARA STREET
NEW CUMBERLAD, PA 17070-0000
Patient: BOMGARDNER ROBIN
Visit #: 1517898
------ ----------------------------- ------?- -
Date I Svc Code Description Units Debits Credits
05/12/01 42207 CRUTCHES-WOOD 1 28.00
05/12/01 46159 ANKLE SUPPORT 1 50.00
05/12/01 46459 TAPE/WRAP/SLING, ANKL 1 58.00
05/12/01 46470 EMERGENCY VISIT, LEVE 1 135.00
05/12/01 305625 TIBIA & FIBULA AP&LAT 1 99.00
05/12/01 305629 ANKLE 3 OR MORE VIEWS 1 92.00
05/29/01 902002 BLUE CROSS PAY HOSP -1 226.56-
05/29/01 920001 BLUE CROSS CONTR. ADJ -1 157.44-
09/30/01 980090 HOSPITAL BAD DEBT W/O -1 78.00-
09/30/01 980091 HOSPITAL BAD DEBT PLA 1 78.00
* - Not posted Balance: 78.00
------------------------
4 IF ANY QUESTIONS, PLEASE CONTA
DATE PROCEDURE D G
CODE CODE
>>> PATIENT: ROBIN M BOMOARDNER
08/07/02 90806
09/06/O2
04/04/03
04/04/03
04/04/03
296.30
09/10/02 90806
04/04/03
04/04/03
04/04/03
09/17/02 90862
04/04/03
04/04/03
04/04/03
10/15/02 90806
04/04/03
04/04/03
04/04/03
10/22/02 90806
04/04/03
04/04/03
04/04/03
10/29/02 90806
04/04/03
04/04/03
04/04/03
296.30
296.36
296.30
ACCOUNT #
PA 17070-1530
1018572
STATEMENT
DATE: 1210910$
LAST STATEMENT
DATE: 101$010$
QTY DESCRIPTION
1018572
2685090
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
BLUE SHIELD PAYMENT*
BC PHYS PAYMENT
BC PHYS CONTRACTUAL AD
BALANCE AFTER INS*
2767353
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
BC PHYS PAYMENT
BC PHYS CONTRACTUAL AD
BALANCE AFTER INS*
2785300
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
PHARMACOLOOIC MANAGMENT
BC PHYS PAYMENT
BC PHYS CONTRACTUAL AD
BALANCE AFTER INS*
2858928
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
INDIV PSYCHO TX 1 HR
BC PHYS PAYMENT
BC PHYS CONTRACTUAL AD
BALANCE AFTER INS*
2876508
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SYC: OP PHYSICIAN
296.30 INDIV PSYCHO TX 1 HR
BC PHYS PAYMENT
BC PHYS CONTRACTUAL AD
BALANCE AFTER INS*
2894495
PERFORMED BY,. DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
296.30 INDIV PSYCHO TX 1 HR
BC PHYS PAYMENT
BC PHYS CONTRACTUAL AD
BALANCE AFTER INS*
2914305 -
ENTER ANY
INS CHARGE
130.00
130.00
USTMENT BALANCE
0.00
12.50-
22.83-
94.67
12,50-
22.83-
94.67
95.00
12.50-
38.04-
44.46
130.00
12.50-
22.83-
94.67
130.00
12,50-
22.83-
94.67
130,00
12.50-
22,83-
94.67
DATE rKU"UUKC UTAU QTY DESCRIPTION
CODE CODE
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
11/05/02 90862 2%.35 PHARMACOLDGIC MANAGMENT
04/04/03 BC PHYS PAYMENT
04/04/03 BC PHYS CONTRACTUAL AD
04/04/03 BALANCE AFTER INS*
2934982
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
11/12/02 90806 296.30 INDIV PSYCHO TX 1 HR
04/114/03 BC PHYS PAYMENT
04/04/03 BC PHYS CONTRACTUAL AD
04/04/03 BALANCE AFTER INS*
2971674
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
11/26/02 90806 296.30 INDIV PSYCHO TX 1 HR
03/26/03 BC PHYS PAYMENT
03/26/03 BC PHYS CONTRACTUAL ADJ
03/26/03 BALANCE AFTER INS*
2975954
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
11/27/02 90862 296.36 PHARMACOLOGIC MANAGMENT
03/26/03 BC PHYS PAYMENT
03/26/03 BC PHYS CONTRACTUAL ADJ
03/26/03 BALANCE AFTER INS*
3002721
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
12/10/02 90806 296.30 INDIV PSYCHO TX 1 HR
03/26/03 BC PHYS PAYMENT
03/26/03 BC PHYS CONTRACTUAL AD
03/26/03 BALANCE AFTER INS*
3048954
PERFORMED BY: DIY OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
12/31/02 90862 296.36 PHARMACOLOGIC MANAGMENT
03/26/03 BC PHYS PAYMENT
03/26/03 BC PHYS CONTRACTUAL AD
03126/03 BALANCE AFTER INS*
3063972
PERFORMED BY% DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
01/07/03 90806 296.30 INDIV PSYCHO TX 1 HR
? CHECK BOX AND ENTER ANY ADDRESS OR INSURA
INS CHARGE rr..no".•
ADJUSTMENT v ?.E
13 BALA ALANCE
95.00
12.50-
38.04-
44.46
130.00
12.50-
22.83-
94.67
130.00
12.50-
22.83-
%.67
95.00
12.50-
38.04-
44.46
130.00
12.50-
22.83-
94.67
95.00
12.50-
38.04-
44.46
130.00
CORRECTIONS ON BACK
PENNSTATE ROBIN M BOMGARDNER 2 or 4
702 BARBARA STREET
The Milton S. Hershey Medical Center NEW CUMBERLAND PA 17070-1530 STATEMENT
The College of Medicine DATE: 12109103
LAST STATEMENT
ACCOUNT # 1018572 DATE: 10/30103
IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035
DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENT/ GUA ANi=OR
CODE CODE ADJUSTMENT BALANCE
03/26/03 APPLIED TO DEDUCTI 0.00
03/26/03 BC PHYS CONTRACTUAL ADJ 22.83-
03/26/03 BALANCE AFTER INS% 107.17
3120972
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
01/28/03 90806 296.30 INDIV PSYCHO TX 1 HR 130.00
03/26/03 APPLIED TO DEDUCTIBLE 0.00
03/26/03 BC PHYS CONTRACTUAL ADJ 22.83-
03/26/03 BALANCE AFTER INS* 107.17
3159509
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
02/11/03 90806 296.30 INDIV PSYCHO TX 1 HR 130.00
03/13/03 APPLIED TO DEDUCTIBLE 0.00
03/13/03 BC PHYS CONTRACTUAL AD 105.00-
08/12/03 BC PHYS PAYMENT 12.50- 12.50
3197385
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
02/25/03 90806 296.30 INDIV PSYCHO TX 1 HR 130.00
03/26103 APPLIED TO DEDUCTI 0.00
03/26/03 BC PHYS CONTRACTUAL ADJ 22.83-
08/12/03 BC PHYS PAYMENT 12.50- 94.67
3232281
PERFORMED BY: DIY OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
03/10/03 90862 296.36 PHARMACOLOGIC MANASMENT 95.00
04/08/03 BC PHYS PAYMENT 12.50-
04/08/03 BC PHYS CONTRACTUAL ADJ 38.04-
04/08/03 BALANCE AFTER INS* 44.46
3278419
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
03/25/03 90806 296.30 INDIV PSYCHO TX 1 HR 130.00
04130/03 BC PHYS PAYMENT 12.50-
04/30/03 BC PHYS CONTRACTUAL ADJ 22.83-
04/30/03 BALANCE AFTER INS* 94.67
3333480
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
04/14103 90862 300.01 PHARMACOLOGIC MANAGMENT 95.00
05/06/03 BC PHYS PAYMENT 12.50-
05/06/03 BC PHYS CONTRACTUAL ADJ 38.04-
05/06/03 BALANCE AFTER INS* , f 44.46
'ENNSTATE ROBIN M BOMGARDNER 3 of 4
702 BARBARA STREET
The Milton S. Hershey Medical Center NEW CUMBERLAND PA 17070-1530 STATEMENT
® The College of Medicine DATE: 12109103
LAST STATEMENT
ACCOUNT # 1018572 DATE: 10130103
H IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 15185-7-015
PROCEDURE
DATE -
CODE R CODE QTY DESCRIPTION INS CHARGE ADPAYPAENTI GUARANTOR
JUSTMENT BALANCE
3338165
PERFORMED BY; DIV DUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
04/15/03 90806 2%.30 INDIV PSYCHO TX 1 HR 130.00
05/13/03 BC PHYS PAYMENT 12.50-
05/13/03 BC PHYS CONTRACTUAL ADJ 22.83-
05/13/03 BALANCE AFTER INS 94.67
BALANCE: ROBIN M BOMGARDNER 41534.97
OTHER CHARGES BILLED TO INSURANCE 131.98-
IF YOU HAVE ANY QUESTIONS ABOUT THE AMOUNT YOUR INSURANCE
COMPANY PAID, CONTACT THEM DIRECTLY. 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 MSHMC PHYSICIANS GROUP FOR YOUR PHYSICIAN
SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE
CONTACT US AT 717-531-5069 OR 800-254-2619, BETWEEN 8:00AM AND
5:30PM MONDAY THROUGH WEDNESDAY OR BETWEEN 8:00AM AND 4:30PM
THURSDAY AND FRIDAY.
BALANCE SUMMARY RESPONSIBLE PARTY POLICY 8 TOTAL
*** GUARANTOR RESPamIBILITY 4 1534.97
.___________________________ /MPORTANTe iLE{SE OETAC?I ANO $EIURN BOTTOM POR7ION_RE STATEMENT WIrH YQUR PAYMENT_I___________-__-__-_____________
BF6
MSHMC PHYSICIANS GROUP
BILLING SERVICES
P O BOX 854
HERSHEY PA 17033.0854
{ul{{?{?{lu{?{?{{w{n{u{{m{{nn{{n{{I U 1{{u{{I{u{?{
Mall DIV OUTPT PSYCH ADULT
TO: MSHMC PHYSICIANS GROUP
P 0 BOX 643313
PITTSBURGH PA 15264-3313
WCE USE
C: F6B0
YP: DMND
STATEMENT DATE: GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT:
12/09/03 $ 1534.97 $ 1534.97
00001018572 56000 0000000000153497120903
{ul{{{ul{{{m{u,{{{un a{{,{?{nl{{I{{m{{uw{?{?{u{{
ROBIN M BOMGARDNER
702 BARBARA STREET
NEW CUMBERLAND PA 17070-1530
CHECK ONE FOR CREDIT CARD PAYMENT, PLEASE FILL IN INFORMATION BELOW
M/C 11111111111111111
VISA CARD NUMBER EXP DATE
CARDHOLDER NAME (PRINT) t{ P4K?
a ,tea
CREDIT CARD SIGNATURE ' MSHMC PHYSICIANS
CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
'ENNSTATE ROBIN M BOMGARDNER 4 of 4
702 BARBARA STREET
The Milton S. Hershey Medical Center NEW CUMBERLAND PA 17070-1530 STATEMENT
® The College of Medicine DATE: 12/09/03
LAST STATEMENT
ACCOUNT # 1018572 DATE: 10/30/03
ACCOUNT # 1018572
STATEMENT
DATE: 01130104
LAST STATEMENT
DATE: 01/16/04
+{;; IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035
DATE PROCEDURE D A QTY DESCRIPTION INS CHARGE
CODE CODE ADJUSTMENT BALANCE
»> PATIENT: ROBIN M BOMGARDNER 1018572
3677627
PERFORMED BY: PENN STATE FAMILY HEALTH
PLACE OF SVC: SATELLITE CLINIC
08/19/03 99396 V72.83 PREV MED VISIT EST 40-64 134.00
09/24/03 NOT COVERED BY INSURANCE 0.00 134.00
BALANCE: ROBIN M BOMGARDNER S134.00
OTHER CHARGES BILLED TO YOUR INSURANCE COMPANY. 188.00
IF YOU HAVE ANY QUESTIONS ABOUT THE AMOUNT YOUR INSURANCE
COMPANY PAID/ CONTACT THEM DIRECTLY. 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 MSHMC PHYSICIANS GROUP FOR YOUR PHYSICIAN
SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE
CONTACT US AT 717-531-5069 OR 800-254-26I91 BET14EEN B:OOAM AND
5:30PM MONDAY THROUGH WEDNESDAY OR BETWEEN &OOAM AND 4i3OPM
THURSDAY AND FRIDAY.
BALANCE SUMMARY RESPONSIBLE PARTY POLICY >E TOTAL
**N GUARANTOR RESPONSIBILITY S 134.00
BOTTOM PORTION OF
STATEMENT_W1TN YOUR PA YMENi: _
STATEMENT DATE: GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT:
BF6 01130104 $ 134.00 $ 134.00
MSHMC PHYSICIANS GROUP
BILLING SERVICES
P O BOX 854
HERSHEY PA 17033-0854 00001018572 UP I1. 000001100000013400013004
II II III'lI,. a 1.1111 I'LL 1'1{U..1"I.n1 It, 1111i All, ,11'11111 ?111I I?III??II?LI LI?IIII tli.l11'1'll1III?IIIIII?II III I'1'l1ll
Matt MSHMC PHYSICIANS GROUP ROBIN M BOMGARDNER
7B; 702 BARBARA STREET
PO BOX 643313 NEW CUMBERLAND PA 17070-1530
PITTSBURG" PA 15264-3313
OFFICE USE ONLY ?CNECK ONE FOR CREDIT CARD PAYMENT, PLEASE FILL IN INFORMATION BELOW IT NI E
1018572
M/C P YY 12A. T z . 4 i?
VISA CARD NUMBER EXP DATE $ 134.GD D2/2D/D4
CARDHOLDER NAME (PRINT) AMOUNT'
HC: F6B0
TYP: DMND -+.- .A,. ,, -
CREDIT CARD SIGNATURE MSHMC PHYSICIANS GROUP
f I CHECK BOX AND ENTER ANY ADDRESS OR INSURANCE CORRECTIONS ON BACK
-vL
ACCOUNT 4 IGISS72
STATEMENT
DATE: 101221O4
LAST STATEMENT
DATE: 10118/04
14 IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035
DATE PROCEDURE WAG QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR
CODE CODE ADJUSTMENT BALANCE
>>> PATIENT: ROBIN M BOMGARDNER 1018572
4409344
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
04/27/04 90806 296.30 INDIV PSYCHO TX 1 HR 138.00
05/17/04 BC PHYS PAYMENT 32.15-
05/17/04 BC PHYS, CONTRACTUAL ADJ 73.70-
07/26/04 THANK YOU FOR PAYMENT 2197- 29.18
4447271
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
05/11/04 90806 296.30 INDIV PSYCHO TX 1 HR 138.00
06/03104 BC PHYS PAYMENT 32.15-
06/03/04 DC PHYS CONTRACTUAL ADJ 73.70-
06/03/04 BALANCE AFTER INS* 32.15
4466828
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
05/18/04 90806 296.30 INDIV PSYCHO TX 1 HR 138.00
06/10/04 BE PHYS PAYMENT 32.15-
06/10/04 BC PHYS CONTRACTUAL AO 73.70-
06/10104 BALANCE AFTER INS* 32.15
4487088
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
05/25/04 90806 296.30 INDIV PSYCHO TX 1 HR 138.00
06/14104 DC PHYS PAYMENT 32.15-
06/14/04 8C PHYS CONTRACTUAL ADJ 73.70-
06/14/04 BALANCE AFTER INS* 32.15
4503068
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
06/01104 90806 296.30 INDIV PSYCHO TX 1 HR 138.00
06/21/04 DC PHYS PAYMENT 32.15-
06/21/04 BC PHYS CONTRACTUAL AD 73.70-
06/21/04 BALANCE AFTER INS* 32.15
4552484
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: SATELLITE CLINIC
06/21/04 90862 300.01 PHARMACOLOGIC MANAGMENT 101.00
07/12/04 BC PHYS PAYMENT 26.48-
07/12/04 BC PHYS CONTRACTUAL ADJ 44.04-
07/12/04 BALANCE AFTER INS* 28,48
4562851
A .(2-? y
DATE QTY DESCRIPTION INS CHARGE rNTmcM a GUwnwP
CODE CODE ADJUSTMENT BAL.AP
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
06/22/04 90806 2%.30 INDIV PSYCHO TX I HR 138.00
07/12/04 BC PHYS PAYMENT 32.15-
07/12/04 BC PHYS CONTRACTUAL ADJ 73.70-
07/12/04 BALANCE AFTER INS* 32.15
4601946
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: OP PHYSICIAN
07/06/04 90806 296.30 INDIV PSYCHO TX 1 HR 145.00
07/26/04 BC PHYS PAYMENT 32.15-
07/26/04 BC PHYS CONTRACTUAL AD 80.70-
07/26/04 BALANCE AFTER INS* 32.15
4673923
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: SATELLITE CLINIC
08/02/04 90862 300.01 PHARMACOLOGIC MANAGMENT 106.00
09/07/04 BC PHYS PAYMENT 28.48-
09/07/04 BC PHYS CONTRACTUAL AD 49.04-
09/07/04 BALANCE AFTER INS* 28.48
4838990
PERFORMED BY: DIV OUTPT PSYCH ADULT
PLACE OF SVC: SATELLITE CLINIC
* 09/27/04 90862 300.01 PHARMACOLOGIC MANAGMENT 106.00
* 10/12/04 BC PHYS PAYMENT 28,48-
* 10/12/04 SC PHYS CONTRACTUAL ADJ 49.04-
* 10/12/04 BALANCE AFTER INS* 28.48
BALANCE: ROBIN M BOMGARDNER 5307.52
* INDICATES NEW FINANCIAL ACTIVITY SINCE LAST BILL.
IF YOU HAVE ANY QUESTIONS ABOUT THE AMOUNT YOUR INSURANCE
COMPANY PAID, CONTACT THEM DIRECTLY. FOR ANY OTHER QUESTIONS
REGARDING YOUR BALANCE, PLEASE CONTACT OUR OFFICE. IF PAYMENT
HAS BEEN MADE, THANK YOU AND DISREGARD THIS BILL.
RNM3
THANK YOU FOR USING MSHMC PHYSICIANS GROUP FOR YOUR PHYSICIAN
SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING THIS BILL, PLEASE
CONTACT US AT 717-531-5069 OR 800-254-2619, BETWEEN 8:00AM AND
5:30PM MONDAY THROUGH WEDNESDAY OR BETWEEN 8:OOAM AND 4:30PM
THURSDAY AND FRIDAY.
ON
H IF ANY QUESTIONS, PLEASE CONTACT: MSHMC PATIENT FINANCIAL SERVICES FED TAX ID # 251857035
DATE PROCEDURE DIAG QTY DESCRIPTION INS CHARGE PAYMENT/ GUARANTOR
CODE CODE ADJUSTMENT BALANCE
BALANCE S"ARY RESPONSIBLE PARTY POLICY 0 TOTAL
II** GUARANTOR RESPONSIBILITY S 307.52
I IMPORTgNT; PLEASE QET4CN AND FT URN 807TOM POftTiON OF STATEMENT WITH YOUR P_gYMENT
STATEMENT DATE: GUARANTOR RESPONSIBILITY: MINIMUM PAYMENT:
BF6 10122104 $ 307.52 S 307.52
MSHMC PHYSICIANS GROUP
BILLING SERVICES
P O BOX B54
HERSHEY PA 17833.8854 00001018572 56000 0000000000030752102204
h,,III,,,IIh,,I„1111,., I,,If,Lh,,ii IIII„ill,,,.1,111.,11
II„li,hh..LLIL,II,Ih,Ih1IILIIJL,II„„ILIIL11IL1
Mail DIV OUTPT PSYCH ADULT ROBIN M BDMGARDNER
TO. MSHMC PHYSICIANS GROUP 702 BARBARA STREET
P 0 BOX 643313 NEW CUMBERLAN PA 17070-1530
PITTSBURGH PA 15264-3313
OFFICE USE ONLY CHECK ONE FOR CREDIT CARD PAYMENT, PLEASE FILL IN INFORMATION BELOW
1018572
m/c I I I I I I I I I I I I I I I I I
-_VISA CARD NUMBER FXP DATE $ 307.52 111
HC: F680 CARDHOLDER NAME (PRINT).
TYP: DMND
CREDIT CARD SIGNATURE MSHMC PHYSICIANS GRI
AND ENTER ANY
Y'
PENNSTATE ROBIN M BOMGARDNER 3 of 3
702 BARBARA STREET
The Milton S. Hershey Medical Center NEW CUMBERLAN PA 17070.1530 STATEMENT
® The College 0f Median DATE: 1 O/22/O4
LAST STATEMENT
ACCOUNT # 1018572 DATE: 10/18104
BOMGARDNER, ROBIN #1018572 $78.00, $10,910.54, $1,534.97, $134.00,
$307.52, $82.00, $797.00
VERIFICATION
LINDA SCHLADER hereby states that she is the
Team Manager, Customer Service of the Milton S. Hershey
Medical Center 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.
C.rsL 6?`GL
LINDA SCHLADER
i
DATE: ? J6 -?-
n ?
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RICHARD F. MAFFETT, JR., ESQUIRE
ID #35539
2201 North Second Street
Harrisburg, PA 17110
717-233-4160
Attorney for Defendants
THE MILTON S. HERSHEY MEDICAL
CENTER,
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY COUNTY,
PENNSYLVANIA
V
ALBERT BOMGARDNER and ROBIN
BOMGARDNER,
Defendants
NO. 05-574 CIVIL
CIVIL ACTION - LAW
TO: PLAINTIFF, The Milton S. Hershey Medical Center
You are hereby notified to file a written response to the
enclosed New Matter within twenty (20) days from service hereof
or a judgment may be entered against you.
Respectfully submitted, X", 0
Richard F. Maffetk! Jr.,?'.Vsq.
Attorney for Defendants
RICHARD F. MAFFETT, JR., ESQUIRE
ID #35539
2201 North Second Street
Harrisburg, PA 17110
717-233-4160
Attorney for Defendants
THE MILTON S.
CENTER,
Plaintiff
V
HERSHEY MEDICAL
ALBERT BOMGARDNER and ROBIN
BOMGARDNER,
Defendants
................................................................................
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY COUNTY,
PENNSYLVANIA
NO. 05-574 CIVIL
CIVIL ACTION - LAW
DEFENDANTS' ANSWER WITH NEW MATTER
AND NOW, this 7th day of March, 2005, comes the Defendants,
ALBERT BOMGARDNER & ROBIN BOMGARDNER, by their attorney,
Richard F. Maffett, Jr., Esquire, and submit Defendants' Answer
With New Matter, and in support thereof, avers the following:
ANSWER
COUNT I
THE MILTON S. HERSHEY MEDICAL CENTER V ROBIN BOMGARDNER
1. Denied. After reasonable investigation, Defendants are
without sufficient knowledge or information to form a belief as
to the truth of this Averment.
2. Admitted.
3. Admitted in part, denied in part. It is admitted
Defendant Robin Bomgardner was treated at Plaintiff hospital on
April 5-14, 2000; from April 17-21, 2000; from April 24-28, 2000;
from May 2-4, 2000; and, on May 12, 2001. It is denied Defendant
Robin Bomgardner received medical treatment at Plaintiff hospital
on any of the other dates alleged. After reasonable
investigation, Defendants are without sufficient knowledge or
information to form a belief as to whether treatment was received
on the other dates alleged.
4. Denied. After reasonable investigation, Defendants are
without sufficient knowledge or information to form a belief as
to the truth of this Averment.
5. Denied. After reasonable investigation, Defendants are
without sufficient knowledge or information to form a belief as
to the truth of this Averment.
6. Denied. Defendants never entered into any written, oral,
or implied contract with Plaintiff for payment of the charges
claimed for the alleged medical care of Defendant Robin
Bomgardner. There was never an agreement with Plaintiff that
Defendants would make payment for the charges alleged. No
implied, constructive and/or oral contracts arose between
Defendants and Plaintiff, nor are Defendants obligated to pay
Plaintiff, for the charges claimed by Plaintiff for the medical
care Plaintiff alleges.
7. Admitted.
8. Denied. No sums are due and owing from Defendants to
Plaintiff.
2
WHEREFORE, Defendants ROBIN BOMGARDNER and ALBERT BOMGARDNER
respectfully request that Your Honorable Court enter judgment in
their favor and against Plaintiff.
COUNT II
THE MILTON S. HERSHEY MEDICAL CENTER v ALBERT BOMGARDNER
9. Denied. Defendants' Answers to Paragraphs 1 through 8
are incorporated herein by reference as fully as though set forth
at length.
10. Admitted.
11. Admitted.
12. Denied. Defendant Albert Bomgardner is without
sufficient knowledge or information to form a belief as to the
truth of this Averment.
13. Denied. After reasonable investigation, Defendants are
without sufficient information to form a belief as to the truth
of this Averment.
14. Admitted.
15. Denied. Defendant Albert Bomgardner does not have the
financial ability to pay for the medical care of Defendant Robin
Bomgardner.
16. Denied. Paragraph 16 states a conclusion of law to
which no responsive pleading is required.
17. Denied. Paragraph 17 states a conclusion of law to
which no responsive pleading is required. By way of further
3
answer, Defendant Albert Bomgardner has received no unjust
enrichment from Plaintiff. Defendant Albert Bomgardner has no
duty of support of Defendant Robin Bomgardner in regard to
Plaintiff's claims. Defendant has not failed to perform any duty
owed to Defendant Robin Bomgardner and/or to Plaintiff.
Defendant Albert Bomgardner owes no duty to Plaintiff.
18. Admitted.
19. Denied. No sums are due and owing from Defendants to
Plaintiffs.
WHEREFORE, Defendants, ROBIN BOMGARDNER and ALBERT
BOMGARDNER, respectfully request this Honorable Court to enter
judgment in their favor and against Plaintiff.
NEW MATTER
20. Defendants incorporates their Answers to Paragraphs 1
through 19 above as fully as though set forth at length herein.
21. Plaintiff's Complaint fails to state a cause of action
upon which relief can be granted.
22. If Plaintiff suffered any damages, which is denied,
Plaintiff failed to mitigate any damages they may have suffered.
23. Plaintiff's claims are barred by the statute of
limitations.
24. Plaintiff's claims are barred by the statute of frauds.
25. Plaintiff is estopped from demanding payment from
Defendants of the sums alleged, because Plaintiff never advised
4
Defendants at the time the medical services were allegedly
provided that payment would be sought by Plaintiff from
Defendants.
WHEREFORE, Defendants, ROBIN BOMGARDNER and ALBERT
BOMGARDNER, respectfully request this Honorable Court to enter
judgment in their favor and against Plaintiff.
Respectfully submitted,
Richard F. Maffet , Jr./ Esq
Attorney for Defendants
5
VERIFICATION
I, ALBERT BOMGARDNER, have read the foregoing Answer With
New Matter and hereby affirm that it is true and correct to the
best of my knowledge, or information and belief. This
verification and statement is made subject to the penalties of 18
Pa. C.S.A. §4904 relating to unsworn falsification to
authorities; I verify that all statements made in the foregoing
are true and correct and that false statements may subject me to
the penalties of 18 Pa. C.S.A. §4904.
Dated: j - 7 "( /? y i
ALBERT B/MGARS , -Defendant
VERIFICATION
I. ROBIN BOMGARDNER, have read the foregoing Answer With New
Matter and hereby affirm that it is true and correct to the best
of my knowledge, or information and belief. This verification
and statement is made subject to the penalties of 18 Pa. C.S.A.
§4904 relating to unsworn falsification to authorities; I verify
that all statements made in the foregoing are true and correct
and that false statements may subject me to the penalties of 18
Pa. C.S.A. 54904. / /j,
Dated: y-?t'?4yn k oa/'??u-?
ROBIN BOMGARDNER, Defendant
CERTIFICATE OF SERVICE
The undersigned hereby certifies that he served a true and
correct copy of the foregoing Answer With New Matter upon counsel
of record by depositing same in the United States Mail, postage
prepaid, addressed as follows:
LEWIS C. TRAUFFER, ESQUIRE
TABAS & ROSEN, P.C.
22ND FLOOR
1845 WALNUT STREET
PHILADELPHIA, PA 19103
Dated: 3/2 A? U
Richard F. Maffet ; Jr., Esq.
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IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
THE MILTON S. HERSHEY MEDICAL
CENTER,
Plaintiff
V
ALBERT BOMGARDNER and ROBIN
BOMGARDNER,
Defendants
NO. 05-574 CIVIL
CIVIL ACTION - LAW
PRAECIPE
TO THE PROTHONTOARY:
Please enter my appearance on behalf of the Defendants,
Albert Bomgardner and Robin Bomgardner, in the above captioned
matter.
Dated: March 7, 2005
Respectfully submitted,
Richard F. Maf ett Jr., Esq.
Attorney ID #35539
2201 North Second Street
Harrisburg, PA 17110
(717) 233-4160
CERTIFICATE OF SERVICE
The undersigned hereby certifies that he served a true and
correct copy of the foregoing Praecipe by depositing same in the
United States Mail, postage prepaid, addressed as follows:
Lewis C. Trauffer, Esquire
Tabas & Rosen, P.C.
22nd Floor
1845 Walnut Street
Philadelphia, PA 19103
Dated: March 7, 2005
Richard F. Maffet , Jr., Esq.
;?
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`r
W. .
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER
Attorney LD. 60267
1845 Walnut Street, 22nd Floor
Philadelphia, PA 19103
(215)569=5050
THE MILTON S. HERSHEY MEDICAL
CENTER,
Plaintiff
V.
ALBERT BOMGARDNER and ROBIN
BOMGARDNER,
Defendants
IN THE COURT OF COMMON
OF CUMBERLAND COUNTY
NO. 05-574
CIVIL ACTION - LAW
PLAINTIFF'S REPLY TO NEW MATTER
20. Admitted.
21 - 25. The averments contained in paragraphs 21 through 25 are conclusions of
response. To the extent a response is required, the same are denied and proof demanded at
WHEREFORE, for al I the foregoing reasons, plaintiff demands judgment in the
plus six percent (6%) interest per annum from the date of discharge to the date ofjudgment,
non record costs.
TABAS & ROSEN, P.C.
LEWIS C. TRAUIT ER, ESQUIRE
ATTORNEY FOR PLAINTIFF
Plaintiff
irine no
3,844.03
costs and
CERTIFICATE OF SERVICE
1, Lewis C. Trauffer, Esquire, certify that on March 22, 2005 a true and correct copy ofpl?jntiffs Reply
to New Matter was served on the following individual(s) via United States mail, first class, poske pre-paid,
and addressed as follows:
Richard F. Maffett, Jr., Esquire
2201 North Second Street
Harrisburg, PA 17110
TABAS & ROSEN, P.C.
C. TRAnFER
Attorney for Plaintiff
J / j
at-/or2Ace
3-,2e/-6j
TABAS & ROSEN, P.C.
BY: LEWIS C. TRAUFFER
Attorney I.D. 60267
1845 Walnut Street, 22nd Floor
Philadelphia, PA 19103
(215) 569-5050
THE MILTON S. HERSHEY MEDICAL
CENTER,
Plaintiff
Attorney For Plaintiff
IN THE COURT OF COMMON P
OF CUMBERLAND COUNTY
NO. 05-574
V.
CIVIL ACTION - LAW
PLAINTIFF'S REPLY TO NEW MATTER
20. Admitted.
21 - 25. The averments contained in paragraphs 21 through 25 are conclusions of law equiring no
ALBERT BOMGARDNER and ROBIN
BOMGARDNER,
Defendants
response. To the extent a response is required, the same are denied and proof demanded at tri
WHEREFORE, for all the foregoing reasons, plaintiff demandsjudgment in the amount 4$13,844.03
plus six percent (6%) interest per annum from the date of discharge to the date ofjudgment, rec?rd costs and
non record costs.
TABAS & ROSEN, P.C.
LEWIS C. TRAUFFER, ESQUIRE
ATTORNEY FOR PLAINTIFF
CERTIFICATE OF SERVICE
1, Lewis C. Trauffer, Esquire, certify that on March 22, 2005 a true and correct copy ofplalhtiffs Reply
to New Matter was served on the following individual(s) via United States mail, first class, pos$ge pre-paid,
and addressed as follows:
Richard F. Maffett, Jr., Esquire
2201 North Second Street
Harrisburg, PA 17110
TABAS & ROSEN, P.C.
LEWIS C. TRAIYFFE
Attorney for Plaintiff
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SHERIFF'S RETURN - REGULAR
CASE NO: 2005-00574 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
MILTON S HERSHEY MEDICAL CENTE
VS
BOMGARDNER ALBERT ET AL
BARYAN WARD Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE was served upon
BOMGARDNER ROBIN t e
DEFENDANT , at 1929:00 HOURS, on the 10th day of February 2005
at 702 BARBARA STREET
NEW CUMBERLAND, PA 17070 by handing to
ALBERT BOMGARDNER, ADULT IN CHARGE
a true and attested copy of COMPLAINT & NOTICE together w th
and at the same time directing His attention to the contents ther of.
Sheriff's Costs
Docketing 6.00
Service .00
Affidavit .00
Surcharge 10.00
1?
So Answers:
comas Kline
02/11/2005
TABAS & ROSEN
Sworn and Subscribed to before
meA this day of
A.D.
J Prothondtary
By:
SHERIFF'S RETURN - REGULAR
CASE NO: 2005-00574 P
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
MILTON S HERSHEY MEDICAL CENTE
VS
BOMGARDNER ALBERT ET AL
BRYAN WARD Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according t<
says, the within COMPLAINT & NOTICE was served upon
ALBERT
the
DEFENDANT , at 1929:00 HOURS, on the 10th day of February ,
at 702 BARBARA STREET
NEW CUMBERLAND, PA 17070 by handing to
ALBERT BOMGARDNER
a true and attested copy of COMPLAINT & NOTICE
together
and at the same time directing His attention to the contents
law,
2005
h
Sheriff's Costs:
Docketing
Service
Affidavit
Surcharge
So Answers:
18.00
12.58 00
10.00 R. Thomas Kline
.00
40.58 02/11/2005
TABAS & ROSEN
Sworn and Subscribed to before
me this day of
A.D.
ary
By:
MILTON S HERSHEY MEDICAL CENTER
vs
ALBERT BOMGARDNER &
ROBIN BOMGARDNER
Case No. 05-0574
To the Court:
Statement of Intention to Proceed
MILTON S. HERSHEY MEDICAL CTR intends to proceed with the above captioned matter.
Print Name LEWIS C TRAUFFER Sign Name
Date: 9,118.10 8 Attorney for Milt-on S Hersbey Medical Center
Plaintiff
Explanatory Comment
The Supreme Court of Pennsylvania has promulgated new Rule of Civil Procedure 230.2 governing the termination of
inactive cases and amended Rule of Judicial Administration 1901. Two aspects of the recommendation merit
comment.
1. Rule of civil Procedure
New Rule of Civil Procedure 230.2 has been promulgated to govern the termination of inactive cases within the
scope of the Pennsylvania Rules of Civil Procedure. The termination of these cases for inactivity was previously
governed by Rule of Judicial Administration 1901 and local rules promulgated pursuant to it. New Rule 230.2 is
tailored to the needs of civil actions. It provides a complete procedure and a uniform statewide practice, preempting
local rules.
This rule was promulgated in response to the decision of the Supreme Court in Shop v. Eagle, 551 Pa. 360,710 A.2d
1104 (1998) in which the court held that "prejudice to the defendant as a result of delay in prosecution is required
before a case may be dismissed pursuant to local rules implementing Rule of Judicial Administration 1901."
Rule of Judicial Administration 1901(b) has been amended to accommodate the new rule of civil procedure. The
general policy of the prompt disposition of matters set forth in subdivision (a) of that rule continues to be applicable.
II Inactive Cases
The purpose of Rule 230.2 is to eliminate inactive cases from the judicial system. The process is initiated by the
court. After giving notice of intent to terminate an action for inactivity, the course of the procedure is with the parties.
If the parties do not wish to pursue the case, they will take no action and "the Prothonotary shall enter an order as of
course terminating the matter with prejudice for failure to prosecute." If a party wishes to pursue the matter, he or she
will file a notice of intention to proceed and the action shall continue.
a. Where the action has been terminated
If the action is terminated when a party believes that it should not have been terminated, that party may proceed
under Rule230(d) for relief from the order of termination. An example of such an occurrence might be the termination
of a viable action when the aggrieved party did not receive the notice of intent to terminate and thus did not timely file
the notice of intention to proceed.
The riming of the filing of the petition to reinstate the action is important. If the petition is filed within thirty days of
the entry of the order of termination on the docket, subdivision (d)(2) provides that the court must grant the petition and
reinstate the action. If the petition is filed later than the thirty-day period, subdivision (d)(3) requires that the plaintiff
must make a show in to the court that the petition was promptly filed and that there is a reasonable explanation or
legitimate excuse both for the failure to file the notice of intention to proceed prior to the entry of the order of
termination on the docket and for the failure to file the petition within the thirty-day period under subdivision (d)(2).
B. Where the action has not been terminated
An action which has not been terminated but which continues upon the filing of a notice of intention to proceed may
have been the subject of inordinate delay. In such an instance, the aggrieved party may pursue the remedy of a
common law non pros which exits independently of termination under Rule 230.2.
r-o
1yifT ?7'
ii
GTy
(DaviorD. Buell
Prothonotary
Office of the <1'rothonotag
Cum6errand County, (Pennsylvania
cis -sly
ORDER OF TERMINATION OF COURT CASES
7rkS. Sohonage, TSQ
Solicitor
CIVIL TERM
AND NOW THIS 28TH DAY OF OCTOBER, 2014, AFTER MAILING NOTICE OF
INTENTION TO PROCEED AND RECEIVING NO RESPONSE—THE ABOVE
CASE IS HEREBY TERMINATED WITH PREJUDICE IN ACCORDANCE WITH
PA R.C.P.230.2.
BY THE COURT,
DAVID D. BUELL
PROTHONOTARY
. One Courthouse Square C Suite100 ®CarfusCe, TA ® (Phone 71 7 240-6195 6 rFar 71 7 240-6573